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:
13602
Service:
DTV
Call Sign:
WEDH
Channel:
45 (UHF)
File Number:
0000028127
FRN:
0003574662
Date Submitted:
08/23/2017

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

CONNECTICUT PUBLIC BROADCASTING, INC.

Doing Business As: CONNECTICUT PUBLIC TELEVISION

Meg Sakellarides

1049 ASYLUM AVENUE

HARTFORD, CT 06105

United States

+1 (860) 278-5310 MSAKELLARIDES@CPTV.ORG Not-for-Profit

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

The Preparer is same as the reimbursement contact.

 

 

 

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. Yes
Briefly describe transition plan Purchase of a new transmitter, new transmission line, and new antenna. Retuning of the existing transmitter to the new channel is cost-prohibitive. Interim antenna and transmission line are planned during transition to main antenna.

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 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? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model DCX Paragon MSDC-IOT
Year 2008
Type Inductive Output Tube
IOT Power Type Two
Power Capacity 36 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 Parallax 40kW UHF Cooled
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 40 kW
Justification for New Transmitter 1) Comark has indicated that retuning the existing transmitter, coupled with the rental of a temporary transmitter, would be higher than the Widelity cost; 2) the temporary rental transmitter would reduce WEDH's public service to its community.

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 N/A
Rigid Conduit and Wiring Yes
Size 4 inches
Length 100.0 feet
Other Electrical Service Yes
Description Labor and materials to accomplish either modification of existing electrical service or new electrical service and new wiring for new transmitter and wiring for 480 3-phase.
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

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Other Transmitter Cost Not Listed

Name Description

Project Expenses

Other services

Mask Filter

8-Pole Mask Filter

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Bottom
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: 490.0 kW
Manufacturer
Model TFU-16DSC-R C170
Year 2009

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 Side Mount
Antenna position in stack Bottom
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: 365.0 kW
Manufacturer
Model TFU-16DSC-R C170
Year 2019
Justification for New Antenna Existing antenna is single channel and is channel-specific. Justification for side mount brackets: antenna is top-mounted on candelabra tower but is side mounted in the bottom of the stack and side mounted brackets are required (see attached quote).

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 7 3/16 inches inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? 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

Reducer

6-75 x 7-75

Project Expenses

Other services

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? Yes
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 3
Number of Panels/Bays 16
Lower Limit 470.00 MHz
Upper Limit 665.00 MHz
Design power capacity in use 95.0 %
Other Antenna Type N/A
ERP: 1500.0 kW
Manufacturer
Model TFU-WB16
Year 2020
Justification for New Antenna Interim antenna is necessary for broadcast operation during tower work for 3 stations.

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? Yes
Type New
Number of channels supported 3
Frequencies of channels supported RF channel
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? No
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? B
Feed Line Size 6 1/8 inches
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

Enter a list of RF channel numbers.

RF Channel Number
31
20
45

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 Purchase New
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
Type Rigid
Diameter 7 3/16 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1480 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 7 3/16 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1480 feet per run
Justification for New Transmission Line Current shared transmission line is no longer supported by manufacturer and will not work on new channel.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Project Expenses

Other services

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 6 1/8 inches
Segment Length Broadband
Other Segment Length
Number of parallel runs 1
Length 1450 feet per run
Justification for New Transmission Line Transmission line for temporary operation of 3 stations during antenna changes.

Interim Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? 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? Yes
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 41° 42' 13.0" N-
Longitude (NAD83) 072° 49' 55.0" W-
Overall Structure Height 1338.89 feet
Support Structure Height 1291.98 feet
Ground Elevation Above Mean Sea Level (AMSL) 709.97 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner COMMUNICATIONS SITE MANAGEMENT, LLC
Date Constructed 09/01/1984

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
14050 WCCT-TV DTV
147 WTIC-TV DTV
1910 WRCH FM
66465 WTIC-FM FM
1900 WZMX 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: Minor 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

Name Description

Tower Lease

Additional tower rent expense for interim antenna and transmission line necessary during transition.

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 100
Explanation Project management services by the transmitter manufacturer and tower landlord.
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 2
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 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 Yes
Number of Days 2
Justification Field Engineering required for RF study for a nearby AM directional system.

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? Yes
Is Remediation needed? Yes
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning Yes
Non-zoning permits Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
FCC Special Temporary Authority Application No
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

