Attachment F Standard Questions for Section 310(b) Petition for Declaratory Ruling Involving a Common Carrier Wireless or Common Carrier Earth Station Licensee Petitioner: FCC File Number(s): Purpose: This list of standard questions solicits the initial information that the Committee for the Assessment of Foreign Participation in the United States Telecommunications Services Sector (Committee) will review in connection with any referral of the above-referenced application by the Federal Communications Commission (FCC) in order to assess any national security and law enforcement concerns raised by the application. After review, the Committee may request additional information, including through tailored questions.  The 120-day initial review period will typically start on the date the Chair of the Committee determines that your responses to these standard questions and any tailored questions, when required, are complete. If the Committee determines no tailored questions are necessary, the 120-day initial review period will start no more than 30 days after the FCC's referral, on the date the Committee informs the FCC that the responses to the standard questions are complete and that no tailored questions are required. If you fail to provide timely responses to any Committee requests for information, the Committee may recommend that the FCC dismiss the application without prejudice.  Dissemination of Information: The information received by the Committee pursuant to 47 CFR § 1.40003 and any subsequent requests for information by the Committee may be shared and used in accordance with Section 8 of Executive Order 13913 of April 4, 2020, Establishing the Committee for the Assessment of Foreign Participation in the United States Telecommunications Services Sector, 85 Fed. Reg. 19643 (Apr. 8, 2020). Instructions 1) Who Must Respond to this Questionnaire: A Petitioner that seeks to obtain (a) a section 310(b)(3) or 310(b)(4) foreign ownership ruling in connection with an application for a new common carrier wireless or common carrier earth station license(s), or (b) a new or modified 310(b)(3) or 310(b)(4) foreign ownership ruling in connection with an application for assignment, transfer of control, or other change in ownership or control of the Licensee must respond to this questionnaire. In the case of (b), a Petitioner must provide information pertaining to the post-transaction ownership, structure, and operations of the Licensee and Relevant Parties. As used in this questionnaire, the term “Licensee” refers to both an Applicant for a common carrier wireless or common carrier earth station license and an existing licensee. 2) Complete all Sections: When a “Yes” answer is indicated, provide further information as appropriate. The questions seek further details regarding the Applicant and security-related practices and some questions are particularly directed at identifying and assessing the complete scope of the equipment that the Applicant will be operating and the services the Applicant will be offering should the FCC grant those authorities. 3) Response Format: Uniquely and sequentially Bates-number your responses to the standard questions, including any attachments, with an endorsement on each page.  The Bates number must be a unique, consistently formatted identifier; the number of digits in the numeric portion of the format should not change in subsequent productions, if any, nor should spaces, hyphens, or other separators be added or deleted.  Produce any Excel documents in native format (if desired, you may also produce a PDF version for record keeping purposes). 4) Identify Sensitive Information: Specifically identify answers or documents for which a claim of privilege or confidentiality is asserted based on the information containing trade secrets or commercial or financial information. If there are multiple applicants, each applicant should also clearly mark any answers or documents that contain sensitive information that should not be disclosed to the other applicants. Personally Identifiable Information (PII) may be submitted in a separate attachment. The PII Supplement is Attachment G. 5) Individuals’ names: For names that follow different naming conventions, such as the use of surnames as first names (e.g., Korean names), or the use of mother's last name as one of two last names that are often hyphenated (e.g., Spanish names), follow standard English convention for purposes of completing this information. For example, if the name is Kim Chul-su, write “Chul-su Kim” in the form. If the name in Spanish is Juan Garcia-Reyes, write “Juan Garcia Reyes.” 6) Residential Addresses: Contract mail receipt locations, post office boxes, co-working or shared virtual locations may not be used in lieu of residence addresses. 7) Business Addresses: For each business address, clearly indicate whether the address is a shared business venue, co-working location, virtual office, or traditional physical office. 8) Obligation to Update: The Applicant must inform the Committee if there is any material change to any of the information provided in the Applicant’s responses while the Committee’s review is ongoing, including, but not limited to, changes in ownership, equipment, and Communications Assistance for Law Enforcement Act (CALEA) compliance. 