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:
1136
Service:
DTV
Call Sign:
KUCW
Channel:
35 (UHF)
File Number:
0000028266
FRN:
0009961889
Date Submitted:
09/07/2017

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

NEXSTAR BROADCASTING, INC.

Elizabeth Ryder

545 E. JOHN CARPENTER FREEWAY

SUITE 700

IRVING, TX 75062

United States

+1 (972) 373-8800 eryder@nexstar.tv 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

Elizabeth Ryder

General Counsel

Nexstar Broadcasting, Inc.

Elizabeth Ryder

545 E. John Carpenter Freeway

Suite 700

Irving, TX 75062

United States

+1 (972) 373-8800 eryder@nexstar.tv

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 DTV Utah is a complex site with 8 stations sharing two main antennas as well as aux antenna, combiner system, tower and building. Replacement antenna panels, combiner, and transmitters will be required. DTVU is still finalizing its transition plan.

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-1H
Year 2001
Type Inductive Output Tube
IOT Power Type Single
Power Capacity 20 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 25 kW
Justification for New Transmitter Existing transmitter is obsolete and can not be re-tuned to the new channel. See attached quotes. Upgrading to a SS at one power step up from the required TPO. Single tube IOT is the max reimbursement, but Gates quote is lower.

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) Yes
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 200.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 30 tons
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

Removal of Existing Equipment

Remove existing equipment from Farnsworth Peak site.

Plan Transmitter Layout and Develop Installation Drawings

Develop installation layout. Develop installation drawings

Remote Control Wiring

Wire Up Existing Remote Control

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 ULXTE-20
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 12.9 kW
Justification for New Transmitter KUCW Allocated costs for DTV Utah interim transmitter. One transmitter will be used to cycle through transmitter change outs on the site.

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) Yes
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring Yes
Size 2 inches
Length 800.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size 50 tons
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A
Inside RF System Is an additional interior RF system required to support this interim transmitter? Yes

Interim Transmitter

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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 Leased
Owner DTV Utah
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
Antenna position in stack Top
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 8
Number of Panels 48
Design power capacity in use 100.0 %
Lower Limit 602.00 MHz
Upper Limit 700.00 MHz
Other Antenna Type N/A
ERP: 200.0 kW
Manufacturer
Model 773 928
Year 1999

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

Facility ID Call Sign
68889 KTVX
1136 KUCW
35823 KUTV
36607 KJZZ-TV
6359 KSL-TV
6823 KBYU-TV
69396 KUED
69582 KUEN

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? Yes
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types Class Full Power
Mounting Top Mount
Antenna position in stack Bottom
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 8
Number of Panels/Bays 48
Lower Limit 482.00 MHz
Upper Limit 608.00 MHz
Design power capacity in use 50.0 %
Other Antenna Type N/A
ERP: 2000.0 kW
Manufacturer
Model 759 25063
Year 2017
Justification for New Antenna The current panel antenna is finely tuned to a specific band, but cannot be retuned to the new band.

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 8
Frequencies of channels supported Upper and lower frequency
Frequency 488.0 MHz - 608.0 MHz
Do you need a combiner output splitter/switcher for dual feed lines? Yes
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Broadband
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

Name Description

Antenna Installation

Costs for antenna install.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? No

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? Terrain Constrained
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 Yes
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 1062408
Coordinates (NAD83) Latitude (NAD83) 40° 39' 33.0" N-
Longitude (NAD83) 112° 12' 10.0" W-
Overall Structure Height 308.40 feet
Support Structure Height 308.40 feet
Ground Elevation Above Mean Sea Level (AMSL) 9035.32 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner DTV UTAH, LC
Date Constructed 10/28/1999

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
6359 KSL-TV DTV
6823 KBYU-TV DTV
36607 KJZZ-TV DTV
35823 KUTV DTV
1136 KUCW DTV
68889 KTVX DTV
69396 KUED DTV
69582 KUEN DTV

Other Types of Users

Users
Multi User Site

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 Terrain constrained
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 800
Explanation This extremely complex project requires coordination between 8 different stations and the umbrella organization, DTV Utah.
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 2
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 30
Justification On site RF Engineer to supervise construction of station facilities.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Reimbursement Reviews

Reimbursement Reviews with FCC and Contractors.