Engineering and Administrative

Internal Project Management

Insurance

Builder's Risk during construction

Site Security

Hire of outside security to secure the site during construction

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 $1,522,725.00 $1,155,892.00 N/A $0.00 N/A
Total for all systems $3,770,621.40 $2,625,438.40 N/A $0.00 N/A
Primary Transmitter Parallax 40kW UHF Cooled $1,522,725.00 $1,155,892.00 $0.00
Mask Filter $15,000.00 $15,000.00 N/A N/A N/A
Project Expenses $0.00 $0.00 N/A N/A N/A
Other Electrical Service: Labor and materials to accomplish either modification of existing electrical service or new electrical service and new wiring for new transmitter and wiring for 480 3-phase. $24,625.00 $24,625.00 See attached vendor quote supporting estimate. N/A N/A
4" Rigid Conduit and Wiring (Cost per foot) $10,100.00 $9,600.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,473,000.00 $1,106,667.00 See COMARK quote and additional narrative with support and explanation for purchase of new Solid State transmitter. 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 $374,150.00 $351,760.00 N/A $0.00 N/A
Total for all systems $3,770,621.40 $2,625,438.40 N/A $0.00 N/A
Interim Antenna TFU-WB16 $138,630.00 $132,400.00 $0.00
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed) $13,700.00 $12,000.00 N/A N/A N/A
New combiner, cost per channel (without antenna) $84,200.00 $80,000.00 N/A N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
UHF - High Power, Side Mount, basic slot antenna, 16 bay,, 1500 kW input, directional,, horizontally polarized $34,000.00 $34,000.00 In resubmission on 8/22/17, item has been reduced to 1/3 the initially submitted amount for sharing of cost with WTIC and WCCT. N/A N/A
Primary Antenna TFU-16DSC-R C170 $235,520.00 $219,360.00 $0.00
UHF - Lower Power Side Mount, One station - 200-500 kW, horizontally polarized $189,500.00 $180,000.00 N/A N/A N/A
Project Expenses $0.00 $0.00 N/A N/A N/A
Reducer $2,240.00 $2,240.00 See attached quote from Dielectric supporting cost. N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $17,520.00 Antenna is top-mounted on candelabra tower but is side mounted in the bottom of the stack of the candelabra and therefore side-mounted brackets are required (see attached quote from Dielectric). N/A N/A
Elbow complex, single channel, at antenna input, per 7 3/16. feedline (if needed) $13,900.00 $13,200.00 N/A 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

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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 $765,600.00 $340,000.00 N/A $0.00 N/A
Total for all systems $3,770,621.40 $2,625,438.40 N/A $0.00 N/A
Interim Transmission Line $336,400.00 $80,000.00 $0.00
Rigid Transmission Line - copper, 6 1/8" broadband $336,400.00 $80,000.00 In resubmission on 8/22/17, item has been reduced to 1/3 the initially submitted amount for sharing of cost with WTIC and WCCT. N/A N/A
Primary Transmission Line $429,200.00 $260,000.00 $0.00
Project Expenses $0.00 $0.00 N/A N/A N/A
Rigid Transmission Line - copper, 7 3/16" $429,200.00 $260,000.00 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 $758,620.00 $459,020.00 N/A $0.00 N/A
Total for all systems $3,770,621.40 $2,625,438.40 N/A $0.00 N/A
Primary Tower TOWER $758,620.00 $459,020.00 $0.00
Tower Lease $167,020.00 $167,020.00 See attached explanation and estimate for COMSITE tower lease cost. N/A N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $421,000.00 $200,000.00 N/A N/A N/A
Minor tower reinforcement/modifications $158,000.00 $80,000.00 N/A N/A N/A
Structural engineering tower load study for well documented tower $12,600.00 $12,000.00 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 $162,020.00 $153,250.00 N/A $0.00 N/A
Total for all systems $3,770,621.40 $2,625,438.40 N/A $0.00 N/A
Outside Professional Services $162,020.00 $153,250.00 $0.00
Additional Field Engineering Service, 2 Days $4,000.00 $4,000.00 N/A N/A N/A
RF Exposure Measurements $21,050.00 $20,000.00 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
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 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
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
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $4,100.00 $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
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 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
Project management of the transition $15,800.00 $15,000.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $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 $187,506.40 $165,516.40 N/A $0.00 N/A
Total for all systems $3,770,621.40 $2,625,438.40 N/A $0.00 N/A
Other Expenses $187,506.40 $165,516.40 $0.00
Develop and air announcement of upcoming channel change $6,000.00 $6,000.00 N/A N/A N/A
Site Security $10,000.00 $10,000.00 N/A N/A N/A
Insurance $5,000.00 $5,000.00 N/A N/A N/A
Engineering and Administrative $20,000.00 $20,000.00 N/A N/A N/A
MVPD Notification of Channel Change $11,000.00 $11,000.00 N/A N/A N/A
Equipment Storage $15,000.00 $15,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $25,000.00 $25,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $30,016.40 $30,016.40 See attached quotes from D'Amato and Tri-S for justification. N/A N/A
Non-zoning permits $10,000.00 $10,000.00 N/A N/A N/A
Local Zoning $15,000.00 $15,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A N/A N/A
AM Pattern Disturbance -- Remedy $21,050.00 $0.00 Disallowed by FCC as it is duplicated by a request from WTIC. N/A N/A
AM Pattern Disturbance -- Impact study $7,890.00 $7,500.00 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 $3,770,621.40 $2,625,438.40 $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.

Meg Sakellarides

Chief Financial Officer


08/23/2017

Attachments

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