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LISTENERS PLEASE REPORT SIGNAL INTERFERENCE

When complete, COPY AND PASTE ONTO A WORD FILE, and email the attachment to us at 965Oldies@outlook.com or fax to 928-425-9393. You may also print it out and mail to 4501 Broadway, Miami Az 85539….attention Lucy Rodriguez.

FILL OUT THIS FORM AND SEND IT TO BACK TO KIKO-FM. PLEASE MAKE SURE TO COMPLETE EVERY BLANK, & SIGN.

I listen to KIKO-FM at 96.5 MHz Facility ID 11894 using an over-theair radio signal at least twice a month. My over-the-air reception of the KIKO-FM signal on 96.5 MHz is being interfered with by interfering signal (96.5, translator K243BN, facility ID 76329) another radio station signal bleeding over 96.5 MHz at the following location(s) or area(s): (please describe clearly and concisely) ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ Note: If the interference is received in a vehicle, please identify the road and location where the interference takes place-such as perhaps between exits or mile markers or in relationship to named cross streets or landmarks. Describe the programming interfering with KIKO-FM: ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ _ I wish to listen to KIKO-FM 96.5 at the above location over-the-air without being subject to the interference described in this statement. Other than listening to KIKO-FM at least twice a month, I am not connected with KIKO-FM. I have no legal, employment, financial, or familial affiliation or relationship with KIKO-FM. I understand that this statement may be filed with the Federal Communications Commission to protect the KIKO-FM signal and state under penalty of perjury that this statement is true and accurate. Signed:___________________________ Date:_____________________________ Print Full Name _________________ Address:__________________________ Phone number:_____________________ Check one of the following: ______I DO NOT WISH to be contacted by the radio station causing the interference to resolve the matter. ______I WISH to be contacted by the radio station causing the interference to resolve the matter.