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:
0000028449
FRN:
0020523114
Facility ID:
71586
Repack Channel:
39 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
09/22/2017

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

NRJ TV SAN FRAN LICENSE CO, LLC

Robert Andrews

722 S DENTON TAP ROAD STE 130

COPPELL, TX 75019

United States

+1 (972) 947-3391 bob@nrjventures.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

Peter Douglas

VP Engineering

NRJ TV VI LLC

Peter Douglas

3310 Keller Springs Rd Ste 110

Carrollton, TX 75006

United States

+1 (303) 881-9185 pdouglas@nrjtv.net

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 Tower Mgt Co will manage all aspects of combiner and antenna installation. KCNS will install new transmitter and coordinate the transition with tower owner and other stations.

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  
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
Model Paragon DCXP-2
Year 2007
Type Inductive Output Tube
IOT Power Type Two
Description  
Power capacity 40 kw
Solid State Cooling  
Solid State Power Capacity  
Other Transmitter Type  

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Description of Use  
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model HPTV-PRLX-U24
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 38 kw
Other Transmitter Type  
Justification for New Transmitter Cost of retuning (including interim transmitter) exceeds replacement cost. Proposed solid state replacement less expensive than IOT replacement. See attached statement.

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 Yes
Size 3 inches
Length 120.0 feet
Other Electrical Service Yes
Description Install additional 400A service disconnect, LV transformer, Surge suppressor
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

Name Description

Installation Crew Expenses

Travel, Per Diem, Lodging for installation crew

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 Retune Existing
Antenna Use Primary (Main)
Description of Use N/A
Ownership Leased
Owner Sutro Tower Inc
Site N/A
Is the existing antenna shared with another station or stations? Yes
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 Top
Polarization Elliptical
Type Broadband Panel
Number of Stations Supported 4
Number of Panels 14
Design power capacity in use 100.0 %
Lower Limit 518.00 MHz
Upper Limit 698.00 MHz
Other Antenna Type N/A
ERP: 1000.00 kW
Manufacturer Dielectric
Model TUM20-C5SP-14/60H-2_R-T
Year 2007

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID Call Sign
35500 KQED

Primary Antenna

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Adjustment to Existing Antenna

Section Question Response
Sweep Test of Existing Antenna Do you need a sweep test of existing antenna? Yes

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 RF channel
Frequency N/A

Enter a list of RF channel numbers.

RF Channel Number
30
32

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Auxiliary Antenna

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Add Antenna Information

Section Question Response
Existing Antenna Description Type of change Retune Existing
Antenna Use Auxiliary (Backup)
Description of Use Aux Backup
Ownership Leased
Owner Sutro Tower Inc
Site N/A
Is this antenna currently shared with any other stations? Yes
Is this 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 stacked
Antenna position in stack Bottom
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 5
Number of Panels 12
Design power capacity in use 100.0 %
Lower Limit 470.00 MHz
Upper Limit 860.00 MHz
Other Antenna Type N/A
ERP: 500.00 kW
Manufacturer Dielectric
Model TUA-C4SP-12/40U-1-S
Year 2007

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID Call Sign
51429 KFSF-DT
35500 KQED
43095 KMTP-TV
58912 KCSM-TV
69619 KBCW

Auxiliary Antenna

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Adjustment to Existing Antenna

Section Question Response
Sweep Test of Existing Antenna Do you need a sweep test of existing antenna? Yes

Auxiliary 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 4
Frequencies of channels supported RF channel
Frequency N/A

Enter a list of RF channel numbers.

RF Channel Number
28
30
32
34

Auxiliary 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 Leased
Owner Sutro Tower Inc
Site N/A
Is the existing transmission line shared with another station or stations? Yes
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Dielectric
Type Rigid
Diameter 6 1/8 inches
Segment Length Broadband
Other Segment Length
Number of parallel runs 1
Length 950 feet per run

Facility ID's and Call Signs of all stations with whom the transmission line is shared.

