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:
11033
Service:
DTV
Call Sign:
WLLA
Channel:
22 (UHF)
File Number:
0000027855
FRN:
0002940195
Date Submitted:
07/11/2017

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

CHRISTIAN FAITH BROADCAST, INC.

Doing Business As: CHRISTIAN FAITH BROADCAST, INC.

Mr. Clyde R. Yost

3809 MAPLE AVENUE

CASTALIA, OH 44824

United States

+1 (419) 684-5311 rustyy@cfbroadcast.net Corporation

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. No
Briefly describe transition plan Must remove existing antenna(s), transmitter, transmission line(s), install interim antenna, transmitter, transmission line - install new transmitter. Must add space to building for heat exchangers, pumps. Must reroute ductwork and install different AC.

Transmitters

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

Primary Transmitter

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Add 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? No
Existing Transmitter Manufacturer and Type Manufacturer
Model ULXTE-40
Year 2017
Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power Capacity 40 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? Yes
Manufacturer
Model ULXTE-40
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 40 kW
Justification for New Transmitter Gates will not re-tune existing - Gates is no longer building IOT transmitters

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) Yes
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring Yes
Size 2 inches
Length 200.0 feet
Other Electrical Service Yes
Description remove and relocate existing disconnects conduit and wiring
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 10 tons
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 320.0 square feet
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

Name Description

modify road

existing access road upgrade for large vehicles

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use N/A
Change Type Purchase
Manufacturer
Model UAXTE-24R44
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 14.4 kW
Justification for New Transmitter will need to use interim transmitter while removing old and installing new

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 Yes
Size 1 inches
Length 250.0 feet
Other Electrical Service Yes
Description Re-route and install new disconnects and conduit
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 10 tons
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 320.0 square feet
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

Name Description

modify road

existing access road renovation to accommodate access by large vehicles required for implementation of station modifications as provided in Repack CP

Antennas

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

Primary Antenna

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Add 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 this antenna currently shared with any other stations? No
Is this 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 Full Power
Mounting Top 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: 275.0 kW
Manufacturer
Model JA/MS-10 / 22
Year 2017

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? 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 Full Power
Mounting Top 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: 275.0 kW
Manufacturer
Model JA 24/22
Year 2017
Justification for New Antenna Existing antenna cannot be retuned.

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 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? 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? No
New Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Slot
Number of Stations Supported 1
Number of Panels/Bays 8
Lower Limit 500.00 MHz
Upper Limit 660.00 MHz
Design power capacity in use 70.0 %
Other Antenna Type N/A
ERP: 190.0 kW
Manufacturer
Model JSL Series
Year 2017
Justification for New Antenna Need interim antenna while removing old and installing new

Interim Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? B
Feed Line Size 4 1/16 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for an 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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Add 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 this transmission currently shared with any other stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1200 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? No
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1200 feet per run
Justification for New Transmission Line The existing line cannot be used on new frequency.

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 Rigid
Diameter 4 1/16 inches
Segment Length Broadband
Other Segment Length
Number of parallel runs 1
Length 1100 feet per run
Justification for New Transmission Line will need to operate with interim facility while removing old and installing new

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 Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1004741
Coordinates (NAD83) Latitude (NAD83) 42° 33' 52.1" N-
Longitude (NAD83) 085° 27' 31.0" W-
Overall Structure Height 1080.04 feet
Support Structure Height 1054.12 feet
Ground Elevation Above Mean Sea Level (AMSL) 872.04 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Christian Broadcasting Ministry
Date Constructed 05/21/2007


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: Major Reinforcements needed

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

tower rigging

may need to rig tower for interim equipment and re-rig for final install

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? No
Number of Hours N/A
Explanation N/A
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 Yes
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
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 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 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 No
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 Yes
RF exposure measurements Yes
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

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 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? 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

