Go to the Federal Communications Commission homepage at www.fcc.gov

FCC Form 399: Reimbursement Request

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

(REFERENCE COPY - Not for submission) FCC Form 399: Reimbursement Request

Facility ID:
168154
Service:
DCA
Call Sign:
KFDF-CD
Channel:
25 (UHF)
File Number:
0000025227
FRN:
0021646880
Date Submitted:
06/26/2017

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

KMYA, LLC

Doing Business As: KTV Media

Larry Morton

PO Box 23808

LITTLE ROCK, AR 72221

United States

+1 (501) 353-2227 EQUITYLEM@GMAIL.COM Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Lindsey McGough

Lori E. Withrow, P.L.L.C

Lindsey McGough

12410 Cantrell Rd.

LIttle Rock, AR 72223

United States

+1 (501) 227-2000 lmcgough@allenwithrow.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan We will be replacing the existing antenna and transmitter to move from Channel 44 to Channel 25. See attached KFDF-CD Project Description.

Transmitters

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Section Question Response
Transmitter Related Expenses Do you have transmitter related expenses? Yes

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model UAX
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 2 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model TRN-5X-U-26D-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.6 kW
Justification for New Transmitter The old transmitter is difficult to re-tune and modify the filters and the cost would be more than a new transmitter. See attached project description.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service Yes
Description MInor electrical wiring in the transmitter building.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size Other
Other Size 1 tons
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use N/A
Change Type Lease New
Manufacturer
Model TRN-5X-4D-U-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity .5 kW
Justification for New Transmitter To keep station operational during construction. See attached project description.

Interim Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A
Inside RF System Is an additional interior RF system required to support this interim transmitter? Yes

Interim Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? Yes
Existing Antenna Manufacturer and Type Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 4.0 kW
Manufacturer
Model SWR-SWLP-08OI
Year 2010

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Ownership Owned
Owner N/A
Is antenna shared? Yes
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Slot
Number of Stations Supported 4
Number of Panels/Bays 16
Lower Limit 536.00 MHz
Upper Limit 542.00 MHz
Design power capacity in use 25.0 %
Other Antenna Type N/A
ERP: 4.0 kW
Manufacturer
Model JA/MS-16/20-35 SHO
Year 2017
Justification for New Antenna Current tower is overloaded and we are planning to put up a broadband antenna and share antenna space with at least one other station. Subject to FCC Channel approval KXUN may share space with us. See attached project description.

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? Yes
Type New
Number of channels supported 2
Frequencies of channels supported Upper and lower frequency
Frequency 512.0 MHz - 602.0 MHz
Do you need a combiner output splitter/switcher for dual feed lines? No
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Broadband or Single Channel? N/A
Feed Line Size N/A
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Interim Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Interim
Description of Use N/A
Change Type Purchase New
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Type Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 2
Lower Limit 470.00 MHz
Upper Limit 862.00 MHz
Design power capacity in use 50.0 %
Other Antenna Type N/A
ERP: 1.0 kW
Manufacturer
Model K723147 Array
Year 2017
Justification for New Antenna Required to continue operations during construction. See attached project description.

Interim Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Broadband or Single Channel? N/A
Feed Line Size N/A
Side Mount Brackets Do you require the separate purchase of side mount brackets for an antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Interim Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? Yes

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Foam
Diameter 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 250 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Type Flexible Air
Diameter Other
Other Diameter 2 1/4 inches
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 250 feet per run
Justification for New Transmission Line Upgraded line is required to handle the broadband antenna that is being installed. See attached project description.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Dehydrator and connectors

Dehydrator to keep moisture out of the line and connectors for the antenna.

Interim Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Flexible Foam
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 250 feet per run
Justification for New Transmission Line Required to continue operations during construction. See attached project description.

Interim Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Move Equipment
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) No
Others Types of Users Yes
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1236377
Coordinates (NAD83) Latitude (NAD83) 35° 26' 51.3" N-
Longitude (NAD83) 094° 21' 54.8" W-
Overall Structure Height 312.99 feet
Support Structure Height 310.04 feet
Ground Elevation Above Mean Sea Level (AMSL) 810.03 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner InSite Towers Development
Date Constructed 10/31/2003


Other Types of Users

Users
KXUN-LD

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Rigging to hang antenna and line

Cost to hang the line and antenna and to dispose of the old antenna.

Tower mapping

To map the tower per owner's request.

Tower reinforcement

Owner's cost to reinforce the tower.

Interim Tower

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Tower Construction Costs

Section Question Response
Construct New Tower Use Interim
Description of Use N/A
Height 160.00 feet
Justification for New Tower Use an existing tower (ASR-1275837) for an interim site. See attached project description.

Interim Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Interim Tower

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Other Tower Expenses Not Listed

Name Description

Rigging to hang antenna and line

Cost to hang the interim antenna and line.

Tower Mapping

Tower/Foundation Mapping as required be Insite Towers

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 70
Explanation We do have an engineer on staff and must outsource the planning and construction of this rebuild.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 4
Justification To fully check out the transmitter and antenna. Two days for interim site and two days for primary site.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning Yes
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change Yes
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Name Description

Travel

Expenses in traveling to the site for supervision and monitoring.

Contingency

Allowance for missed items and cost changes occurring during the construction period.

Sales tax

Arkansas or other state sales taxes that are not included in the purchase price.