9) Definitions – These terms, as used in this questionnaire, have the following definitions: · A “Controlling Interest” is generally a 50% or greater Ownership Interest (either equity or voting). Also, a Controlling Interest shall be determined on a case-by-case basis considering the distribution of ownership, and the relationships of the owners, including family relationships. The term Controlling Interest includes Individuals or Entities with positive or negative de jure or de facto control of the Applicant/Licensee. De jure control includes holding 50% or more of the voting stock of a corporation or holding a general partnership interest in a partnership. Ownership Interests that are held indirectly by any party through one or more intervening corporations may be determined by successive multiplication of the ownership percentages for each link in the vertical ownership chain except that if the ownership percentage for an interest in any link in the chain is equal to or exceeds 50% or represents actual control, it may be treated as if it were a 100% interest. De facto control is determined on a case-by-case basis. Examples of de facto, or actual, control include constituting or appointing 50% or greater of the board of directors or management committee; having authority to appoint, promote, demote, and fire senior executives that control the day-to-day activities of the Applicant/Licensee; or playing an integral role in management decisions. In the case of a consortium, each member of the consortium shall be considered to have a Controlling Interest in the consortium. o “Ultimate Owner” and “Ultimate Parent” refer to the Entity or Individual that ultimately owns and controls the Applicant/Licensee. o “Immediate Owner” refers to the Entity or Individual in the vertical ownership chain that immediately owns and controls the Applicant/Licensee. In other words, the Immediate Owner is the Entity or Individual in the ownership chain that is closest to the Applicant/Licensee. o An Entity or Individual with an “Ownership Interest” is any entity in the ownership chain with more than a 5% attributable interest in the Applicant/Licensee, including the “Ultimate Owner/Parent” to the “Immediate Owner,” and all Controlling Interest holders. Note that Controlling Interests include de facto control, for which equity and/or voting ownership may be below 5%. · “Corporate Officer” refers to any Individual hired or appointed by the Entity’s board of directors that has actual or apparent authority to exercise day-to-day management responsibilities over an Entity. · “Director” refers to any Individual serving on an Applicant’s board of directors or similar governing body organized to set policies for corporate management of or oversight for an Applicant/Licensee. · “Entity” includes a partnership, association, estate, trust, corporation, limited liability company, consortium, joint venture, governmental authority, or other organization. · An “Equity Interest Holder” is any Individual or Entity that has the right to receive or the power to direct the receipt of dividends from, or the proceeds from the sale of, a share or other ownership stake in the Applicant/Licensee. · The term “Foreign Government” includes any person or group of persons exercising sovereign de facto or de jure political jurisdiction over any country, other than the United States, or over any part of such country, and includes any subdivision of any such group and any group or agency to which such sovereign de facto or de jure authority or functions are directly or indirectly delegated. Such term shall include any faction or body of insurgents within a country assuming to exercise governmental authority whether such faction or body of insurgents has or has not been recognized by the United States. · “Individual” refers to a natural person, as distinguished from an Entity. · A “Non-U.S. Individual” is an Individual who is not a U.S. citizen. · An “Owner” is an Individual or Entity that holds an Ownership Interest in the Applicant/Licensee. · An “Ownership Interest” is a 5% or greater equity (non-voting) and/or voting interest, whether directly or indirectly held, or a Controlling Interest in the Applicant, and includes the ownership in the ultimate parent/owner of the Applicant and any other Entity(ies) in the chain of ownership (i.e., all entities that exist in the ownership structure between the Applicant itself and its ultimate parent). · “Senior Officer” refers to the Chief Executive Officer, President, Chief Financial Officer, Chief Information Officer, Chief Technical Officer, Chief Operating Officer, or any other similarly situated Individual that has actual or apparent authority to act on behalf of the Entity. Section I: Identification of Relevant Parties 1) Provide the name, address, principal place of business, and place of incorporation of Relevant Parties. For the purposes of the following questions “Relevant Parties” means the following: a) Current or Proposed Common Carrier Wireless or Common Carrier Earth Station Licensee (“Licensee”) b) Controlling U.S. Parent of the Licensee (“Petitioner”) c) Any Individual or Entity with an Ownership Interest in either the Licensee or the Petitioner (“Owner(s)/Controller(s)”). Section II: Petitioner/Licensee Ownership 2) To the extent not otherwise identified in response to Question 1, identify each Individual or Entity that holds an Ownership Interest in the Relevant Parties, specifically listing any foreign Entities or Foreign Government-controlled Entities, including the Ultimate Parent