INTENTION TO PAY ICANN (Alternative Form)
(2004-2005 Fiscal Year)

It is our intention to pay ICANN the amount of US$____________ for ICANN’s role in providing global services to the Internet community.  This amount is our share of financial support required by ICANN for the fiscal year 1 July 2004 through 30 June 2005. It will be used in accordance with the Budget, posted at http://www.icann.org/financials/budget-fy04-05-06oct04.htm and adopted by the ICANN Board of Directors on 23 July 2004. 

We agree to pay this amount within _____ days of receipt of invoice from ICANN.

This payment will be made by the ccTLD registry listed below:

Registry Name: ___________________________________________

Two Letter Country Code:  ___________________________________

Name: __________________________________________________

Mailing Address: __________________________________________

________________________________________________________

________________________________________________________

Telephone: __________________       Fax: _______________________

E:mail address:  ____________________________________________

Signed: _______________________________  Date:  ______________

Title:    ________________________________