employee expense

must bring in employees from OH and overtime for onsite employees

lodging

OH employees lodging and meals

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 $2,483,900.00 $2,353,000.00 N/A $0.00 N/A
Total for all systems $4,390,595.00 $4,178,565.00 N/A $0.00 N/A
Interim Transmitter UAXTE-24R44 $840,400.00 $831,000.00 $0.00
Other -- Building Addition Size: 320.0 $0.00 $0.00 Price reflected under Primary transmitter cost N/A N/A
1" Rigid Conduit and Wiring $0.00 $0.00 Price reflected in Electric estimate under Interim transmitter cost N/A N/A
Other Electrical Service: Re-route and install new disconnects and conduit $47,000.00 $47,000.00 N/A N/A N/A
10 Ton system $38,900.00 $37,000.00 N/A N/A N/A
UHF inside RF system including switching $147,500.00 $140,000.00 N/A N/A N/A
modify road $57,000.00 $57,000.00 existing access road renovation to accommodate access by large vehicles required for implementation of station modifications as provided in Repack CP N/A N/A
UHF - Air Cooled Solid State Transmitter 14.4 kW $550,000.00 $550,000.00 N/A N/A N/A
Primary Transmitter ULXTE-40 $1,643,500.00 $1,522,000.00 $0.00
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,473,000.00 $1,400,000.00 N/A N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $5,200.00 $0.00 included in electric estimate under Interim transmitter cost N/A N/A
Other -- Building Addition Size: 320.0 $37,000.00 $37,000.00 additional space for pumps and heat exchangers etc covered area with ice protection and tied into existing structure N/A N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $13,700.00 N/A N/A N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A
Transformer 3 phase/480v - 300 KVA $36,800.00 $35,000.00 N/A N/A N/A
Other Electrical Service: remove and relocate existing disconnects conduit and wiring $0.00 $0.00 Included in electric estimate under Interim transmitter N/A N/A
10 Ton system $38,900.00 $0.00 Included under Interim transmitter N/A N/A
modify road $0.00 $0.00 include under interim transmitter costs 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 $401,520.00 $381,900.00 N/A $0.00 N/A
Total for all systems $4,390,595.00 $4,178,565.00 N/A $0.00 N/A
Interim Antenna JSL Series $135,490.00 $128,800.00 $0.00
Elbow complex, broadband, at antenna input, per 4 1/16. feedline (if needed) $10,950.00 $10,400.00 N/A N/A N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,260.00 $5,000.00 N/A N/A N/A
UHF - Lower Power Side Mount, One station antenna - medium power (50-200 kW), horizontally polarized $89,400.00 $85,000.00 N/A N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $22,000.00 N/A N/A N/A
Primary Antenna JA 24/22 $266,030.00 $253,100.00 $0.00
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,300.00 $11,700.00 N/A N/A N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized $247,000.00 $235,000.00 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 $421,700.00 $400,900.00 N/A $0.00 N/A
Total for all systems $4,390,595.00 $4,178,565.00 N/A $0.00 N/A
Interim Transmission Line $179,300.00 $170,500.00 $0.00
Rigid Transmission Line - copper, 4 1/16" broadband $179,300.00 $170,500.00 N/A N/A N/A
Primary Transmission Line $242,400.00 $230,400.00 $0.00
Rigid Transmission Line - copper, 6 1/8" $242,400.00 $230,400.00 N/A 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 $857,800.00 $825,000.00 N/A $0.00 N/A
Total for all systems $4,390,595.00 $4,178,565.00 N/A $0.00 N/A
Primary Tower TOWER $857,800.00 $825,000.00 $0.00
Tall Tower (greater than 500') $210,500.00 $200,000.00 N/A N/A N/A
tower rigging $200,000.00 $200,000.00 N/A N/A N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $25,000.00 N/A N/A N/A
Major tower reinforcement/modifications $421,000.00 $400,000.00 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 $138,595.00 $131,250.00 N/A $0.00 N/A
Total for all systems $4,390,595.00 $4,178,565.00 N/A $0.00 N/A
Outside Professional Services $138,595.00 $131,250.00 $0.00
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A N/A N/A
Attorney Fees - Aux Antenna, prepare and File Form 2100 Construction Permit or License Application $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 $3,500.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A N/A N/A
RF Exposure Measurements $21,050.00 $20,000.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 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
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, Construction Permit Application $2,105.00 $2,000.00 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 Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, License to Cover Application $1,580.00 $1,500.00 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 $87,080.00 $86,515.00 N/A $0.00 N/A
Total for all systems $4,390,595.00 $4,178,565.00 N/A $0.00 N/A
Other Expenses $87,080.00 $86,515.00 $0.00
Develop and air announcement of upcoming channel change $5,000.00 $5,000.00 N/A N/A N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 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
employee expense $15,000.00 $15,000.00 Must take employee off regular duty for the re-pack plus maintain his responsibilties N/A N/A
lodging $10,000.00 $10,000.00 approx. 30-40 days lodging plus meals N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $15,000.00 $15,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $17,000.00 $17,000.00 N/A N/A N/A
Equipment Storage $8,000.00 $8,000.00 3 45ft containers for temp storage approx. 6 months rental plus drop-off / pick-up 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 $4,390,595.00 $4,178,565.00 $0.00

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.

Clyde R. Yost

Vice President


07/11/2017

Attachments

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