1 201 sA1-2 THIS FOR M IS EFFECTIVE FOR ACCOUNTING PERIODS BEGIN NING JANUARY r the correct form Short Form tf are fit for a contact the Licensin Divi si on fo Return to: STATEMENT OF ACGOUNT FOR COPYRIGHT OFFICE USE ONLY Library of Congress Copyright Oflice'LD AMOUNT for Seco ndary Transmissions DATE RECEIVED 101 lndependence Avenue SE Form) Washington, DC 20557-6400 by Cabte Sysfems $nort $ (202)707-8150

General instructions are at the For courier deliveries, 09/08/2020 ALLOCATION NUMBER see page ii of the general end of this form [pages (i)-(vii)]. instructions.

and fill in the year date.) A ACCOUNTING PERIOD GoVERED BY THIS STATEMENT: (Check one of the boxes . 1_December a, Accounting I January 1-June 30 .2Q?0 . . . !July Period (Yead U"ur)

INSTR UCTIONS: another corporation, give fullthe Give the full legal name of the owner of the cable system in line tf the owner IS a subsidiary of B corporate title of subsidthe iary, not that of the parent corporation. system Owner n line 2, list any other names under which the owner cond ucts the business of the cable period should submit tf there were different owners during the accounting period, only the owner on the /ast day of the accounting period. single statement of account royalty fee payment covering the entire accounting n ber assigned by the Licensing Division. 62643 tr Check here if this IS the system's first fit ing. tf not, enter the system's D um 1 LEGAL NAME OF OWNER OF CABLE SYSTEM: BULLOCH COUNTY RURAL TELEPHONE COOPER INC. 62643 2 BUSTNESS NAME(S) OF OWNER OF CABLE SYSTEM (IF DIFFERENT):

3 MAILING ADDRESS OF OWNER OF CABLE SYSTEM:

?9q9 N9BTTI9IqE qB!YE WEgT (Number, street, rural route, apartment, or suite number) STATESBORO, GA 30458 (iuv,.r*, it"i" }pj

unless these lnstructions: ln ne give any business or trade names used to identify the business and operation of the system the add rESS given tn S pace B. c names aieady appear n space B. ln rne 2, give the m ail ing address of the system, if different from System IDENTIFICATION OF CABLE SYSTEM: 1

MAILING ADDRESS OF CABLE SYSTEM: ;;'&;; ;;;";i,;;.,ii" 2 iil;;";:i;: ",i,6J,i' i;iry,i;;,'.4;,'.iol'''' unit" as defined lnstructions: List each separate community served by the cable system. A "community" is the same as a "community ,,a unincorporated in FCC rules: separate and distinct community or municipal entityJ,l.tygjF jtingorporated communities.within you list will serve as a form D areai ana includinj single, discrete unincorporated areas):' 47 C.F.R: S76.5(dd). The first community that all future filings. Area ot iy.t", identificition-hereafter known as ihe "first community." Please use it as the first community on parks be reported in paronthesos below the Served Note: Entities and properties such as hotels, apartments, condominiums, or mobil€ home should identified city. OR

First ) EBAgKLEI Community POBIAL

pll be used to identiry or trace an individual, such as name, address, and telephone form in order to process your statement o, account. is any personal inlormation that can a public record, which includes appearing in the otfice's public indexes and in numbers. By providing pll, you are agreeing to the routine use of it to establish and maintain pll that it may delay processing ol your statement of account and its placement in the search reports prepared for the public. The effect of not providint the requested is the filing, a determination that would be made by a court of law' completed record ot statements of account, and it may atfect theiegal sufficiency o,

Form SA'1-2c Rev 05/2O2O FORM SA1-2. PAGE 1b.

Name BULLOCH COUNTY RURAL TELEPHONE COOPERTIVE, INC 62643

unit" as defined lnstructions: List each separate community served by the cable system. A "community" is the same as a "community ,,a unincorporated in FCC rules: separate and distinct community or municipal entity {incluaing uniniorporated communities.within form D oiicrete unincorporated areas)." 47 C.F.R: S76.5(dd). The first community that you list will serve as a areas and including singte, Area of system identificltion hereafter known as ihe "first community." Pleaie use it as the flrst community on all future filings. parentheses below the Served Note: Entities and properti€s such as hotels, apartments, condominiums, or mobile home parks should be reported in identified city.