Entity of the Licensee and the Petitioner and any other companies/Individuals holding an Ownership Interest in the chain of ownership. a) For each Individual or Entity with Ownership Interest in any of the Relevant Parties (identified in response to either Question 1 or Question 2), include a clear explanation of its involvement in the Relevant Party, including whether the Individual or Entity will have a management role in the Petitioner or Licensee. b) For each Individual or Entity with Ownership Interest in any of the Relevant Parties (identified in response to either Question 1 or Question 2), provide all identifying information, as follows: i) For Individuals, provide name (including all names and aliases used by that person), country of citizenship (indicate whether the Individual is a dual citizen and all countries where citizenship is held), date and place of birth, U.S. alien number (indicate whether the Individual is a U.S. Lawful Permanent Resident) and/or social security number (if applicable), passport identifying information (including number and country), all residence addresses, all business addresses, and all phone numbers. PII may be provided in Attachment G, a PII Supplement to the Standard Questions. ii) For Entities, provide country of incorporation (if United States, include state of incorporation), principal place of business, general business type (e.g., holding company, investment firm, etc.), all business addresses, email addresses, and related phone numbers. Section III: Petitioner/Licensee Details 3) Does any of the Relevant Parties have existing, planned, or prior relationships, partnerships, funding arrangements, or service contracts, directly or indirectly, with any of the following: a) Foreign companies or foreign Entities; b) Any Foreign Government or any entity owned or controlled by a Foreign Government; or c) An Individual or Entity outside the United States, not a citizen of, or domiciled within, the United States, or not subject to the jurisdiction of the United States, and not having as a principal place of business or presence in the United States. Yes No If yes to any question above, explain each answer in detail. 4) Identify the total number of current employees of the Licensee and the Petitioner, and planned number of employees for the next 12 months. 5) Does the Licensee or Petitioner currently operate or plan to operate a website? Yes No If yes, provide all URL addresses for any current or known future websites and describe whether the information therein is up to date. 6) Have any of the Relevant Parties or any of their Corporate Officers, Senior Officers or Directors been involved in bankruptcy proceedings, or any other legal proceeding undertaken for the purpose of liquidating, reorganizing, refinancing, or otherwise seeking relief from all or some of their debts in any jurisdiction over the past 5 years? Yes No If yes, provide details. 7) Have any of the Relevant Parties or any of their Corporate Officers, Senior Officers or Directors ever been involved or associated with a previous application to the FCC? Yes No If yes, provide application identifying information. 8) Have any of the Relevant Parties or any of their Corporate Officers, Senior Officers or Directors ever been involved or associated with a previous filing with the Committee on Foreign Investment in the United States (CFIUS)? Yes No If yes, provide filing identifying information. 9) Have any of the Relevant Parties or any of their Corporate Officers, Senior Officers or Directors ever been blocked, sanctioned, penalized, or had an authorization or other permission revoked by the FCC? Yes No If yes, provide details. 10) Have any of the Relevant Parties or any of their Corporate Officers, Senior Officers or Directors ever been blocked, sanctioned, penalized, or had an authorization or other permission prohibited, suspended, or revoked by CFIUS? Yes No If yes, provide details. 11) Have any of the Relevant Parties or any of their Corporate Officers, Senior Officers or Directors ever been convicted of any felony (an offense carrying a maximum potential sentence of a term of imprisonment of more than a year) in the United States or any other country? This includes any settlements or negotiated resolutions, non-prosecution agreements, or deferred prosecution agreements. Yes No If yes, , provide details, including name(s) of the Individual or Entity involved, dates, offenses, jurisdiction/court, and sentence. 12) Have any of the Relevant Parties or any of their Corporate Officers, Senior Officers or Directors ever been subject to any criminal, administrative, or civil penalties imposed for violating the regulations of the FCC, U.S. Department of State, U.S. Department of the Treasury (including, but not be limited to, the Internal Revenue Service, Office of Foreign Assets Control, Financial Crimes Enforcement Network (FinCEN), or the Office of the Comptroller of the Currency), U.S. Department of Energy, U.S. Department of Commerce, U.S. Federal Trade Commission, U.S. Securities and Exchange Commission, U.S. Environmental Protection Agency, the World Bank Group, or U.S. Commodity Futures Trading Commission, or for violating the regulations of any comparable state or foreign agency? This includes any settlements or negotiated resolutions, non-prosecution agreements, or deferred prosecution agreements. Yes No If yes, provide details, including name(s) of the Individual or Entity involved, dates, violations, agency, penalty, and if a fine was imposed, status of payment. 