Facility ID Call Sign
58912 KCSM-TV
35500 KQED
43095 KMTP-TV

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Retune Existing Line

Retune line, Install additional components and test as necessary for new CH.

Auxiliary Transmission Line

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Add Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Utilize Existing
Use Auxiliary (Backup)
Description of Use Aux Backup
Ownership Leased
Owner Sutro Tower Inc
Site N/A
Is this transmission currently shared with any other stations? Yes
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Dielectric
Type Rigid
Diameter 6 1/8 inches
Segment Length Broadband
Other Segment Length
Number of parallel runs 1
Length 750 feet per run

Facility ID's and Call Signs of all stations with whom the transmission line is shared.

Facility ID Call Sign
58912 KCSM-TV
35500 KQED
69619 KBCW
43095 KMTP-TV

Auxiliary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Retune Existing Line

Retune, install additional components and test lines for new channel

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? 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? Yes
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1001289
Coordinates (NAD83) Latitude (NAD83) 37° 45' 19.0" N-
Longitude (NAD83) 122° 27' 10.0" W-
Overall Structure Height 976.69 feet
Support Structure Height 779.85 feet
Ground Elevation Above Mean Sea Level (AMSL) 833.98 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner SUTRO TOWER INC
Date Constructed 03/27/1998

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
65484 KOSF FM
59964 KISQ FM
6380 KOIT FM
70032 KSOL FM
25452 KPIX-TV DTV
43095 KMTP-TV DTV
51429 KFSF-DT DTV
35500 KQED DTV
35703 KTVU DTV
69619 KBCW DTV
54770 KFOG FM
58912 KCSM-TV DTV
65526 KRON-TV DTV
34470 KGO-TV DTV

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 tower with candelabra
Tower Reinforcements Please select whether tower reinforcements are needed: No reinforcements needed

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

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 700
Explanation Complex tower and transition require substantial coordination with vendors, governments, and other tenants on Sutro tower. Transmitter installation logistics and planning. 125hr rate
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 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 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

Name Description

Alternate Site Study

Engineering, antenna designs, architectural budgeting etc

Outside Consultant Expenses

Travel, Per Diem, Lodging etc for outside consultant on-site visits

Post Assignment Antenna Studies

Antenna design, application data, vertical sketches for structural eng, cost estimates

Neighborhood RF Survey

Local RF Survey required by planning commision

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

Sales Tax

Sales tax on items pertaining to transmission lines, combiners , antennas and lines.

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 $1,480,050.00 $1,272,192.00 N/A $0.00 N/A
Total for all systems $4,206,774.00 $2,671,268.00 N/A $0.00 N/A
Primary Transmitter HPTV-PRLX-U24 $1,480,050.00 $1,272,192.00 $0.00
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,434,000.00 $1,226,262.00 N/A N/A N/A
Other Electrical Service: Install additional 400A service disconnect, LV transformer, Surge suppressor $35,000.00 $35,000.00 Estimated cost for adding additional equipment for new transmitter. Required for proper pre-air testing. N/A N/A
Installation Crew Expenses $5,050.00 $5,050.00 On-site for transmitter installation crew. Not included on transmitter quote. N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $6,000.00 $5,880.00 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 $1,234,100.00 $179,810.00 N/A $0.00 N/A
Total for all systems $4,206,774.00 $2,671,268.00 N/A $0.00 N/A
Primary Antenna TUM20-C5SP-14/60H-2_R-T $1,147,550.00 $107,210.00 $0.00
Sweep test of existing antenna $6,550.00 $6,240.00 N/A N/A N/A
New combiner, cost per channel (without antenna) $80,000.00 $100,970.00 Very complex system as required by Sutro Tower. Incl design, purchase, install and remove old unit. Entire cost triggered by KCNS channel change because other user is not changing channel. N/A N/A
UHF - High Power Top Mount (200-1000 kW), Four Station broadband panel antenna, elliptically or circularly polarized $1,061,000.00 $0.00 N/A N/A N/A
Auxiliary Antenna TUA-C4SP-12/40U-1-S $86,550.00 $72,600.00 $0.00
New combiner, cost per channel (without antenna) $80,000.00 $66,360.00 KCNS Share N/A N/A
Sweep test of existing antenna $6,550.00 $6,240.00 N/A N/A N/A
UHF - High Power Top Mount Five Station broadband panel antenna horizontally polarized $0.00 $0.00 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 $387,676.00 $387,676.00 N/A $0.00 N/A
Total for all systems $4,206,774.00 $2,671,268.00 N/A $0.00 N/A
Primary Transmission Line $259,102.00 $259,102.00 $0.00
Retune Existing Line $259,102.00 $259,102.00 KCNS Share. Retune of lines required by Sutro system for new channel. See Sutro Cost Estimate attachment. N/A N/A
Auxiliary Transmission Line $128,574.00 $128,574.00 $0.00
Retune Existing Line $128,574.00 $128,574.00 KCNS Share. Retune of existing lines as required by Sutro system for new channel. See Sutro Cost Estimate attachment. 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 $428,950.00 $166,042.00 N/A $0.00 N/A
Total for all systems $4,206,774.00 $2,671,268.00 N/A $0.00 N/A
Primary Tower TOWER $428,950.00 $166,042.00 $0.00
Structural engineering tower load study for a documented tower with candelabra $19,450.00 $13,877.00 N/A N/A N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $409,500.00 $152,165.00 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 $332,655.00 $325,800.00 N/A $0.00 N/A
Total for all systems $4,206,774.00 $2,671,268.00 N/A $0.00 N/A
Outside Professional Services $332,655.00 $325,800.00 $0.00
Neighborhood RF Survey $3,333.00 $3,333.00 Required by local planning board N/A N/A
Outside Consultant Expenses $3,720.00 $3,720.00 Project Manager on-site expenses. N/A N/A
Alternate Site Study $58,619.00 $58,619.00 Required by Sutro Tower Inc. Very complex system. See Sutro Cost Estimate attachment. N/A N/A
RF Exposure Measurements $20,500.00 $6,666.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $81,900.00 $75,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,585.00 $3,500.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,095.00 $22,667.00 Complex tower situation requires extensive legal work with tower company (Sutro Tower Inc.) N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,305.00 $2,250.00 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), Construction Permit Application $5,120.00 $5,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,535.00 $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 $1,535.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $1,500.00 N/A N/A N/A
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, Construction Permit Application $2,050.00 $2,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,170.00 $24,482.00 KCNS Share. Very complex situation at Mt. Sutro. Requires extensive outside work using prime contractor Sutro Tower Inc. See Sutro Cost Estimate attachment. 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
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A N/A N/A
Project management of the transition $107,800.00 $86,500.00 Includes Sutro Costs and KCNS costs for 40 hrs PM @ $100 hr N/A N/A
Post Assignment Antenna Studies $15,563.00 $15,563.00 Required by Sutro Tower Inc. Very complex system. 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 $343,343.00 $339,748.00 N/A $0.00 N/A
Total for all systems $4,206,774.00 $2,671,268.00 N/A $0.00 N/A
Other Expenses $343,343.00 $339,748.00 $0.00
Develop and air announcement of upcoming channel change $500.00 $500.00 N/A N/A N/A
Equipment Delivery and Handling Charges $78,469.00 $78,469.00 Complex site requires substantial handling equipment and charges. KCNS Portion N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $16,442.00 $16,442.00 N/A N/A N/A
Local Zoning $202,108.00 $202,108.00 Super complex project requires extensive zoning work. KCNS portion. See Sutro Cost Estimate attachment N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 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
DTV Medical Facility Notification $11,250.00 $7,668.00 N/A N/A N/A
Equipment Storage $1,200.00 $1,200.00 Storage for KCNS only equipment N/A N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 N/A N/A N/A
Sales Tax $26,776.00 $26,776.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,070.00 $1,070.00 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 $4,206,774.00 $2,671,268.00 $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.

Robert Andrews

Sr VP


09/22/2017

Attachments

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