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:
70416
Service:
DCA
Call Sign:
WBXI-CD
Channel:
36 (UHF)
File Number:
0000028443
FRN:
0004498853
Date Submitted:
07/12/2017

Applicant Information

Back to Top

Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

CBS OPERATIONS INC.

Doing Business As: CBS OPERATIONS INC.

EDWIN NASS

1725 DESALES ST NW

SUITE 501

WASHINGTON, DC 20036

United States

+1 (202) 457-4505 elnass@cbs.com Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

Back to Top

Preparer Contact Name and Information

Applicant Address Phone Email

Edwin L Nass , Nass .

Director of Spectrum Management

CBS

Edwin L Nass

1725 DeSales Street NW

Suite 501

Washington, DC 20036

United States

+1 (202) 457-4602 elnass@cbs.com

Broadcaster Information and Transition Plan

Back to Top
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 See attached statement.

Transmitters

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

Primary Transmitter

Back to Top

Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Retune Existing
Use Primary (Main)
Ownership Owned
Owner 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 GatesAir
Model UAXT-1
Year 2015
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 0.9 kW

Primary Transmitter

Back to Top

Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed N/A
New Mask Filter
Power Other
Other Power 0 kW
New Exciter Is a new exciter needed? No

Primary Transmitter

Back to Top

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

Primary Transmitter

Back to Top

Other Transmitter Cost Not Listed

Name Description

Re-tune transmitter and mask filter

Re-tune transmitter and mask filter by manufacturer.

Interim Transmitter

Back to Top

New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use N/A
Change Type Purchase
Manufacturer
Model UAXTE-4R37
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2 kW
Justification for New Transmitter Required to allow the station to remain on the air during the re-tuning of its main transmitter and replacement of its antenna.

Interim Transmitter

Back to Top

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 Yes
Size 2 inches
Length 100.0 feet
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

Back to Top

Other Transmitter Cost Not Listed

Information not provided.

Antennas

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

Primary Antenna

Back to Top

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? No
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: 7.8 kW
Manufacturer
Model B8UA
Year 2000

Primary Antenna

Back to Top

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? No
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? No
New Antenna Manufacturer and Types 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/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 7.8 kW
Manufacturer
Model TLP-8M
Year 2018
Justification for New Antenna Present antenna cannot be re-tuned. See Attachment 3

Primary Antenna

Back to Top

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? 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

Back to Top

Other Antenna Cost Not Listed

Information not provided.

Interim Antenna

Back to Top

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? No
New 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/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 7.0 kW
Manufacturer
Model TLP-8M
Year 2018
Justification for New Antenna Interim antenna required during transition to allow station to remain on the air during channel change. See Attachment 3

Interim Antenna

Back to Top

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

Back to Top

Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Primary Transmission Line

Back to Top

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 Flexible Foam
Diameter 7/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 180 feet per run

Primary Transmission Line

Back to Top

Other Transmission Line Expenses Not Listed

Information not provided.

Interim Transmission Line

Back to Top

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 1000 feet per run
Justification for New Transmission Line New interim site. No existing line.

Interim Transmission Line

Back to Top

Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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

Primary Tower

Back to Top

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? Located on Building
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? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 39° 46' 11.1" N-
Longitude (NAD83) 086° 09' 25.9" W-
Overall Structure Height 830.00 feet
Support Structure Height 630.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 717.00 feet
Structure Type BANT - Building with an Antenna
Tower Owner Hertz Investment Group
Date Constructed 01/01/1990

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
59590 WFBQ FM
59589 WOLT FM

Primary Tower

Back to Top

Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: No study needed
Tower Reinforcements Please select whether tower reinforcements are needed: No reinforcements needed

Primary Tower

Back to Top

Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower Located on Building
Helicopter Services Required Are helicopter services required? No

Primary Tower

Back to Top

Other Tower Expenses Not Listed

Information not provided.

Auxiliary Tower

Back to Top

Add Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Auxiliary (Backup)
Description of Use Interim Antenna
Ownership Leased
Is this tower consider Complex? Candelabra
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? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1253064
Coordinates (NAD83) Latitude (NAD83) 39° 53' 39.2" N-
Longitude (NAD83) 086° 12' 20.5" W-
Overall Structure Height 1009.83 feet
Support Structure Height 849.73 feet
Ground Elevation Above Mean Sea Level (AMSL) 829.06 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner American Tower, LLC
Date Constructed 07/24/2006

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
37102 WHMB-TV DTV
69115 WICR FM
7908 WDTI DTV

Auxiliary Tower

Back to Top

Tower Modification Costs

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

Auxiliary Tower

Back to Top

Tower Rigging Costs

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

Auxiliary Tower

Back to Top

Other Tower Expenses Not Listed

Name Description

Permits

Preparation and submission of forms for electrical, building and other permits. See Attachment 4.

Tower Rent

Tower rent for duration of repack period. See Attachment 4.

Site Coordination Meeting

Site coordination meetings with tower owner, broadcasters, and vendors. See Attachment 4.

Tower Project Management

Construction project management for tower work. Please see Attachment 4.

