Modified 02-22-2018 OMB Control Number 3060-1251 Page 1 of 1 
Challenge Data Certification Form MF-II Challenge Process 
Challenger / Challenged Party Identification 
Enter the following information about the entity submitting data in the MF-II Challenge Process: 
Entity Legal Name:   If your organization is a mobile service provider, enter your FCC Registration Number (FRN) as it appears on the most recent FCC Form 477 filing below: 
FRN:    If your organization is a state, local, or tribal governmental entity, enter your entity’s legal jurisdiction below (i.e., name of the state, municipality, or tribal territory): 
Legal Jurisdiction:   Data submitted by each entity in the Mobility Fund Phase II Challenge Process must be substantiated by the certification of a qualified engineer, or, for a governmental entity that does not have a qualified engineer available to certify, by a government official authorized to act on behalf of the organization and with actual knowledge of the accuracy of the underlying data. Engineer (or Government Official) Certification 
Enter the requested information for the certifying qualified engineer (or government official): 
Name:   
Phone:   Extension:   
Email:   
Title:   On behalf of the entity identified above, I certify under penalty of perjury that: a) I have examined the information prepared for submission, and b) all data and statements contained therein were generated in accordance with the parameters specified by the Commission, and are true, accurate, and complete to the best of my knowledge, information, and belief. I understand that persons making willful false statements in any part of this data submission can be punished by fine or imprisonment, pursuant to 47 U.S.C. §§ 416(c), 503(b)(1)(B), and 18 U.S.C. § 1001. Enter your name in the Signature field below to sign this form. Signature:   Date: