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:
0000028728
FRN:
0018223693
Facility ID:
7893
Repack Channel:
17 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
08/22/2017

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GRAY TELEVISION LICENSEE, LLC

Robert Folliard

4370 Peachtree Road

Atlanta, GA 30319

United States

+1 (202) 750-1585 Robert.Folliard@gray.tv 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

Samuel Hariton

Widelity

Samuel Hariton

4031 University Dr

Suite 100

Fairfax, VA 22030

United States

+1 (339) 222-8107 sam.hariton@widelity.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan WEAU will be transitioning from channel 38 to 17. The station plans to replace their existing main transmitter, antenna, and transmission line. The station also plans to install interim facilities to continue broadcasting during the transition.

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 PRW90D3
Year 2011
Type Inductive Output Tube
IOT Power Type Three
Description  
Power capacity 90 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 ULXTE-120
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 76 kw
Other Transmitter Type  
Justification for New Transmitter Replacing retunable IOT with solid state transmitter

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 Yes
Description The new transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors.
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

Pad for Heat Exchangers

Additional Heat Exchanger Concrete Pad plus Ice shield

Concrete Cutting Work

Cutting holes in concrete walls and floors for pipes and electrical.

Transmitter remote control

New transmitter will not work with existing remote control system.

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use  
Change Type Purchase
Manufacturer
Model HPTV-PRLX-U16
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 27.5 kw
Other Transmitter Type  
Justification for New Transmitter Interim transmitter needed to stay broadcasting during the transition

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 Yes
Description The new transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors.
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? No

Interim Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
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: 1000.00 kW
Manufacturer
Model ATW28H4-ETO-38H
Year 2011

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? No
Will antenna be located on or in close proximity to an antenna farm? No
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: 700.00 kW
Manufacturer
Model TFU-23JTH/VP-R 06
Year 2018
Justification for New Antenna Our existing coaxial antenna is a single channel antenna tuned to channel 38 including Ellipitical polorization and 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
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

Name Description

Top Plate Adapter

Adapted for the top of the tower to match the bolt pattern on the antenna

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? No
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 1
Lower Limit 488.00 MHz
Upper Limit 494.00 MHz
Design power capacity in use 100.0 %
Other Antenna Type N/A
ERP: 230.00 kW
Manufacturer
Model TFU-WB24-C160H
Year 2018
Justification for New Antenna Interim antenna needed to continue broadcasting through the transition.

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? 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? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Interim Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change 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 ERI
Type Rigid
Diameter 8 3/16 inches
Segment Length 19 ½ '
Other Segment Length
Number of parallel runs 1
Length 2050 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Sweep Test

Sweep test of existing transmission line

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 4 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 1680 feet per run
Justification for New Transmission Line Interim line needed to continue broadcasting during the transition period.

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? 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? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1033664
Coordinates (NAD83) Latitude (NAD83) 44° 39' 50.0" N-
Longitude (NAD83) 090° 57' 41.0" W-
Overall Structure Height 1997.68 feet
Support Structure Height 1895.97 feet
Ground Elevation Above Mean Sea Level (AMSL) 1096.77 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Gray Television Group, Inc.
Date Constructed 03/23/1981

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
9866 WAXX FM
185159 WWJC 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 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

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 900
Explanation Strategic Support
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 N/A
For Main Facility Yes N/A
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification Yes
FAA Consultation (including preparation of FAA Form 7460) Yes
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 No
RF exposure measurements No
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 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

Name Description

Security

Security for site while equipment is being stored.

