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

FCC Form 399: Incentive Auction Relocation Reimbursement Fund System

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

(REFERENCE COPY - Not for submission)FCC Form 399: Incentive Auction Relocation Reimbursement Fund System

File Number:
0000028472
FRN:
0019509470
Facility ID:
30601
Repack Channel:
16 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
07/12/2017

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

NBC TELEMUNDO LICENSE LLC

Doing Business As: NBC TELEMUNDO LICENSE LLC

300 NEW JERSEY AVE, N.W.

SUITE 700

WASHINGTON, DC 20001

United States

+1 (202) 524-6401 MARGARET.TOBEY@NBCUNI.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

The Preparer is same as the reimbursement contact.

 

 

 

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. Yes
Briefly describe transition plan A broadband interim panel antenna will be installed to allow the current DTV antenna to be removed and replaced with one for the new channel. A new interim facility will maintain coverage while the main antenna is replaced and transmitter retuned.

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 Retune Existing
Use Primary (Main)
Description of Use  
Ownership Owned
Owner  
Site  
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer Rohde & Schwarz
Model NV-8610V
Year 2011
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 7.55 kw
Other Transmitter Type  

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed  
New Mask Filter Power 10 kw
Other Power  
New Exciter Is a new exciter needed? No
Exciter Type

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
Rigid Conduit and Wiring No
Size
Length
Other Electrical Service No
Description  
HVAC Service Does the replacement transmitter require HVAC Service? No
Type
Size
Other Size  
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size
Channel 14 Costs Is an RF Consulting Engineer needed?
Is a channel 14 Mask Filer needed?
Is additional field engineering time needed?
Number of Days  

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  
Change Type Purchase
Manufacturer
Model THU9-8
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 11.9 kw
Other Transmitter Type  
Justification for New Transmitter New Transmitter required to maintain coverage while work is done on main antenna and transmitter

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
Rigid Conduit and Wiring No
Size
Length
Other Electrical Service No
Description  
HVAC Service Does the replacement transmitter require HVAC Service? No
Type
Size
Other Size  
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size
Channel 14 Costs Is an RF Consulting Engineer needed?
Is a channel 14 Mask Filer needed?
Is additional field engineering time needed?
Number of Days  
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

Name Description

System Installation

Interim Transmitter Installation including cooling & electrical work

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? Yes
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 Full Power
Mounting Top-mount single
Antenna position in stack Not in Stack
Polarization Elliptical
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: 366.00 kW
Manufacturer
Model ATW25H5-HTCX-40S
Year 1985

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? 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 Full Power
Mounting Top-mount single
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 235.00 kW
Manufacturer
Model TFU-14ETT/VP-R 4C230
Year 2018
Justification for New Antenna New antenna is required because the current antenna is designed for our current channel (40)

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? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 6 1/8 inches
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? No

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Antenna Input Adapter

Input Adapter

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 Full Power
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 2
Number of Panels/Bays 5
Lower Limit 470.00 MHz
Upper Limit 698.00 MHz
Design power capacity in use 50.0 %
Other Antenna Type N/A
ERP: 300.00 kW
Manufacturer
Model TUA-C2-5/10H-1-S
Year 2018
Justification for New Antenna New interim antenna required to maintain coverage while main antenna is replaced

Interim Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 4 1/16 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? Yes
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 Utilize Existing
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 Andrew
Type Rigid
Diameter 6 1/8 inches
Segment Length 19 ½ '
Other Segment Length
Number of parallel runs 1
Length 260 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

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 Air
Diameter 3 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 475 feet per run
Justification for New Transmission Line New line required to feed new interim antenna

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 Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? Terrain Constrained
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 32° 14' 55.8" N-
Longitude (NAD83) 111° 06' 59.1" W-
Overall Structure Height 196.90 feet
Support Structure Height 159.10 feet
Ground Elevation Above Mean Sea Level (AMSL) 4375.00 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner American Tower, LLC
Date Constructed 01/26/1998

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID Call Sign Service
36022 KZLZ FM

Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower Terrain constrained
Helicopter Services Required Are helicopter services required? Yes

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Tower Permit Drawling Package

Ground & Building A&E Permit Drawing Package (Cost per customer)

Auxiliary Tower

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Add Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Auxiliary (Backup)
Description of Use Used during transition to maintain coverage
Ownership Leased
Is this tower consider Complex? Terrain Constrained
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1218276
Coordinates (NAD83) Latitude (NAD83) 32° 14' 57.0" N-
Longitude (NAD83) 111° 07' 00.9" W-
Overall Structure Height 210.96 feet
Support Structure Height 152.89 feet
Ground Elevation Above Mean Sea Level (AMSL) 4351.98 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner American Towers, LLC.
Date Constructed 01/26/1998

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID Call Sign Service
56053 KHYT FM
36022 KZLZ FM

Auxiliary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Auxiliary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower Terrain constrained
Helicopter Services Required Are helicopter services required? No

Auxiliary Tower

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Other Tower Expenses Not Listed

Name Description

Tower Permit Drawing Package

Ground & Building A&E Permit Drawing Package (Cost per customer)

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 1040
Explanation Project oversight of transmitter install, electrical connectivity, tower work, and antenna installation. Additional time will be spent tracking financial and legal process and coordinating with other broadcasters.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development No
Prepare engineering section of Form FCC Construction Permit Application No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare engineering section of Form FCC License to Cover Application No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare request for Special Temporary Authority No
Quantity N/A
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 Yes
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
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 No
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 Yes
Additional Field Engineering Service Yes
Number of Days 30
Justification Ground Level RF design for primary and interim systems

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 Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
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

Information not provided.