Allocation Consulting

DTVU RF Consultant Analysis of Repack Allocations, interference issues, and spectrum issues.

Building Structural Engineering

Structural Engineer to review and analyze building and 2nd floor weights and combiner issues.

Prepare and File FCC Progress Reports

Prepare and file FCC Quarterly Progress Reports

RF Consultant

DTVU RF Consulting Engineer for antenna and combiner system design.

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 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

Site Access and Transportation

Snow Cat; Helicopter site access, road clearing and plowing etc.

Accounting

DTV Utah Accounting and Allocation of Costs to stations.

DTV Utah Operating Agreement Equity Equalization

Per 1988 Operating Agreement. See Exhibit M attached.

KSTU Mask Filter

Adjacent Channel Mask Filter for KSTU. See Exhibit N attached.

Removal and Disposal of Existing Equipment

Removal and Disposal of Common Equipment, Antenna Panels, Combiner, Rigging, Mountain Road access, packing materials

Temporary Sanitation

Required for work on the mountaintop.

Road Maintenance

Showplowing Grating and repairs to existing road to remote mountain top.

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 $2,104,700.00 $1,069,439.00 N/A $0.00 N/A
Total for all systems $4,155,522.25 $2,140,126.25 N/A $0.00 N/A
Interim Transmitter ULXTE-20 $1,003,800.00 $130,909.00 $0.00
Transformer 3 phase/480v - 300 KVA $36,800.00 $4,375.00 1/8th shared cost. N/A N/A
UHF inside RF system including switching $147,500.00 $17,500.00 1/8 Shared cost N/A N/A
50 Ton system $266,000.00 $31,625.00 1/8 Shared Cost N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $20,800.00 $2,500.00 1/8th Shared Cost N/A N/A
Switchgear - industrial 800 amp $38,200.00 $4,375.00 1/8 Shared Cost N/A N/A
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW $494,500.00 $70,534.00 1/8 Shared Cost N/A N/A
Primary Transmitter ULXTE-40 $1,100,900.00 $938,530.00 $0.00
Other -- HVAC Service Type: C Size:30 (Other) $25,000.00 $25,000.00 KUCW Allocated costs for modification of DTV Utah HVAC Systems. N/A N/A
Remote Control Wiring $3,500.00 $3,500.00 Wire up existing remote control to new transmitter N/A N/A
Plan Transmitter Layout and Develop Installation Drawings $15,000.00 $15,000.00 Develop transmitter layout plan and installation drawings N/A N/A
Removal of Existing Equipment $25,000.00 $25,000.00 Removal of IOT Transmitter, mask filter, 2 beam supplies, 2 heat exchangers, glycol, and oil from transformers from mountain top. N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $10,400.00 $9,800.00 Catalog N/A N/A
Transformer 3 phase/480v - 300 KVA $36,800.00 $35,000.00 Catalog N/A N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 Catalog N/A N/A
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW $947,000.00 $788,930.00 See attached Gates quote. 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 $436,593.00 $394,713.00 N/A $0.00 N/A
Total for all systems $4,155,522.25 $2,140,126.25 N/A $0.00 N/A
Primary Antenna 759 25063 $436,593.00 $394,713.00 $0.00
New combiner, cost per channel (without antenna) $84,200.00 $185,000.00 1/8 Shared Cost. See Exhibit E. N/A N/A
Antenna Installation $37,677.00 $37,677.00 1/8 Shared Cost N/A N/A
Combiner output splitting/switching for dual feed lines, if applicable $126,000.00 $0.00 Included in combiner costs. N/A N/A
Sweep test of existing antenna $6,730.00 $2,125.00 1/8 Shared Cost N/A N/A
UHF - High Power Top Mount Eight Station broadband panel antenna horizontally polarized $168,286.00 $168,286.00 1/8 Shared Cost N/A N/A
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed) $13,700.00 $1,625.00 1/8 Shared Costs N/A N/A

Components

Information not provided.