Tower Permit Packages

Tower, ground, and building construction drawing package required for local permits. Please see Attachment 4

Outside Professional Services Costs

Back to Top
Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 100
Explanation Staff not available.
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 No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare and file 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
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 No
Address transition timing and coordination issues w/ other stations and wireless providers No
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements Yes
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

Outside Professional Services Costs

Back to Top

Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

Back to Top
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 No
Non-zoning permits No
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? No
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? No
Does this relocation require MVPD Notification of a Channel Change? No

Other Expenses

Back to Top

Other Expenses Not Listed

Name Description

Studio Transmitter Link

Data and programming terminal equipment required to convey digitized television programming to interim site.

Cost Information

Back to Top

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 $393,221.52 $304,297.29 N/A $0.00 N/A
Total for all systems $1,698,316.52 $985,129.29 N/A $0.00 N/A
Interim Transmitter UAXTE-4R37 $276,100.00 $281,234.17 $0.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $138,734.17 See Attachment 2. Note that WBXI-CD is licensed for 7.8 kW and the interim site will operate during pre-transition. N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $2,600.00 $2,500.00 N/A N/A N/A
UHF inside RF system including switching $147,500.00 $140,000.00 N/A N/A N/A
Primary Transmitter UAXT-1 $117,121.52 $23,063.12 $0.00
UHF and VHF - minor banding issues $105,200.00 $11,141.60 See Attachment 1. N/A N/A
Other 0 kW mask filter $0.00 $0.00 Existing mask filter can be retuned. N/A N/A
Re-tune transmitter and mask filter $11,921.52 $11,921.52 See Attachment 1 N/A N/A

Components

Information not provided.

Cost Information

Back to Top

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 $66,060.00 $62,800.00 N/A $0.00 N/A
Total for all systems $1,698,316.52 $985,129.29 N/A $0.00 N/A
Interim Antenna TLP-8M $33,030.00 $31,400.00 $0.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $25,000.00 Widelity Cost Catalog Estimate N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
Primary Antenna TLP-8M $33,030.00 $31,400.00 $0.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $25,000.00 Widelity Cost Catalog Estimate N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A

Components

Information not provided.

Cost Information

Back to Top

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 $59,000.00 $56,000.00 N/A $0.00 N/A
Total for all systems $1,698,316.52 $985,129.29 N/A $0.00 N/A
Interim Transmission Line $59,000.00 $56,000.00 $0.00
Flexible Air Transmission Line - dielectric, 3" $59,000.00 $56,000.00 N/A N/A N/A
Primary Transmission Line $0.00 $0.00 $0.00

Components

Information not provided.

Cost Information

Back to Top

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 $1,092,750.00 $497,517.00 N/A $0.00 N/A
Total for all systems $1,698,316.52 $985,129.29 N/A $0.00 N/A
Primary Tower BANT $421,000.00 $200,000.00 $0.00
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $421,000.00 $200,000.00 50% of Widelity Cost Catalog Estimate N/A N/A
Auxiliary Tower GTOWER $671,750.00 $297,517.00 $0.00
Tower Project Management $2,500.00 $2,500.00 Construction project management. See Attachment 4. N/A N/A
Tower Permit Packages $9,400.00 $9,400.00 Construction drawings for tower, building, and ground required for local permits. See Attachment 4. N/A N/A
Permits $750.00 $750.00 Prepare and submit forms for electrical, building and other permits necessary for local approvals. See Attachment 4. N/A N/A
Tower Rent $57,600.00 $57,600.00 Required for operation on interim tower. See Attachment 4. N/A N/A
Site Coordination Meeting $2,500.00 $2,500.00 Site coordination meeting with tower owner, other broadcasters, contractors, and vendors at interim tower site. See Attachment 4. N/A N/A
Structural engineering tower load study for a documented tower with candelabra $20,000.00 $14,767.00 Tower mapping and structural engineering for a tower with a candelabra. N/A N/A
Minor tower reinforcement/modifications $158,000.00 $10,000.00 It is expected that additional loads imposed on the tower by the new repack antennas will cause the tower to fail. The structural failure is expected to be in the minor category. See Attachment 4. N/A N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $421,000.00 $200,000.00 50% of Widelity Cost Catalog Estimate. N/A N/A

Components

Information not provided.

Cost Information

Back to Top

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 $55,205.00 $42,000.00 N/A $0.00 N/A
Total for all systems $1,698,316.52 $985,129.29 N/A $0.00 N/A
Outside Professional Services $55,205.00 $42,000.00 $0.00
Project management of the transition $15,800.00 $15,000.00 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 - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 N/A N/A N/A
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
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
RF Exposure Measurements $21,050.00 $10,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

Back to Top

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 $32,080.00 $22,515.00 N/A $0.00 N/A
Total for all systems $1,698,316.52 $985,129.29 N/A $0.00 N/A
Other Expenses $32,080.00 $22,515.00 $0.00
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $5,000.00 $5,000.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 N/A N/A N/A
Studio Transmitter Link $10,000.00 $10,000.00 Data and programming terminal equipment. Required to convey digitized television programming to interim site. N/A N/A
DTV Medical Facility Notification $11,550.00 $2,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

Back to Top

Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,698,316.52 $985,129.29 $0.00

Reimbursement Status

Back to Top
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

Back to Top
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.

Andrew J. Siegel

Assistant Secretary


07/12/2017

Attachments

Back to Top