13) Have any of the Relevant Parties or any of their Corporate Officers, Senior Officers or Directors, or any associated foreign Entities ever been on the Specially Designated Nationals And Blocked Persons List (SDN List), the BIS Unverified List or Entity List in 15 CFR part 744, or equivalent list of the United Nations Security Council or European Union? Yes No If yes, provide details. 14) Have any of the Relevant Parties or any of their Corporate Officers, Senior Officers or Directors ever been investigated, arraigned, arrested, indicted, or convicted of any of the following: a) Criminal violations of U.S. law, including espionage-related acts or criminal violations of the International Trade in Arms Regulations (ITAR) or the Export Administration Regulations (EAR)? Yes No b) Deceptive sales practices, violations of the Consumer Fraud Act and regulations, and/or other fraud or abuse practices whether pursuant to Federal, state, or local law? Yes No c) Violations of Federal, state, or local law in connection with the provision of telecommunications services, equipment and/or products, and/or any other practices regulated by the Telecommunications Act of 1996 and/or by state public utility commissions? Yes No If yes to any of the above, describe in detail, including name(s) of Individuals and entities involved, date(s), and current status or final disposition of matter, including any terms of settlement. Provide any available supporting documentation. Section IV: Licensee Operations 15) Has the Licensee been operational over the course of the current or previous year? Yes No If yes, answer the following: a) Provide separately for each year its gross revenue; b) Provide separately for each year the Cost of Goods Sold (COGS); c) Provide the total amount of COGS allocated for telecommunications equipment and service types; and d) Describe the customer base of the Licensee (business, residential, carrier, enterprise, etc.). Is this expected to change, and if so, how?; and e) Describe, for all services provided to each category of customer (e.g., enterprise, residential, carrier, etc.): i) Total number of subscribers; ii) Total annual gross revenue for preceding fiscal year; and iii) Percentage of total gross revenue per category of customer for preceding fiscal year. iv) Is this expected to change, and if so, how? 16) List all expected and actual Federal, state, and local government customers, including pursuant to any classified contracts, and include a description of all services to be provided, or services that are currently being provided, to such customers. 17) Name each of the Licensee’s and Petitioner’s Corporate Officers, Senior Officers, and Directors, and for each provide the following: a) Explain the nature and extent of each Corporate Officer’s, Senior Officer’s or Director’s involvement in the Entity’s business; and b) Provide all countries of citizenship, date and place of birth, U.S. alien number and/or social security number (if applicable), passport identifying information (including number and country), all residence addresses, all business addresses, and all phone numbers. PII may be provided in Attachment G. 18) Identify the Senior officer or employee (who is a U.S. citizen residing in the United States with an active security clearance or who is eligible to obtain one) who will be the Licensee’s authorized law enforcement point of contact responsible for accepting and responding to requests or compulsory processes from U.S. law enforcement or other U.S. government agencies. a) Explain the Individual’s relationship to the Licensee and provide name, all countries of citizenship, date and place of birth, U.S. social security number, all passport identifying information (including number and country), all residence addresses, all business addresses, and all phone numbers. Also identify whether the Individual has an active U.S. Government security clearance. PII may be provided in Attachment G. 19) Identify whether, if required by law, regulation, or license condition, the Licensee will report the following to the appropriate law enforcement agencies, immediately upon discovery: a) Any act of compromise of a lawful interception of communications? Yes No b) Any unauthorized access to customer information and/or call-identifying information? Yes No c) Any artificially inflated or fraudulent call traffic detected on your network? Yes No d) Any felony (an offense carrying a maximum potential sentence of a term of imprisonment of more than a year) conviction, U.S. or foreign, of the Licensee, any company officers/directors, or any Individual/company with 5% or greater direct or indirect ownership interest in the Licensee? Yes No e) Any act of unlawful electronic surveillance that occurred on its premises or via electronic systems under its control? Yes No 20) Will the Licensee store and/or maintain any U.S. communications content, transactional data, call-associated data, billing records, or other subscriber information? Yes No If yes, answer the following: a) Describe the types of records that will be stored; b) Provide all addresses of locations where such records will be stored and/or remotely accessed/managed via electronic systems; c) If any storage location differs from the Licensee’s address, explain the general purpose of the location and its function within the Licensee’s business; d) If any of the records will be accessible from outside the United States, explain where, how, and who will have access to them; and e) Describe all physical/electronic security measures utilized for all locations/systems to protect the confidentiality of records. 