CITY OR TOWN STATE CITY OR TOWN STATE { First Community FORM SA1-2. PAGE 2

LEGAL NAN,4E OF OWNER OF CABLE SYSTEM: Name 62643 BULLOCH COUNTY RURAL TELE PHONE COOPERTIVE INC.

SECONDARY TRANSMISSION SERVICE: SUBSCRIBERS AND RATES service of the cable ln General: The intormation in space E should cover atl categories of secondary transmission E to subscribers. Give information system, that is, the retransmission of television and radio broadiasts by your system tne tatts you state must be those existing on the last Secondary about other services linctuoing pay cable) in space F, not here. nl the case may be)' Transmission iiy of the accounting perioO (June 30 or December 31, as for the number of subscribers to the cable system, broken Service: Number of Subscribers: Both blocks in space E call general, you can compute the number of subscribers in each Subscribers Oo*n Oy categories of secondary transmission service. ln (the number of persons or organizations charged separately and Rates oy c6unting rhe numbei of billings in that categori tor.""t"g"ry tfie seirice at the rate indicited-not the number of sets receiving service)' faricular of the charge and the Rate: Give the standard rate charged for each category of service. lnclude both the amount within a particular rate unit in which it is generally oiiieo. lriimple: "$2olmth")lsummarize any standard rate variations category, but do not include discounts allowed for advance payment' service that cable Block 1: ln the left-hand block in space E, the form lists the iategories of secondary transmission each listed category systems most commonlv provioe to their subscribers. Give the number of subscribers and rate for under different that applies to your system. Note: Where an individual or organization is receiving service that falls Example: a residential categories, that person oi"ntity.norld be counted as a subsciiber in each applicable category' "Service to the first subscriber who pays extra for iable service to additional sets would be included in the count under set," and would be counted once again under "service to additional set(s)." from those ilock 2: lf your cable iy"t", ha-s rate categories for secondary transmission service that are different together printeO in bloci< 1, (for exarnple, tiers of servicei that include one or more secondary transmissions), list them, is with the number of subscribers and rates, in the right-hand block. A two- or three-word description of the service sufficient.

BLOCK 1 BLOCK 2 NO. OF NO. OF RS OF BSCRI E

Residentia!: q79,q8. $34.95 1,?9p . . Service to first set .Elper9p.d. F.esis . . $19,99. . Service to additional set(s) .Pis.ilet.q?9rc ...... :19.e...... 132 . FM radio (if separate rate) lBq ... $:r199 . , $l{,99. Mote!, hotel .9trcwtiqp...... 11?. $l?,99. Commercial .qinsrg.x...... 19.6...... 1p?...... $q 9!. . Converter .Qtse...... Residential . Nonresidential

SERVICES OTHER THAN SECONDARY TRANSMTSSIONS: RATES F were ln General: Space F calls for rate (not subscriber) information with respect to all your cable system's services that service not covered in space E, that is, those services that are not offered in combination with any secondary transmission Services (1)services furnished for a single fee. There are two exceptions: you do not need to give rate information concerning Other Than of the at cost oi (2) services or facilities fuinished io nonsubscribers. Rate information should include both the amount Secondary unit in which it is usually billed. lf any rates are charged on a variable per-program basis, enter only the Transmissions: "n"rg" "PP""niine in the rate column' Rates letters Block 1: Give the standard rate charged by the cable system for each of the applicable services listed. Btock 2: List any services that youriablesystem furnished or offered during the accounting period that were not form a listed in block 1 and for which a separate charge was made or established. List these other services in the of brief (two- or three-word) description and include the rate for each. BLOCK 2 BLOCK 1

CATEGORY OF SERVICE RATE CATEGORY OF SERVICE RATE CATEGORY OF SERVICE RATE Gontinuing Seruices: Installation: Non-residentia! . Pay cable . Motel, hotel . Pay cable-add'l channel . Commercial . Fire protection . Pay cable . Burglar protection . Pay cable-add'l channel lnstallation: Residential . Fire protection . First set . Burglar protection . Additional set(s) Other Services: . FM radio (if separate rate) . Reconnect . Converter . Disconnect . Outlet relocation . Move to new address FORM SA1-2. PAGE 3. LEGAL NAME OF OWNER OF CABLE SYSTEM: Name 62643 BULLOCH CO UNTY RURAL TELEPHONE COOPERTIVE, INC.

PRTMARY TRANSMTTTERS: TELEVISION power television stations) i' Cenerat: ln space G, identify every television station (including translator stations and low part-time basis under G carried by your baule sysiem

1. CALL 2. B'CAST 3. ryPE 4. LOCATION OF STATION SIGN CHANNEL OF NUMBER STATION

WSAV 3 N Savannah

WJCL 4 N Savannah

WTGS q N Savannah

WVAN o E Savannah

WTOC 11 N Savannah

WGSA ''t 3 I Savannah FORM SA1-2. PAGE 4.

LEGAL NAME OF OWNER OF CABLE SYSTEM: Name 62643 BULLOCH COUNTY RURAL TELEPHONE COOPERTIVE INC

PRIMARY TRANSMITTERS: RADIO stations carried on an General: List every radio station carried on a separate and discrete basis and list those FM ln period' H basis whose sign"t. *"r" generally receivable by your cable system during the accounting "ff-O"nO signal is generally Primary Speciat !nstructions Concerning All-Band FM Carriage: Under Copyright Office regulations,.an FM (2) be expecfed, on Transmitters: if (1) it is carried by the System whenever il is Lceived at the system's headend; and it can r*Lir"oi" intervals' For Radio the basis of monitoring, to be received at the headend, with the system's FM antenna, during certain stated (iv) general instructions. detailed information aoout tne-tne copyright office regulations on this point, see page of the Cotumn 1: ldentify the call sign of each station carried. Column 2: State whether the station is AM or FM. and discrete Golumn 3: lf the radio station's signal was electronically processed by the cable system as a separate signal, indicate this by placing a check mark in the "S/D" column' in the case of Column 4: Give the statioi's location (the community to which the station is licensed by the FCC or, Mexican or Canadian stations, if any, the community with which the station is identified).

OF STATION CALL SIGN AM or FM S/D LOCATION OF STATION CALL SIGN AM or FM S/D LOCATION

I

- FORM SA1.2. PAGE 5. Name LEGAL NAME OF OWNER OF CABLE SYSTEM: 62643 BULLOCH COUNTY RURAL TELEPHONE COOP tNc.

SUBSTITUTE CARRIAGE: SPEGTAL STATEMENT AND PROGRAM LOG that your cable In General: ln space t, iaiinry-every nonnetwork television program, broadcast by a distant station, present and.former FCC rules, regula- iystem carried on a substltute basis iuring the accounting pei'ioO, under specific see page (v) of tions, or authorizations. roi a turtner expl-anation of the plogramming thai must be included in this log, Substitute the general instructions. Garriage: Special STATEMENT CONCERNING SUBSTITUTE CARRIAGE Statement and 1. SPECIAL program . During the accounting period, did your cable system carry, on a substitute basis, anY nonnetworkt_elevision Program Log No. broad"cast by a distan't station? [-J Yes lll you the program Note: lf your ans*"r. is "No," leave the rest of this page blank. If your answer is "Yes," must complete log in block 2.

