Annual Compliance Certification

OMB Control Number: 0648-0174

Expiration Date: XX/XX/20XX

CUI//PRVCY/PROPIN//FEDCON

when filled in

Licensee Exempt from CUI Handling and Dissemination Restrictions

NOAA Private Remote Sensing License

Annual Compliance Certification

Pursuant to 15 C.F.R. § 960.14 and Part B of your National Oceanic and Atmospheric Administration (NOAA) remote-sensing license, your Annual Compliance Certification (ACC) is due annually by October 15th. This annual certification requires you to certify to the accuracy of each material fact in your license per the regulations, 15 C.F.R. § 960.14(a). A “material fact” is any fact in Parts C or D of your license, per the regulations, 15 C.F.R. § 960.4. It is your responsibility to carefully review all material facts in your license to ensure that each fact is still accurate.

If any material fact in the license is no longer accurate at the time the certification is due, you must provide all accurate material facts; explain the reason for any discrepancies between the terms in your license and the accurate material fact(s); and seek guidance from CRSRA on how to correct any errors, which may include requesting a license modification per the regulations, 15 C.F.R. § 960.14(b). Failing to comply with 15 C.F.R. § 960.14 and/or this license condition may result in enforcement actions, per the regulations, 15 C.F.R. § 960.16.

Privacy Act Statement

Authority: The collection of this information is authorized under 5 U.S.C. § 301, Departmental regulations, which authorizes the operations of an executive agency, including the creation, custodianship, maintenance and distribution of records; and the National and Commercial Space Programs Act of 2010, 51 U.S.C. § 60101, et seq. and regulations at 15 CFR Part 960.

Purpose: NOAA collects this information to verify the accuracy of the information provided in your license.

Routine Uses: NOAA will use this information to assess the accuracy of the information contained in the initial license. Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) to be shared among CRSRA staff for work-related purposes. Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act system of Records Notice Commerce/NOAA-11, Contact Information for Members of the Public Requesting or Providing Information Related to NOAA’s Mission.

Disclosure: Furnishing this information is mandatory. Failing to comply with 15 C.F.R. § 960.14 and/or this license condition may result in enforcement actions, per the regulations, 15 C.F.R. § 960.16.

Name: Date:

Company/Organization Name: System Name:

License Date (found on the last page of the license):

I certify that all the information in Part C: Description of Licensee is correct Yes

No

If no, provide details including all accurate material facts and the reason(s) for any discrepancies between the terms in your license and the accurate material fact(s). Please attach additional explanation(s) to this form if you need additional space.

I certify that all the information in Part D: Description of System is correct (including the information in the Ground Station Appendix)

Yes No

If no, provide details including all accurate material facts and the reason(s) for any discrepancies between the terms in your license and the accurate material fact(s). Please attach additional explanation(s) to this form if you need additional space.

Please send questions, concerns, and requests for guidance on correcting discrepancies in material facts to crsra@noaa.gov.

By the following signature, I certify under penalty of perjury that the foregoing is true and correct.

Name: ___________________________________

Title/Position: ____________________________

Signature: ________________________________

Executed on: ______________________________

PRA Burden Statement:

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0648-0174. Without this approval, we could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are mandatory pursuant to 15 C.F.R § 960. This information is necessary to verify that all facts in the license remain true Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to NOAA, 1401 Constitution Ave., NW Washington, D.C. 20230, Attn: CRSRA Director, Dr. Sarah Brothers, sarah.brothers@noaa.gov.

CUI//PRVCY/PROPIN//FEDCON

when filled in

Licensee Exempt from CUI Handling and Dissemination Restrictions

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