Cost Information

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Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $284,000.00 $66,670.00 N/A $0.00 N/A
Total for all systems N/A N/A
Interim Transmitter TRN-5X-4D-U-C $151,500.00 $7,000.00 $0.00
UHF inside RF system including switching $147,500.00 $3,000.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter .5 kW $4,000.00 $4,000.00 To lease a 500 watt transmitter during the construction period. N/A N/A
Primary Transmitter TRN-5X-U-26D-C $132,500.00 $59,670.00 $0.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $53,170.00 N/A N/A N/A
Other -- HVAC Service Type: C Size:1 (Other) $1,500.00 $1,500.00 To upgrade air-conditioning in the transmitter building for the new transmitter. N/A N/A
Other Electrical Service: MInor electrical wiring in the transmitter building. $5,000.00 $5,000.00 Structural and electrical wiring required for the transmitter to go inside the building (current transmitter is in a separate, free-standing container with its own air-conditioning). N/A N/A

Components

Information not provided.

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $146,480.00 $36,000.00 N/A $0.00 N/A
Total for all systems N/A N/A
Interim Antenna K723147 Array $35,550.00 $6,000.00 $0.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $5,000.00 Includes cost of panels and power dividers. N/A N/A
Sweep test of existing antenna $6,730.00 $1,000.00 N/A N/A N/A
UHF - Lower Power Side Mount, Class A broadband panel (cost per panel) $2,520.00 $0.00 N/A N/A N/A
UHF – Broadband Panel, Side Mount Auxiliary/Interim, 1 horizontally polarized $0.00 $0.00 N/A N/A N/A
Primary Antenna JA/MS-16/20-35 SHO $110,930.00 $30,000.00 $0.00
UHF - Lower Power, Side Mount, Class A, basic slot antenna, 16 bay,, 4 kW input, directional,, horizontally polarized $20,000.00 $20,000.00 Cost exceeds the basic cost for a Class A antenna due to the broadband nature of the antenna, as required by the tower operator. N/A N/A
Sweep test of existing antenna $6,730.00 $5,000.00 N/A N/A N/A
New combiner, cost per channel (without antenna) $84,200.00 $5,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $20,750.00 $19,250.00 N/A $0.00 N/A
Total for all systems N/A N/A
Interim Transmission Line $6,000.00 $4,500.00 $0.00
Flexible Foam Transmission Line - dielectric, 1 5/8" $6,000.00 $4,500.00 N/A N/A N/A
Primary Transmission Line $14,750.00 $14,750.00 $0.00
Flexible Air Transmission Line - dielectric, 2 1/4" $9,750.00 $9,750.00 N/A N/A N/A
Dehydrator and connectors $5,000.00 $5,000.00 Cost of the dehydrator and connectors is not included with the line. N/A N/A

Components

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $345,300.00 $177,300.00 N/A $0.00 N/A
Total for all systems N/A N/A
Interim Tower $110,200.00 $26,400.00 $0.00
Rigging to hang antenna and line $15,000.00 $15,000.00 Cost to hang the antenna and line. N/A N/A
New tower $0.00 $0.00 N/A N/A N/A
Short Tower (less than 500') $84,200.00 $400.00 Cost to lease space on the tower during construction period. N/A N/A
Tower Mapping $11,000.00 $11,000.00 Cost to map the tower and foundation per Insite Towers N/A N/A
Primary Tower TOWER $235,100.00 $150,900.00 $0.00
Short Tower (less than 500') $84,200.00 $0.00 N/A N/A N/A
Tower mapping $900.00 $900.00 Estimated cost to map the tower as required by owner. N/A N/A
Rigging to hang antenna and line $25,000.00 $25,000.00 Cost to hang antenna and line. N/A N/A
Tower reinforcement $125,000.00 $125,000.00 Maximum estimated amount of reinforcement required per the owner. N/A N/A

Components

Information not provided.

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $134,180.00 $61,750.00 N/A $0.00 N/A
Total for all systems N/A N/A
Outside Professional Services $134,180.00 $61,750.00 $0.00
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,000.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $20,000.00 N/A N/A N/A
Additional Field Engineering Service, 4 Days $4,000.00 $4,000.00 Four days of field work at the two sites to verify completion per the plans (2 people, one day at each site). N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $4,250.00 N/A N/A N/A
Project management of the transition $11,060.00 $7,000.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Other Expenses

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $65,375.00 $61,770.00 N/A $0.00 N/A
Total for all systems N/A N/A
Other Expenses $65,375.00 $61,770.00 $0.00
Sales tax $17,481.00 $17,481.00 Estimated Arkansas state sales taxes N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $2,000.00 $2,000.00 Cost to dispose of unusable equipment and supplies, if required. N/A N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 Cost to deliver equipment to the site, not included in equipment pricing. N/A N/A
Develop and air announcement of upcoming channel change $2,000.00 $2,000.00 Cost to develop announcement of upcoming channel change. N/A N/A
Travel $1,500.00 $1,500.00 Expenses of traveling to the site for supervision and monitoring. N/A N/A
Contingency $18,204.00 $18,204.00 Allowance for unscheduled items and cost changes occurring during construction period. N/A N/A
DTV Medical Facility Notification $11,550.00 $8,000.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
Local Zoning $2,000.00 $2,000.00 N/A N/A N/A
Equipment Storage $2,000.00 $2,000.00 Cost to hold equipment during construction. N/A N/A
MVPD Notification of Channel Change $2,000.00 $2,000.00 Cost to notify MVPD providers. N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
Construction of final facilities or all necessary modifications are complete. No
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator. No

Certification

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Section Question Response
Submission of Estimated Expenses Statements

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.

  1. The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  3. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  4. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).

  5. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  6. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.

  7. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  8. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Larry Morton

Manager


06/26/2017

Attachments

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