2. LOG OF SUBSTITUTE PROGRAMS ln General: List each substitute program on a separate line. Use abbreviations wherever possible, if their meaning is clear. lf you need more space, please attach additional pages' Column 1: Give the title of'every nonnetwork televisibn-program ("substitute program") that, during the accounting station period, was broadcast by a distant itation and that your cabie system substituted forthe programming of another under certain FCC rules, regulations, or authorizations. See pige (v) of the general instructions for further information. or Do not use general categori'es like "movies" or "basketball." Liit specific program titles, for example, "l Love Lucy" "NBA Basketball: 76ers vs. Bulls." column 2: lf the program was broadcast live, enter "Yes.". othenvise, enter "No." Column 3: Give the call sign of the station broadcasting the substitute program. Column 4: Give the broadiast station's location (the community to which the station is licensed by the FCC or, in the case of Mexican or Canadian stations, if any, the community with which the station is identified). Column 5: Give the month and day when your system carried the substitute program' Use numerals, with the month first. Example: for May 7, give "5/7." Column 6: State the tiries when the substitute program was carried by your cable system. List the times accurately to the nearest five minutes. Example: a program canied by a system from 6:01 :15 p.m' to 6:28:30 p.m' should be stated as "6:00-6:30 p.m." Column 7: Enter the letter "R" if the listed program was substituted for programming that your system was required to delete under FCC rules and regulations in effect during the accounting period; enter the letter "P" if the listed program was substituted for programmin! tnat your system was permitted to delete under FCC rules and regulations in effect on October 19, 1976.

WHEN SUBSTITUTE SUBSTITUTE PHOGRAM CARRIAGE OCCURRED 7. REASON FOR DELETION 2. LIVE? 3. STATION'S 5. MONTH 6. TIMES 1. TITLE OF PROGRAM _ Yes orNo CALL SIGN 4. STATION'S LOCATION AND DAY FROI\4 TO FORM SAl-2. PAGE 6,

NAME OF OWNER OF CABLE SYSTEM: Name LEGAL BULLOCH COUNTY RURAL TELEPHONE COOPERTIVE, INC. 62643

K total of service Gross Receipts see

$ aoz,ogt.oo ' ' during the accounting Period' > lr,i,"r'it bi"ri intiptil IMPORTANT You must complete a statement in space P concerning gross receipts. "i

COPYRIGHT ROYALTY AND FILING FEES L tnstructons: To compute the royalty fee you owe: . Complete block 1, block 2, or block 3 Copyright . Use block 1 if the amount of gross receipts in space K is $137,100 or less Royalty Fee to . Use block 2 if the of lross receipts in space K is more than $137,100 but less than or equal $263,800 . Use block 3 if the amount"1nornt of lross receipts in space K is more than $263,800 but less than $527,600 See page (vi) of the general instructions for more information'

37 1 pay six-month lnstructions: As a cable system with gross receipts of $137,100 or less, the royalty fee that you must for this accounting period is $52.00 $ 00 Line 1. Royalty fee for accounting period $ Line 2. lnterest charge. Enter the amount from line 4, space Q, page 8 $t ,00 Line 3. Filing Fee. . . .

Line 4. TOTAL ROYALTY AND FILING FEES PAYABLE FOR ACCOUNTING PERIOD. Addlinesl,2and3 ..... $

BLOCK 2: GROSS RECEIPTS OF OR LESS more than 37 1 $263.800 1. Base amount under statutory formula $ 2. Enter amount of gross receipts from space K . . . . . $ 3. Subtract line 2 from line 1 . . . 4. Entertheamountof grossreceiptsfrom spaceK ...... $ $ 5. Enterthe amount from line 3 ...... $ 6. Subtract line 5 from line 4 . . $ 7. Multiply line 6 by .005 (enter figure here) $ 8. lnterest charge. Enter the amount from line 4, space Q' page 8 $ 20.00 9. Filing Fee '...

FOR ACCOUNTING PERIOD. 10. TOTAL ROYALTY AND FILING FEES PAYABLE $ Add lines 7, 8 and I ......

BLOCK 3: GROSS RECEIPTS OF MORE THAN less than $527 467,631.00 1. Enter the amount of gross receipts from space K .r.$ $ 263.800 2. Base amount under statutory formula $ $203,831.00 3. Subtract line2 from line 1 .'. "'.... $ $2,038.31 4. Multiply line 3 by.01... . . $$ 1 .319 5. Royalty due on the first $263,800 of gross receipts (under statutory formula) ' ' 1.67 page 6. lnterest Charge. Enter the amount from line 4, space Q, 8 . . . ' . $ $ 2o.oo 7.FilingFee.....