Cost Information

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Transmission Line

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 $854,600.00 $101,500.00 N/A $0.00 N/A
Total for all systems $4,155,522.25 $2,140,126.25 N/A $0.00 N/A
Primary Tower TOWER $854,600.00 $101,500.00 $0.00
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $421,000.00 $50,000.00 1/8 Shared Cost N/A N/A
Major tower reinforcement/modifications $421,000.00 $50,000.00 1/8 Shared Cost N/A N/A
Structural engineering tower load study for well documented tower $12,600.00 $1,500.00 1/8 Shared Cost 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 $396,900.00 $212,350.00 N/A $0.00 N/A
Total for all systems $4,155,522.25 $2,140,126.25 N/A $0.00 N/A
Outside Professional Services $396,900.00 $212,350.00 $0.00
Comprehensive coverage verification via field study, if needed $84,200.00 $10,000.00 1/8 Shared Cost N/A N/A
RF Exposure Measurements $21,050.00 $2,500.00 1/8 Shared Costs N/A N/A
RF Consultant $16,000.00 $16,000.00 KUCW Allocation of costs RF Consulting Engineer for antenna and combiner system design. Vendor specs and system range testing. N/A N/A
Prepare and File FCC Progress Reports $18,000.00 $18,000.00 Prepare and file FCC Progress Reports N/A N/A
Reimbursement Reviews $10,600.00 $10,600.00 Reimbursement Reviews with FCC and E&Y N/A N/A
Additional Field Engineering Service, 30 Days $45,000.00 $45,000.00 RF Engineer to supervise construction and installation of KUCW equipment N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $7,360.00 $7,000.00 Catalog N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 Catalog N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 Catalog N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 Catalog N/A N/A
Prepare request for Special Temporary Authorization $4,100.00 $3,000.00 Catalog N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 Catalog N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 Catalog N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 Catalog N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 Catalog N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 Catalog N/A N/A
Building Structural Engineering $20,000.00 $20,000.00 KUCW Allocated cost estimate for cost related to structural analysis of building N/A N/A
Project management of the transition $126,400.00 $37,500.00 Catalog N/A N/A
Allocation Consulting $15,000.00 $15,000.00 KUCW Allocation of RF Engineering costs to review channel assignments, allocatoins, interference issues, alternative channels. Support can not construct filings. 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 $362,729.25 $362,124.25 N/A $0.00 N/A
Total for all systems $4,155,522.25 $2,140,126.25 N/A $0.00 N/A
Other Expenses $362,729.25 $362,124.25 $0.00
Equipment Delivery and Handling Charges $25,000.00 $25,000.00 KUCW specific costs plus allocated cost estimate for delivery and handling of equipment up the mountain. N/A N/A
Temporary Sanitation $3,000.00 $3,000.00 1/8 Cost Share N/A N/A
DTV Utah Operating Agreement Equity Equalization $223,083.00 $223,083.00 See Exhibit M N/A N/A
Road Maintenance $10,000.00 $10,000.00 1/8 Cost Share N/A N/A
KSTU Mask Filter $6,756.25 $6,756.25 1/8 Cost Share. See Exhibit N. N/A N/A
Accounting $5,800.00 $5,800.00 KUCW allocated costs estimate for DTV Utah cost accounting for project and bookkeeping. N/A N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 Estimate to notify MVPD of channel change. N/A N/A
Develop and air announcement of upcoming channel change $3,500.00 $3,500.00 Production costs to develop and air channel change announcement N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $27,500.00 $27,500.00 KUCW allocated cost estimate for combiner and other common equipment to be removed from building, transported down mountain, and disposed. Rigging. N/A N/A
Non-zoning permits $5,900.00 $5,900.00 KUCW allocated cost estimate for permits DTV Utah N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 Catalog N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 Catalog N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 Catalog N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 Catalog N/A N/A
Site Access and Transportation $25,000.00 $25,000.00 KUCW specific plus allocated cost estimate for site access and transportation: Snow Cat; Helicopter Access, Road Clearing, Plowing; etc. N/A N/A
Removal and Disposal of Existing Equipment $5,000.00 $5,000.00 Removal and disposal of KUCW equipment and other general garbage down the mountain. N/A N/A
Equipment Storage $4,000.00 $4,000.00 DTV Utah allocated cost estimate for KUCW for equipment storage at mountain base, pod rentals, land lease,storage logistics. 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 $4,155,522.25 $2,140,126.25 $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.

Elizabeth Ryder

General Counsel


09/07/2017

Attachments

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