Federal Communications Commission
Washington, D.C. 20554
Approved by OMB
3060-0906 (November 2008)
FCC 317
FOR FCC USE ONLY
 
ANNUAL DTV ANCILLARY/SUPPLEMENTARY SERVICES REPORT FOR DIGITAL TELEVISION STATIONS

Read INSTRUCTIONS Before Filling Out Form

FOR COMMISSION USE ONLY
FILE NO.

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Section I - General Information
1. Legal Name of the Licensee or Permittee

Mailing Address


City
State or Country (if foreign address)
ZIP Code
-
Telephone Number (include area code)
E-Mail Address (if available) 
FCC Registration Number:

Facility ID Number
60850
Call Sign 
2. Contact Representative (if other than Licensee or Permittee)

Firm or Company Name

Telephone Number (include area code)

E-Mail Address (if available)

3. For the twelve-month period ended September 30th, has the DTV licensee or permittee provided, at any time during the period, an ancillary or supplementary service as defined by 47 C.F.R. Section 73.624?

If "No," complete Question 7 and submit this Report to the Commission.

If "Yes," proceed to Questions 4 through 7.

Yes No
4. Ancillary/Supplementary Services Provided. Briefly describe below the service provided; whether a fee was charged for the provision of such service; and, if so, the amount of gross revenues received therefrom and the amount of DTV bitstream used to provide such service.

[Services Provided]



5. Total amount of gross revenues derived from feeable ancillary or supplementary services: $
6. Has the DTV licensee or permittee remitted to the Commission, through the filing of FCC Form 159, a payment in the amount of 5% of the gross revenues derived from the feeable ancillary or supplementary services? Yes No
N/A
7. Certification. I certify that I have examined this Report and that, to the best of my knowledge and belief, all statements in this Report are true, correct and complete.
Typed or Printed Name of Person Signing
Typed or Printed Title of Person Signing
Signature
Date

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1)), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503).



Exhibits