Attachment Form 159

This document pretains to SAT-MOD-20040405-00075 for Modification on a Satellite Space Stations filing.

IBFS_SATMOD2004040500075_371071

R E A D INSTRUCTrONS CAREFULLY ORIGINAL Approved by OMB BEFORE PROCEEDING FEDERAL COMMUNICATIONS COMMISSION 30606589 REMIITANCE ADVICE Page 1- of_' (2) PAYER NAME (ifpaying by credit card enter name exactly as i t appears on the card) (3) TOTAL AMOUNT PAID (U S Dollars and cents) PanAmSat Licensee CorD. $7.050.00 (6) CITY (7) STATE (8) ZIP CODE Washinaton DC 20006 0005848577 PanAmSat Licensee CorD. (1 4) STREET ADDRESS LINE NO 1 1801 K Street, N.W. (1 5) STREET ADDRESS LINE NO 2 Suite 440 ( 16) CITY I (I7)STATE I (18)ZIPCODE Washinaton I BFY I1 I (28A) FCC CODE I 1 lB2004000721 (23B) CALL SIGN/OTHER ID (248) PAYMENT TYPE CODE I (25B) QUANTITY I SECTION D - CERTIFICATION CERTIFICATION STATEMENT I, , certify under penalty ofperjury that the foregoing and supporting information is true and correct to the best ofmy knowledge, information and belief SIGNATURE DATE SECTION E - C R E D I T CARD PAYMENT INFORMATION MASTERCARD- VISA___ AMEX- DISCOVER-- ACCOUNT NUMBER EXPIRATION DATE I hereby authorize the FCC 10 charge my credit card for the service(s)/authorlzatim herein described SIGNATURE DATE SEE PUBLIC BURDEN ON REVERSE FCC FORM I59 FEBRUARY 2003(REVISED)


Document Created: 2004-04-29 14:25:45
Document Modified: 2004-04-29 14:25:45
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