21) Will any Non-U.S. Individual have access to one or more of the following: a) Physical facilities and/or equipment under the Licensee’s control? Yes No If yes, provide identity of person(s) and explain the type of access that will be provided. b) Customer records, including Customer Proprietary Network Information (CPNI), billing records, and/or Call Detail Records (CDRs)? Yes No If yes, provide identity of person(s) and explain the type of access and records that will be provided. c) Network control, monitoring, and/or auditing features? Yes No If yes, explain the type of access that will be provided, and how access will be logged and archived. d) Electronic interfaces that allow control and/or monitoring of the infrastructure under the Licensee’s control, including, but not limited to, access to actual communications content and data? Yes No If yes, provide identity of person(s) and explain the type of access and control that will be provided. For each Individual identified in response to these questions, provide the following information: name, countries of citizenship, date and place of birth, U.S. alien number and/or social security number (if applicable), passport identifying information (including number and country), all residence addresses, all business addresses, and all phone numbers. PII may be provided in Attachment G, a Supplement to the Standard Questions. 22) What access control/security policies (physical and cyber) are in place, or will be in place prior to commencing operations, for your network? If the policies exist and are available in writing, provide copies of these policies. 23) What encryption products/technologies have been installed on this network, or will be installed prior to commencing operations? 24) Does/will the Licensee have any screening and/or vetting procedures which will be applied to U.S. or non-U.S. persons who have access, remote or otherwise, to the Licensee’s communications network facilities, equipment, or data? Yes No If yes, explain all such procedures. 25) Identify whether, if required by law, regulation, or a license condition, the Licensee will inform the National Security Division (NSD) of the U.S. Department of Justice if, in the future, any record storage/access location is transferred and/or newly established outside of the United States. 26) Explain how the Licensee, in accordance with U.S. law, regulation, or a license condition, would make any and all records not stored in the United States electronically available in the United States within five (5) business days pursuant to a lawful request to the authorized law enforcement point of contact identified above if such a point of contact is maintained or intended to be maintained. 27) Describe all lawful intercept capabilities of the Licensee. Will they be changing, if so, how? 28) What, if any, outside capabilities via remote access will exist within the Licensee to control or monitor operations over the network (e.g., audit mechanisms, record access monitoring)? Will they be changing, if so, how? 30) Do/will any third-party vendors, associated companies, or Owners have remote access to the Licensee’s network, systems, or records to provide managed services? Yes No If yes, provide a detailed explanation. 31) Do/will any third parties have access, post-transaction, to the Licensee’s network, systems, or records for any other reason (e.g., sharing subscriber data for marketing purposes)? Yes No If yes, provide a detailed explanation. Section V: Licensee Services 32) List the types of common carrier wireless licenses (e.g. cellular, microwave) and/or common carrier earth station licenses held (or applied for) by the Relevant Parties including the geographic area of service for each type of license. 33) Provide a general summary of the nature of the Licensee’s current and planned services and operations, to include an explanation of the Licensee’s intended overall business model and its relationship with any sister and/or partner companies. Will they be changing, if so, how? 34) Why is the Petitioner seeking foreign investment/ownership? 35) Provide all addresses of the present and anticipated physical locations for all of the Licensee’s network equipment, data centers, and infrastructure (e.g. towers, earth stations). Will they be changing, if so, how? Advise whether these locations are owned or leased – if leased, provide details of the owner(s) and a list of goods/services the owner(s) provides – and the make and model of the principal equipment used, including, but not be limited to, the portions of the network covered below: a) Describe the carrier transport facilities (e.g., T1, DS3, Optical Carrier) that will enable customer data flow into and out of owned and/or leased equipment. b) Will the Licensee be operating any physical and/or virtual telecommunications switching platforms (e.g., TDM and/or VoIP switches)? Yes No If yes, provide a network architecture diagram that shows all switches and connection points. c) Provide a description of any other intended network equipment and/or proposed infrastructure (e.g., routers, media gateways, multiplexing/cross-connect facilities, signaling devices, data centers, other equipment). d) Does the Licensee have a network topology map that shows its Points of Presence (POPs), Network Operation Centers (NOC), towers, and other network elements? Yes No If yes, attach to your response. e) Is the Licensee or its affiliates able to control operations at any POP and/or Network Operations Center (NOC) from any overseas locations? Yes No If yes, what is the nature of the foreign-based control? Where is it? Who has it? How? Will it be changing, if so, how? 36) Will the Licensee use interconnecting carriers and/or peering relationships? Yes No If yes, provide details and list the carriers. 