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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:
64969
Service:
DTV
Call Sign:
KVDA
Channel:
15 (UHF)
File Number:
0000028248
FRN:
0019509470
Date Submitted:
02/06/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

NBC TELEMUNDO LICENSE LLC

Doing Business As: NBC Telemundo License LLC

Margaret Tobey

300 NEW JERSEY AVE, N.W.

SUITE 700

WASHINGTON, DC 20001

United States

 +1 (202) 524-6401 MARGARET.TOBEY@NBCUNI.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

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 Keep existing IOT transmitter/antenna in place for interim use on old channel. Install new antenna in old analog antenna location and install new transmitter for new channel. Remove old IOT transmitter and antenna after channel change.

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 DXC-2H
Year 2001
Type Inductive Output Tube
IOT Power Type Two
Power Capacity 40 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model THU9-30
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 43.71 kW
Justification for New Transmitter A new solid state transmitter is less expensive then a new IOT transmitter. Proposal for IOT is attached as well as Solid State. R&S THU-9/30 chosen as it offers 43.71 kW after filter/RF system which is 1 unit of Headroom above needed TPO of 33.32kW

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) Yes
Power 150 kVA
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
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? Yes
Size 40.0 square feet
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

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? 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 Side Mount
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: 1000.0 kW
Manufacturer
Model ATW26HS3/5-ESCX-39/38H
Year 2001

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? Yes
New Antenna Manufacturer and Types Class Full Power
Mounting Side Mount
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: 602.0 kW
Manufacturer
Model TFU- 18DSC/VP-R 4C200
Year 2017
Justification for New Antenna New antenna required because the current antenna is for channel 38 and post repack channel is 15

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? Yes
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

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 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1512 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 19 3/4 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1630 feet per run
Justification for New Transmission Line New line required because the current line will not work on the new channel (15)

Primary 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 Yes
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1054166
Coordinates (NAD83) Latitude (NAD83) 29° 17' 39.0" N-
Longitude (NAD83) 098° 15' 32.0" W-
Overall Structure Height 1517.37 feet
Support Structure Height 1513.43 feet
Ground Elevation Above Mean Sea Level (AMSL) 525.91 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner TELEMUNDO OF SAN ANTONIO LICENSE CORP
Date Constructed 09/01/1989

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
35881 KWEX-DT DTV
64969 KVDA DTV

Other Types of Users

Users
KRTX-LP
KGMM-CD

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 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 1040
Explanation Project oversight of transmitter install, electrical connectivity, tower work, and antenna installation. Additional time will be spent tracking financial and legal process and coordinating with other broadcasters.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development No
Prepare engineering section of Form FCC Construction Permit Application No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare engineering section of Form FCC License to Cover Application No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare request for Special Temporary Authority No
Quantity N/A
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 No
Quantity N/A
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 40
Justification Transmitter and RF design at ground level

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Transmitter Installation

Transmitter, Electrical, and RF System Installation

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Information not provided.

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 $1,537,520.00 $994,375.00 N/A $29,200.00 N/A
Total for all systems $3,175,831.94 $2,249,928.19 N/A $558,500.98 N/A
Primary Transmitter THU9-30 $1,537,520.00 $994,375.00 $29,200.00
Transformer 3 phase/480v - 150 KVA $25,550.00 $11,200.00 N/A $11,200.00 N/A
Other -- Building Addition Size: 40.0 $38,970.00 $38,970.00 install ice bridge over new heat exchangers including 8.25% tax. - see attached "quote1744-2" $18,000.00 N/A
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,473,000.00 $944,205.00 Please see attached R&S proposal. We have subtracted install costs as they are included elsewhere in the 399. N/A N/A

Components

Actual Information Description File Name
Transformer 3 phase/480v - 150 KVA

Component Description:
Transformers for 3 cabinet DTV transmitter
Amount:
$11,200.00
Other -- Building Addition Size: 40.0

Component Description:
See invoice "building modification"
Amount:
$18,000.00
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW 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 $181,140.00 $170,222.50 N/A $142,940.26 N/A
Total for all systems $3,175,831.94 $2,249,928.19 N/A $558,500.98 N/A
Primary Antenna TFU- 18DSC/VP-R 4C200 $181,140.00 $170,222.50 $142,940.26
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $5,760.00 N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,260.00 $5,000.00 N/A N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $16,425.00 N/A $14,782.50 N/A
UHF - High Power, Side Mount, basic slot antenna, 602 kW input, directional,, elliptically or circularly polarized $132,100.00 $132,100.00 See attached proposal. Cost for new antenna and sweep test. $16,950 for V-pol is removed. $113,130.00 N/A
Elbow complex, single channel, at antenna input, per 7 3/16. feedline (if needed) $13,900.00 $10,297.50 N/A $9,267.76 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
See line 23 of invoice.
Amount:
$2,880.00

Component Description:
See line 23 of invoice.
Amount:
$2,880.00
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) Information not provided.
Side mount brackets for high power antennas (if not included in antenna base cost)

Component Description:
See line 2 of invoice.
Amount:
$7,391.25

Component Description:
See line 2 of invoice.
Amount:
$7,391.25
UHF - High Power, Side Mount, basic slot antenna, 602 kW input, directional,, elliptically or circularly polarized