8. TOTAL ROYALTY AND FILING FEES PAYABLE FOR ACCOUNTING PERIOD. $ 3,378.98 Add lines 4, 5, 6 and 7 " " "

Seepageiof the lMpoRTANTyourremittancemustbeintheform of anelectronicpayment payableloRegisterof copyrights. general instructions for more information. FORM SAl-2. PAGE 7

LEGAL NAME OF OWNER OF CABLE SYSTEM: Name 62643 BULLOCH COU NTY RURAL TELEPHONE COOPERTIVE, INC

CHANNELS M stations you must give (1) the number of channels on which the cable system carried television broadcast lnstructions: period' its subscribers, and in,i system's total number of activated channels during the accounting Channels to tZl "inf" 1. Enter the total number of channels on which the cable system carried television broadcast stations. 6

2. Enler the total number of activated channels on which the cable system carried television broadcast stations and nonbroadcast services. ?97

INDIVIDUAL TO BE CONTACTED tF FURTHER INFORMATION IS NEEDED N (ldentify an individual we can contact about this statement of account') lndividual to

Teleohone . 9:t?-.QQ0:1 10Q Be Contacted ruame..QHRl9 J.qNES ' (tuea code) for Further lnformation Address ?9.qq ry9BIliSlA.E PBlyF.WF.qL (Numbe( street, rural route, apartment, or suite number) 9rAT.q9.q9B9, 94. 991Q9. (City, town, state, zip)

Email (optionarl 9J.gN F.q@P V!Lqq!-l $9lUTl9ry9 Fax (optional) . .91?:9.QQ.?99.Q

with Copyright Office regula- CERTIFICATION o'his statement of account must be certified and signed in accordance o tions, as explained in the general instructions') Certification . l, the undersigned, hereby certify that (Check one, but only one, of the boxes') ! (O*n", other than corporation or partnership) I am the owner of the cable system as identified in line 1 of space B; or fl (egent of owner other than corporation or partnership) I am the duly authorized agent of the owner of the - ir6f" system as identified in line i of space B, and that the owner is not a corporation or partnership; or entity identified as Q lOtticer or partner) I am an officer (if a corporation) or a partner (if a partnership) of the legal owner of the cable system in line 1 of space B' of fact con- . I have examined the statement of account and hereby declare under penalty of law that all statements in tained herein are true, complete, and correct to the best of my knowledge, information, and belief, and are made good faith. [See 18 U.S.C. sec.1001]

Handwritten signature

Typed or printed name:'l9.f l'{ .?, 99.oil'. JE

GENERAL MANAGER/CHIEF OPERATING OFFICER Title: ' ' criir,i oni.ii p".rti," iii r^ ti i''ii"ilnrpr "i "",:pl,i'1r1,'

oate: .9F.?I.E|4.PEB 9, ?g?9

(PIl) requested on this the Copyright Office to collect the personally identifying inJormation 1 1 1 7 of the United States Code authorizes Privacy Act Notice: Section 1 of title address, and telephone personal information that can be used to identify or trace an individual, such AS name, form tn order to process your statement of account. Pll is any public record, which includes appearing tn the Office's public indexes and you agreeing to the routine use oI to establish and maintain a numbers. By providing Pil, are account and its placement tn the providing the Pll requested rs that may delay processing of your statement of in search reports prepared for the public. The effect of not of the ling determination that would be made by coun oJ law completed record of statements of account, and it may affect the legal sufficiency FORM SA1-2. PAGE 8.

