DEBTOR CERTIFICATE
The undersigned _____________, a ______________ (the “Debtor”), hereby represents, warrants and certifies with reference to the Deferred Payment Plan and Security Agreement dated as of __________ __, 200_ between the Debtor and the Federal Communications Commission (the “Commission”) (terms defined therein being used herein as therein defined), to the Commission as follows (for purposes of this Debtor Certificate, those questions for which no response is completed shall be deemed to read “None”): 1. Names.
(a) The exact legal name of the Debtor as it appears in its [certificate of incorporation] [certificate of formation], as amended to date, is as follows:
(b) The following is a list of all other names (including trade names or similar appellations) used by the Debtor, or any of its divisions or other business units, or any other business or organization to which the Debtor became the successor by merger, consolidation, acquisition, change in form, nature or jurisdiction of organization or otherwise, now or at any time during the past five years together with the dates such names were used:
(c) The following is a list of all subsidiaries of the Debtor (whether wholly owned, or where the Debtor has a controlling or majority interest):
(d)
The following is the type of organization of the Debtor:
(e)
The jurisdiction of organization of the Debtor is as follows:
(f)
The following is the Debtor’s state issued organizational identification number, if any:
(g)
The Debtor’s federal taxpayer identification number is:
(h)
The Debtor currently maintains its bank and investment accounts at: (1) (2) (3) (4) Bank Accounts Investment Accounts Payroll Accounts Other depository/operating accounts
(i)
The Debtor currently has the following commercial tort claims against other parties:
(j) Attached hereto as Schedule A is the information required above for any other business or organization to which the Debtor became the successor by merger, consolidation, acquisition, change in form, nature or jurisdiction of organization or otherwise, now or at any time during the past five (5) years:
2.
Current Locations. (a) The following is the mailing address of the Debtor: City State
Mailing Address
(b) If different from its mailing address, the Debtor’s place of business, or if more than one, its chief executive office is located at the following address: Mailing Address City State
(c) If different from the addresses set forth in subparagraphs (a) and (b) above, the following are all other locations in which the Debtor maintains any books or records relating to any of the Collateral consisting of accounts, instruments, chattel paper, general intangibles or mobile goods: Mailing Address City State
(d) If different from the addresses set forth in subparagraphs (a), (b) or (c) above, the following are all places of business of the Debtor and/or locations maintained by the Debtor where any Collateral consisting of equipment and/or inventory are located: Mailing Address City State
(e) The following are the names and addresses of all persons or entities other than the Debtor (such as lessees, bailees, consignees, warehousemen, or purchasers of chattel paper), which have possession or are intended to have possession of any of the Collateral consisting of instruments, chattel paper, inventory or equipment and the nature of such party’s possession (such as lessee, bailee, consignee, warehouseman, purchaser of chattel paper, or other): Mailing Address Nature of Possession
Name
City
State
2
Prior Locations. (a) Set forth below is the information required by subparagraphs (a), (b), (c) and 3. (d) of paragraph 2 with respect to each location or place of business previously maintained by the Debtor at any time during the past five (5) years in a state in which the Debtor has previously maintained a location or place of business: Mailing Address City State
(b) Set forth below is the information required by subparagraph (e) of paragraph 2 with respect to each other location at which, or other person or entity with which, any of the Collateral consisting of instruments, chattel paper, inventory or equipment has been previously held at any time during the past twelve months: Mailing Address Nature of Possession
Name
City
State
4. Litigation and Judgments. Schedule B attached hereto sets forth all litigation and other proceedings against the Debtor pending or threatened in all state and federal courts and all judgments against the Debtor that have not been paid or otherwise discharged in full.
Real Property. Schedule C attached hereto sets forth all Real Property in which Debtor or any of 5. Debtor’s subsidiaries hold an interest. For each entry, please identify each and every mortgage, lien, or other encumbrance associated with that entry.
The undersigned hereby acknowledges and agrees that the Commission is relying on the representations and warranties made herein in connection with financial arrangements to be entered into between the undersigned and the Commission.
Executed under seal as of ___________ __, 2004. [DEBTOR]
By: Name: Title:
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SCHEDULE A
If applicable, please provide information required by Section 1(j).
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SCHEDULE B I. Pending or Threatened Litigation.
Name of Case
Court
Recovery Sought
Description of Case
II.
Judgments.
Name of Case
Court
Amount of Judgment
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SCHEDULE C III. Real Property.
Name of Property and Location
Tax Assessed Value
Mortgage, Lien, or other Encumbrance
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TRA 1871199v1