Component Description:
See line 1 of invoice. See attached explanation of variance for line 25.
Amount:
$56,565.00

Component Description:
See line 1 of invoice. See attached explanation of variance for line 25.
Amount:
$56,565.00
Elbow complex, single channel, at antenna input, per 7 3/16. feedline (if needed)

Component Description:
See line 3 of invoice.
Amount:
$4,633.88

Component Description:
See line 3 of invoice.
Amount:
$4,633.88

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 $472,700.00 $287,754.75 N/A $258,979.28 N/A
Total for all systems $3,175,831.94 $2,249,928.19 N/A $558,500.98 N/A
Primary Transmission Line $472,700.00 $287,754.75 $258,979.28
Rigid Transmission Line - copper, 7 3/16" $472,700.00 $287,754.75 N/A $258,979.28 N/A

Components

Actual Information Description File Name
Rigid Transmission Line - copper, 7 3/16"

Component Description:
See line 4 of invoice.
Amount:
$129,489.64

Component Description:
See line 4 of invoice.
Amount:
$129,489.64

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 $381,100.00 $209,184.00 N/A $64,859.00 N/A
Total for all systems $3,175,831.94 $2,249,928.19 N/A $558,500.98 N/A
Primary Tower TOWER $381,100.00 $209,184.00 $64,859.00
Minor tower reinforcement/modifications $158,000.00 $77,730.00 Tower modification cost, plus tax $38,865.00 N/A
Tall Tower (greater than 500') $210,500.00 $119,454.00 N/A $25,994.00 N/A
Structural engineering tower load study for well documented tower $12,600.00 $12,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Minor tower reinforcement/modifications

Component Description:
See invoice "Tower modification" and "Tax on tower modification"
Amount:
$38,865.00
Tall Tower (greater than 500')

Component Description:
See invoice "Tower crew to install side mount main antenna and 7-3-1/6" line"
Amount:
$25,994.00
Structural engineering tower load study for well documented tower 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 $525,005.32 $510,590.32 N/A $47,879.13 N/A
Total for all systems $3,175,831.94 $2,249,928.19 N/A $558,500.98 N/A
Outside Professional Services $525,005.32 $510,590.32 $47,879.13
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $565.02 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $245.70 N/A
Project management of the transition $164,320.00 $156,000.00 N/A $22,068.41 N/A
Additional Field Engineering Service, 40 Days $40,000.00 $40,000.00 N/A $10,000.00 N/A
Transmitter Installation $198,340.32 $198,340.32 includes installation of transmitter, RF, and electrical equipment from attached "KVDA_Install" proposal. Also includes Comark system programming from last line of attached Marsand proposal $15,000.00 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 - 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
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Prepare and or review reimbursement form

Component Description:
See lines 2-4, less 10% vendor discount.
Amount:
$273.06

Component Description:
Amendments to Form 399.
Amount:
$197.46

Component Description:
See half of line 1, less 10% vendor discount.
Amount:
$94.50
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
See line 2 and half of line 1, less 10% vendor discount.
Amount:
$132.30

Component Description:
See line 1 of invoice, less 10% vendor discount.
Amount:
$113.40
Project management of the transition

Component Description:
Project Management Services
Amount:
$348.95

Component Description:
Project Management Services
Amount:
$3,510.00

Component Description:
See itemized breakdown of project management fees on invoice.
Amount:
$9,499.46

Component Description:
Project Management Services
Amount:
$4,420.00

Component Description:
Project Management Services
Amount:
$2,145.00

Component Description:
Project Management Services
Amount:
$2,145.00
Additional Field Engineering Service, 40 Days

Component Description:
Engineering site visit, inspection, measurements, drawing and planning for repack transmitter and RF installation, budgeting and planning
Amount:
$10,000.00
Transmitter Installation

Component Description:
See last line of invoice.
Amount:
$15,000.00
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Address transition timing and coordination issues w/ other stations and wireless 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 $78,366.62 $77,801.62 N/A $14,643.31 N/A
Total for all systems $3,175,831.94 $2,249,928.19 N/A $558,500.98 N/A
Other Expenses $78,366.62 $77,801.62 $14,643.31
MVPD Notification of Channel Change $12,000.00 $12,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $20,000.00 $20,000.00 N/A N/A N/A
Equipment Storage $2,500.00 $2,500.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $29,286.62 $29,286.62 see attached "KVDA_Install" proposal for disposal costs of old Comark transmitter after transition. $14,643.31 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 $335.00 $325.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $2,500.00 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
See 1st item of invoice.
Amount:
$14,643.31
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
DTV Medical Facility Notification Information not provided.
Equipment Delivery and Handling Charges Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $3,175,831.94 $2,249,928.19 $558,500.98

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.

Margaret L Tobey

Assistant Secretary


02/06/2018

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (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 AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).

  1. The Authorized Person signing below certifies and represents 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 certifies that the statements in this form and attached documentation are true, complete, and correct.

  3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  4. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  5. 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 (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .

  6. 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.

  7. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

  8. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  9. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite 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.

Margaret L Tobey

Assistant Secretary


02/06/2018

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