37) Will the Licensee rely on underlying carrier(s) to furnish services to its customers and/or resell any services? Yes No If yes, provide details and list whose services and what services will be resold. 38) In what manner will services be delivered to customers? 39) Does/will the Licensee serve any sectors of U.S. critical infrastructure? Yes No If yes, check all that apply: a. Defense Industrial Base b. U.S. Intelligence Community c. Emergency Services (i.e., Federal, state, local law enforcement, fire, police) d. Government Facilities (i.e., Federal, state, local entities) e. Banking and Finance f. Nuclear Reactors, Materials, or Waste g. Drinking Water and Water Supply h. Energy i. Information Technology j. Chemical k. Commercial Facilities l. Agriculture and Food Supply m. Health Care n. National Monuments o. Transportation p. Postal Shipping q. Dams r. Other (explain in detail) Will this be changing, if so, how? Section VI: Licensee Services Portfolio Checklist and Reference Questions Instructions: Check all applicable boxes that reflect the types of telecommunication services the Licensee intends to provide in the United States only. Do not select any services that will be provided outside the United States. For each checked box: (1) provide a separate and full explanation at the end of this questionnaire and (2) answer the Reference Questions below the table regarding the services you have indicated in the checklist. PROPOSED LICENSEE SERVICES VoIP (Voice over Internet Protocol) POTS (Plain Old Telephone Service) TDM (Time Division Multiplexing) Voicemail PBX (Private Branch Exchange) Centrex (Hosted/Managed PBX) Callback Service Calling Card Dial Tone Service Issue DID (Direct Inward Dial) Local Telephone Numbers Local Exchange Service Local Toll Service Domestic/International Long Distance (Interexchange Service) Tollfree Service IVR (Interactive Voice Response) Conference Calling Operator Service Directory Assistance Dial Around Service (1010XXX Casual Calling) Switched Access Special Access (Dedicated Line) Mobile Top Up/Reload Services Mobile Network Operator Services (MNO) Mobile Virtual Network Operator Services (MVNO) Automatic Call Distribution (ACD) Other Data/Private Line ISP (Internet Service Provider) VPN (Virtual Private Network) Web Hosting LAN (Local Area Network) WAN (Wide Area Network) ISDN (Integrated Services Digital Network) BRI (Basic Rate Interface) ISDN PRI (Primary Rate Interface) DSL (Digital Subscriber Line) Frame Relay Email International Voice/Data Service Wireless/Mobile Voice/Data Services Satellite Services RF (Radio Frequency), Microwave Video Cloud Services Other Routing, Signaling Services Transport Facilities Leased Lines Collocation Services Other Reference Questions: Instructions: Answer each question below as it relates to each of the services selected in the above table. a) In what manner will the service(s) be delivered to your customers? b) What kind of network infrastructure will be utilized to deliver the service(s)? c) What equipment (manufacturer, make, and model) and software version will be utilized to provide the service(s)? Will the software be regularly updated? d) Will the service(s) be facilities based, resold, or both? Provide description. e) Are you planning to implement and deploy 5G? If so, describe the plans, approach, anticipated services, and the intended vendors. WARNING If the Petitioner or Licensee knowingly and willfully (1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; (2) makes any materially false, fictitious, or fraudulent statement or representation; or (3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, the Petitioner or Licensee may be subject to prosecution under Title 18, United States Code, Section 1001. The FCC may also terminate, revoke, or render null and void any license or authorization granted in this matter if any responses provided are false or intentionally misleading. Licensee Certification Pursuant to Title 28, United States Code, Section 1746, I, an authorized representative of the Licensee, declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge. Executed this _________ day of _________, year of ________. Representative Name: _________________________ Representative Title: _________________________ Representative Signature: ____________________________________________ Petitioner Certification Pursuant to Title 28, United States Code, Section 1746, I, an authorized representative of the Petitioner, declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge. Executed this _________ day of _________, year of ________. Representative Name: _________________________ Representative Title: _________________________ Representative Signature: ____________________________________________