Attachment Form 159

This document pretains to SAT-MOD-20040405-00076 for Modification on a Satellite Space Stations filing.

IBFS_SATMOD2004040500076_371069

READ INSTRUCTIONS CAREFULLY ORIGINAL Approved by OMB FEDERAL COMMUNICATIONS COMMISSION 30600589 BEFORE PROCEEDING REMITTANCE ADVICE Page 1- o ~ l Suite 440 (6) CITY (7) STATE (8) ZIP CODE Washinaton DC 20006 )DAYTIME TELEPHONENUMBER (include areacode) (IO)COUNTRY CODE (if notin U S A ) ..^ 1 'anAmSat Licensee Corm 14) STREET ADDRESS LINENO I 801 K Street, N.W. 15) STREET ADDRESS LINENO 2 16) CITY (1 7) STATE ( I 8) ZIP CODE !02-2924300 2 I) APPLICANT(FRN) DO05848577 C O M P L E T E SECTION 23A) CALL SIGNIOTHER ID 9YMENT TYPE CODE (25A) QUANTITY I SECTION D - CERTIFICATION CERTIFICATION STATEMENT I, , certify under penalty ofperjury that the foregoing and supporting information is true and correct 10 the best o f m y knowledge. information and belief SIGNATURE DATE- SECTION E - CREDIT CARD PAYMENT INFORMATION MASTERCARD- VISA- AMEX- DISCOVER- ACCOUNT NUMBER EXPIRATION DATE I hereby authorize the FCC to charge my credit card for the service(s)lauihorizatiol herein described. SIGNATURE DATE SEE PUBLIC BURDEN ON REVERSE FCC FORM 159 FEBRUARY 2003(REVISED)


Document Created: 2004-04-29 14:27:07
Document Modified: 2004-04-29 14:27:07
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