Attachment Form 159 Remittance

This document pretains to SES-STA-INTR2019-02580 for Special Temporal Authority on a Satellite Earth Station filing.

IBFS_SESSTAINTR201902580_1767836

READ INSTRUCTIONS CAREFULLY Approved by OMB BEFORE PROCEEDING FEDERAL COMMUNICATIONS COMMISSION 3060—0589 REMITTANCE ADVICE Page No_! of2 FORM 159 (I)LOCKBOX # SPECIAL USE ONLY TCC USE ONLY SECTION A — PAYER INFORMATION (2) PA YER NAME (if paying by credit card enter name exactly as it appears on the card) (3) TOTAL AMOUNT PAID (U.S. Dollars and cents) Krystle Curnutte $210.00 (4) STREET A DDRESS LINE NO.1 15330 Barranca Parkway (5) STREET ADDRESS LINE NO. 2 (6) CITY (7) STATE (8) ZIP CODE Irvine CA 92618—2606 (9) DAYTIME TELEPHONE NUMBER (include area code) (10) COUNTRY CODE (if not in U.$.A.) 310—987—3843 FCC REGISTRATION NUMBER (FRN) REQUIRED (11) PAYER (FRN) (12)FCC USE ONLY 0023408065 IF MORE THAN ONE APPLICANT, USE CONTINUATION SHEETS (FORM 159—C) COMPLETE SECTION BELOW FOR EACH SERVICE, IF MORE BOXES ARE NEEDED, USE CONTINUATION SHEET (13) APPLICANT NAME (14) STREET ADDRESS LINE NO.1 (15) STREET ADDRESS LINE NO. 2 (16) CITY (17) STATE (18) ZIP CODE (19) DAYTIME TELEPHONE NUMBER (include area code) (20) COUNTRY CODE (if not in U.S.A.) FCC REGISTRATION NUMBER (FRN) REQUIRED (21) APPLICANT(FRN) (22)FCC USE ONLY COMPLETE SECTION C FOR EACH SERVICE, IF MORE BOXES ARE NEEDED, USE CONPI"INUATKON SHEET (23A) CALL SIGNJOTHER ID (CiA)PAYMENT TYPE CoDE (25A) QUANTITY N/A CGX 1 (26A) FEE DUE FOR (PTC) (27A) TOTAL FEE FCC USE ONLY $210.00 $210.00 (28A) FCC CODEI (29A) FCC CODE 2 312 159 (23B) CALL SIGN/OTHER ID (24B) PAYMENT TYPE CODE (25B) QUANTITY (26B) FEE DUE FOR (PTC) (27B) TOTAL FEE FCC USE ONLY (283B)FCC CODE I (29B) FCC CODE 2 SECTION D — CERTIFECATION CERTIFICATION STATEMENT L__Krystle Curnutte certify under penalty ofperjury that the foregoing and supporting information is true and correct to the best of my knowledge, information and belief. SIGNATURE _\ FRi ,;f)éé cA'L/ , DATE__ July 1, 2019 17 7 C T &" SECTION E — CREDIT CARD PAYMENT INFORMATION MASTERCARD VISA AMEX % DISCOVER ACCOUNT NUMBER 3791 2180 7741 001 EXPIRATION DATE 02/2022 a . . 1 hereby authorize the FCC to charge%{service(s)/authorization herein described. SIGNATURE % i22 DATE___July 1, 2019 Ttz (24 SEE PUBLIC BURDEN ON REVERSE FCC FORM 159 FEBRUARY 2003


Document Created: 2019-07-18 03:42:27
Document Modified: 2019-07-18 03:42:27
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