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 $3,274,320.96 $3,224,494.82 N/A $0.00 N/A
Total for all systems $4,790,827.96 $4,604,212.93 N/A $0.00 N/A
Interim Transmitter HPTV-PRLX-U16 $902,000.00 $852,173.86 $0.00
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW $900,000.00 $850,173.86 N/A N/A N/A
Other Electrical Service: The new transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors. $2,000.00 $2,000.00 N/A N/A N/A
Primary Transmitter ULXTE-120 $2,372,320.96 $2,372,320.96 $0.00
Concrete Cutting Work $690.00 $690.00 See attached ERV Smith Services, Inc. quote date 6/20/17 for concrete cutting work. N/A N/A
Pad for Heat Exchangers $10,200.00 $10,200.00 See attached ERV Smith Services, Inc. quote dated 6/20/17 for concrete pad work. N/A N/A
UHF - Liquid Cooled Solid State Transmitter 76 kW $2,255,657.96 $2,255,657.96 Includes tax and shipping. N/A N/A
Other Electrical Service: The new transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors. $99,773.00 $99,773.00 B&B Electric Quote Dated June 21, 2017 tax included N/A N/A
Transmitter remote control $6,000.00 $6,000.00 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 $521,052.00 $428,318.97 N/A $0.00 N/A
Total for all systems $4,790,827.96 $4,604,212.93 N/A $0.00 N/A
Interim Antenna TFU-WB24-C160H $208,400.00 $166,752.00 $0.00
UHF - Lower Power Side Mount, One station - 200-500 kW, horizontally polarized $180,000.00 $156,468.00 N/A N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $22,000.00 $3,884.00 N/A N/A N/A
Sweep test of existing antenna $6,400.00 $6,400.00 N/A N/A N/A
Primary Antenna TFU-23JTH/VP-R 06 $312,652.00 $261,566.97 $0.00
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $275,000.00 $222,846.97 N/A N/A N/A
Sweep test of existing antenna $6,400.00 $6,400.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $11,700.00 $12,768.00 JEHQ1285-01 N/A N/A
Top Plate Adapter $19,552.00 $19,552.00 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 $124,000.00 $88,259.14 N/A $0.00 N/A
Total for all systems $4,790,827.96 $4,604,212.93 N/A $0.00 N/A
Interim Transmission Line $117,600.00 $81,859.14 $0.00
Flexible Air Transmission Line - dielectric, 4" $117,600.00 $81,859.14 N/A N/A N/A
Primary Transmission Line $6,400.00 $6,400.00 $0.00
Sweep Test $6,400.00 $6,400.00 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 $612,000.00 $612,000.00 N/A $0.00 N/A
Total for all systems $4,790,827.96 $4,604,212.93 N/A $0.00 N/A
Primary Tower TOWER $612,000.00 $612,000.00 $0.00
Structural engineering tower load study for well documented tower $12,000.00 $12,000.00 N/A N/A N/A
Major tower reinforcement/modifications $400,000.00 $400,000.00 N/A N/A N/A
Tall Tower (greater than 500') $200,000.00 $200,000.00 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 $167,750.00 $167,750.00 N/A $0.00 N/A
Total for all systems $4,790,827.96 $4,604,212.93 N/A $0.00 N/A
Outside Professional Services $167,750.00 $167,750.00 $0.00
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase $2,000.00 $2,000.00 N/A N/A N/A
ASR modification (prepare FCC Form 854) $2,000.00 $2,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,500.00 $3,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,500.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,000.00 $3,000.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,000.00 $7,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,500.00 $1,500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,000.00 $5,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,250.00 $2,250.00 N/A N/A N/A
Project management of the transition $135,000.00 $135,000.00 N/A N/A N/A
Prepare and or review reimbursement form $2,500.00 $2,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,500.00 $2,500.00 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 $91,705.00 $83,390.00 N/A $0.00 N/A
Total for all systems $4,790,827.96 $4,604,212.93 N/A $0.00 N/A
Other Expenses $91,705.00 $83,390.00 $0.00
Security $12,000.00 $12,000.00 N/A N/A N/A
MVPD Notification of Channel Change $1,200.00 $1,200.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $10,000.00 $10,000.00 N/A N/A N/A
Equipment Storage $12,000.00 $12,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,000.00 $2,685.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $325.00 $325.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $190.00 $190.00 N/A N/A N/A
Non-zoning permits $11,000.00 $11,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $18,990.00 $18,990.00 See attached OK Tower Service estimate #413. N/A N/A
Equipment Delivery and Handling Charges $15,000.00 $15,000.00 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 $4,790,827.96 $4,604,212.93 $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 Folliard

Assistant Secretary


08/22/2017

Attachments

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