LEGAL NAME OF OWNER OF CABLE SYSTEM: Name 62643 BULLOCH COUNTY RURAL TELEPHONE COOPERTIVE, INC

SPECTAL STATEMENT CONCERNING GROSS RECEIPTS EXCLUSIONS 1 1 1 (dxl of the Copyright Act by adding the fol- P The Sateflite Home Viewer Act of 1 988 amended fitf e r i, section XA) lowing sentence: paid the cable system for the basic Special ,,ln determining the total number of subscribers and the gross amounts to shall.not include sub- Statement service of proviOing sec;nJary transmissions of primary br-oadcast transmitters, the system pursuant to section 119"' Goncerning scribers and amounts collected from subscribers receiving secondary transmissions Gross Receipts general instructions. Exclusions For more information on when to exclude these amounts, see the note on page (vi) of the for secondary transmissions During the accounting period, did the cable system exclude any amounts of gross receipts maOJby satellite carriers to satellite dish owners? nr.ro E VeS. Enter the total here and list the satellite carrier(s) below' $

Name

INTEREST ASSESSMENT payment underpayment' o you must complete this worksheet for those royalty payments submitted. as a result of a late or assessment, see page (vi) of the general instructions' !nterest For an explanation of interest Assessment 3,377.31 Line '1 . Enter the amount of late payment or underpayment $

2 %

$67.55 Line 2. Multiply line 1 by the interest rate* and enter the sum here 9.00 x days

$607.95 Line 3. Multiply line 2 by the number of days late and enter the sum here x.OO274

in space L (page 6) block 1, Line 4, Multiply line 3 by .00274-- and enter here and 1.67 line 2, or block 2, line 8, or block 3, line 6 . $ (interest charge)

please * To view the interest rate chart click on www.copyright.gov/ticensing/interest-rate.pdf . For furlher assistance contact the Licensing Division al (2o2) 7o7-8150 or [email protected].

.*This is the decimal equivalent of 1/365, which is the interest assessment for one day late. Office, please Note: lf you are filing this worksheet covering a statement of account already submitted to the Copyright given original filing' list below the owner] address, first communify served, lD number, and accounting period as in the

pll to identity or trace an individual, such as name, address, and telephone to process your statement of account. is any personal intormation that can be used form in order in the office's public indexes and pll, the routine use ot it to establish and maintain a public recori, which includes appearing numbers. By providing you are agreeing to placement in the pll is that it may delay processing of your statement of account and its in search reports prepared for the public. The effect of not providing the requested of the filing, a determination that would be made by a court of law completed record of statements oi account, and it may affect the le'gal sufficiency Fed 9t812020 Non Repetitive

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Fed Non Repetitive * required

Amount:* $3,378.98

CurrencY: USD Value Date:* OglOBt2O2O m Debit Account: 181248 - General Funds-003

Receiving Bank lD:" 021 030004 Receiving Bank Name:* TREAS NYC FUNDS TRANSFER DIVISION I Receiving Bank Address:

WASHINGTON DC

Beneficiary Bank lD: -J Beneficiary Bank Name: *l Beneficiary Bank Address:

Beneficiary Account:* 00007985

Beneficiary Name:* REGISTER OF COPYRIGHTS

Beneficiary Address:* 101 INDEPENDENCE AVE SE

WASHINGTON DC 20557-6400

"t Reference for Benefi ciary: oBt:

BBI

I

Requesting Party Account:- 181248 1t2 https://businessinternetbankin g.synovus.com/wcmfd/jsp/mainWeb'jsp RePetitive Fed 9t812020 Non

Requesting PartY Name:* BULLOCH COUNTY RURAL TELEPHONE COOF

Requesting PartY Address:- 2903 NORTHSIDE DR W

STATESBORO, GA 30458

Revision: 5.9

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2t2 https://businessinternetbanking synovus'com/wcmfd/jsp/mainWeb'jsp 9t8t2020 Wire Transaction List

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Fod ahd lntemational USD Wiros must bo released before 5:00 PM ET lor same day procossing.

o Wire *,:. Status": Applicatlon* Line lD Value Date...,, Batch No... Item Count Customer Account No.,r" Amount... Bene Nameo Host Ref. No. Payment Network Ref. No. Date/Time'" 181248 1322602 PRocEssED NEF 09t08t2020 g3,378.98 REGTSTEROFCOpyRTGHTS 2OO9O813O323H6OO 2O2OO9O8F1OCZ7OC000703 09/08/202013:03:42 O General Funds-003

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