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 $839,849.71 $503,173.20 N/A $0.00 N/A
Total for all systems $2,904,768.67 $1,751,895.56 N/A $0.00 N/A
Interim Transmitter THU9-8 $729,359.71 $450,763.31 $0.00
UHF inside RF system including switching $143,500.00 $24,103.60 6,962.00 switching N/A N/A
System Installation $104,359.71 $104,359.71 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW $481,500.00 $322,300.00 N/A N/A N/A
Primary Transmitter NV-8610V $110,490.00 $52,409.89 $0.00
10 kW mask filter $8,090.00 $0.00 included in transmitter install N/A N/A
UHF and VHF - minor banding issues $102,400.00 $52,409.89 N/A 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 $435,822.50 $321,037.50 N/A $0.00 N/A
Total for all systems $2,904,768.67 $1,751,895.56 N/A $0.00 N/A
Interim Antenna TUA-C2-5/10H-1-S $141,422.50 $133,062.50 $0.00
Sweep test of existing antenna $6,550.00 $4,500.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed) $9,320.00 $9,255.00 see attached quote for actual cost N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $22,550.00 $16,425.00 N/A N/A N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,120.00 $5,000.00 N/A N/A N/A
UHF – Broadband Panel, Side Mount Auxiliary/Interim, 300 horizontally polarized $97,882.50 $97,882.50 Required to maintain service to current audience during transition between removal of existing main and completion of channel change. N/A N/A
Primary Antenna TFU-14ETT/VP-R 4C230 $294,400.00 $187,975.00 $0.00
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,000.00 $10,297.50 N/A N/A N/A
Antenna Input Adapter $900.00 $900.00 see attached proposal N/A N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $281,500.00 $176,777.50 Cost above reflects Antenna cost and line sweep from attached antenna proposal 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 $27,075.00 $26,600.00 N/A $0.00 N/A
Total for all systems $2,904,768.67 $1,751,895.56 N/A $0.00 N/A
Interim Transmission Line $27,075.00 $26,600.00 $0.00
Flexible Air Transmission Line - dielectric, 3" $27,075.00 $26,600.00 N/A N/A N/A
Primary Transmission Line $0.00 $0.00 $0.00

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 $1,186,600.00 $533,081.40 N/A $0.00 N/A
Total for all systems $2,904,768.67 $1,751,895.56 N/A $0.00 N/A
Primary Tower GTOWER $593,300.00 $322,915.60 $0.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $25,600.00 $10,300.00 N/A N/A N/A
Minor tower reinforcement/modifications $153,500.00 $26,500.00 N/A N/A N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $409,500.00 $281,415.60 New Main antenna install including helicopter N/A N/A
Tower Helicopter Lift $0.00 $0.00 included in above install cost N/A N/A
Tower Permit Drawling Package $4,700.00 $4,700.00 N/A N/A N/A
Auxiliary Tower GTOWER $593,300.00 $210,165.80 $0.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $25,600.00 $8,173.00 N/A N/A N/A
Minor tower reinforcement/modifications $153,500.00 $20,000.00 N/A N/A N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $409,500.00 $177,292.80 Interim Antenna Install, old line removal, new line install N/A N/A
Tower Permit Drawing Package $4,700.00 $4,700.00 N/A 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 $309,205.00 $262,050.00 N/A $0.00 N/A
Total for all systems $2,904,768.67 $1,751,895.56 N/A $0.00 N/A
Outside Professional Services $309,205.00 $262,050.00 $0.00
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A N/A N/A
Project management of the transition $160,160.00 $156,000.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,560.00 $2,500.00 N/A N/A N/A
Attorney Fees - Aux Antenna, prepare and File Form 2100 Construction Permit or License Application $4,100.00 $4,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,305.00 $2,050.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $81,900.00 $40,000.00 N/A N/A N/A
RF Exposure Measurements $20,500.00 $20,000.00 N/A N/A N/A
Additional Field Engineering Service, 30 Days $30,000.00 $30,000.00 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 $106,216.46 $105,953.46 N/A $0.00 N/A
Total for all systems $2,904,768.67 $1,751,895.56 N/A $0.00 N/A
Other Expenses $106,216.46 $105,953.46 $0.00
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $333.00 $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 $4,700.00 $4,700.00 N/A N/A N/A
Non-zoning permits $4,700.00 $4,700.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $38,038.46 $38,038.46 removal of old transmitter N/A N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $20,000.00 $20,000.00 N/A N/A N/A
Equipment Storage $5,000.00 $5,000.00 N/A N/A N/A
MVPD Notification of Channel Change $12,000.00 $12,000.00 N/A 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 $2,904,768.67 $1,751,895.56 $0.00

Construction Status

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Question Response
Is construction complete? 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.

Margaret L. Tobey

Assistant Secretary


07/12/2017

Attachments

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