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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:
0000028935
FRN:
0001607407
Facility ID:
6823
Repack Channel:
17 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
04/09/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

BRIGHAM YOUNG UNIVERSITY

Scott Halvorsen

A-357 ASB

PROVO, UT 84602

United States

+1 (801) 422-8450 scott.halvorsen@byu.edu 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

Gary Rex

Director of Accounting and Controller

KBYU

3103 BYUB

Provo, UT 84602

United States

+1 (801) 422-8487 gary.rex@byu.edu

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 See Exhibit A

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 DiamondCD DHD60P2
Year 2000
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 14 kw
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-16
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 12.0 kw
Other Transmitter Type  
Justification for New Transmitter Unable to retune current transmitter - See Exhibit B This is reimbursable configuration. We will actually buy a larger transmitter and pay the difference. Quote for upgraded transmitter will be provided when it is available

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 2 inches
Length 800.0 feet
Other Electrical Service No
Description  
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

Information not provided.

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use  
Change Type Purchase
Manufacturer
Model ULXTE-20
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 12.9 kw
Other Transmitter Type  
Justification for New Transmitter See Exhibit C

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  
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size 50 tons
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? 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 Owned
Owner N/A
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 stacked
Antenna position in stack Bottom
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 8
Number of Panels 48
Design power capacity in use 81.0 %
Lower Limit 590.00 MHz
Upper Limit 680.00 MHz
Other Antenna Type N/A
ERP: 346.00 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
35823 KUTV
36607 KJZZ-TV
6359 KSL-TV
68889 KTVX
69582 KUEN
69396 KUED
1136 KUCW

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 Type Class Full Power
Mounting Top-mount stacked
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: 188.00 kW
Manufacturer
Model 759 25063
Year 2017
Justification for New Antenna Cannot be retuned. (See Exhibit D) Current panel antennas are finely tuned to a specific band, but the new repacked channels are not within the specific 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
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

Installation of 48 new panels w/ harness See Exhibit D

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 Owned
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
68889 KTVX DTV
1136 KUCW DTV
69582 KUEN DTV
69396 KUED DTV
36607 KJZZ-TV DTV
35823 KUTV DTV
6359 KSL-TV DTV
77512 KPNZ DTV

Other Types of Users

Users
GoGo Air

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 Due to the very complex nature of handling the project for 8 combined stations, outside services are required - See Exhibit K
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility Yes
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 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 Yes
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 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 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 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

Garbage Disposal

Remove general garbage from mountaintop site (not equipment removal)

KSTU Mask Filter

Needed for KSTU(CH28) to protect KUED (CH27) (See exhibit N)

Road Maintenance

Snow plowing, grading, and repairs to existing road to remote mountaintop site. (See exhibit R)

Temporary Sanitation

For onsite workers (See exhibit S)

Temporary Storage

For tools and equipment onsite and staging area off site. (See exhibit P)

Transportation Services

Snow Cat and helicopter to move equipment and personnel to remote mountaintop site during winter season. (See exhibit R)

DTV Utah Operating Agreement Equity Equalization

Per Operating Agreement signed July 1998 (See exhibit M)

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 $1,553,100.00 $692,191.00 N/A $0.00 N/A
Total for all systems $3,417,340.25 $1,609,078.25 N/A $0.00 N/A
Interim Transmitter ULXTE-20 $977,800.00 $130,891.00 $0.00
UHF inside RF system including switching $143,500.00 $17,500.00 1/8 shared cost $0.00 N/A
50 Ton system $259,000.00 $31,625.00 1/8 shared cost N/A N/A
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW $481,500.00 $70,534.00 1/8 shared cost See exhibit C N/A N/A
Switchgear - industrial 800 amp $37,150.00 $4,357.00 1/8 shared cost N/A N/A
Transformer 3 phase/480v - 300 KVA $35,850.00 $4,375.00 1/8 shared cost N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $20,800.00 $2,500.00 1/8 shared cost N/A N/A
Primary Transmitter ULXTE-16 $575,300.00 $561,300.00 $0.00
Switchgear - industrial 800 amp $37,150.00 $36,300.00 N/A N/A N/A
Transformer 3 phase/480v - 300 KVA $35,850.00 $35,000.00 N/A N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $20,800.00 $20,000.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW $481,500.00 $470,000.00 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 $425,813.00 $394,713.00 N/A $0.00 N/A
Total for all systems $3,417,340.25 $1,609,078.25 N/A $0.00 N/A
Primary Antenna 759 25063 $425,813.00 $394,713.00 $0.00
Antenna Installation $37,677.00 $37,677.00 1/8 shared cost - Total cost is 282,098.32 + Tax. See exhibit D N/A N/A
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed) $13,300.00 $1,625.00 1/8 shared cost N/A N/A
Combiner output splitting/switching for dual feed lines, if applicable $120,000.00 $0.00 Included in combiner cost - see exhibit E N/A N/A
New combiner, cost per channel (without antenna) $80,000.00 $185,000.00 1/8 shared cost - See Exhibit E 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 - Total cost is 1,179,902.46 + Tax See Exhibit D N/A N/A
Sweep test of existing antenna $6,550.00 $2,125.00 1/8 shared cost 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 $831,300.00 $101,500.00 N/A $0.00 N/A
Total for all systems $3,417,340.25 $1,609,078.25 N/A $0.00 N/A
Primary Tower TOWER $831,300.00 $101,500.00 $0.00
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $409,500.00 $50,000.00 1/8 shared cost Total cost to be determined. Partial cost in exhibit L N/A N/A
Major tower reinforcement/modifications $409,500.00 $50,000.00 1/8 shared cost N/A N/A
Structural engineering tower load study for well documented tower $12,300.00 $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 $271,940.00 $85,750.00 N/A $0.00 N/A
Total for all systems $3,417,340.25 $1,609,078.25 N/A $0.00 N/A
Outside Professional Services $271,940.00 $85,750.00 $0.00
RF Exposure Measurements $20,500.00 $2,500.00 1/8 shared cost N/A N/A
Comprehensive coverage verification via field study, if needed $81,900.00 $10,000.00 1/8 shared cost N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $7,170.00 $7,000.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,095.00 $4,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,305.00 $2,250.00 N/A N/A N/A
Attorney Fees - Aux Antenna, prepare and File Form 2100 Construction Permit or License Application $4,100.00 $4,000.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $3,070.00 $3,000.00 N/A N/A N/A
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, License to Cover Application $1,535.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $1,500.00 N/A N/A N/A
Project management of the transition $123,200.00 $28,000.00 1/8 shared cost N/A N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,560.00 $2,500.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A N/A N/A
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, Construction Permit Application $2,050.00 $2,000.00 N/A N/A N/A

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 $335,187.25 $334,924.25 N/A $0.00 N/A
Total for all systems $3,417,340.25 $1,609,078.25 N/A $0.00 N/A
Other Expenses $335,187.25 $334,924.25 $0.00
DTV Utah Operating Agreement Equity Equalization $223,083.00 $223,083.00 See Exhibit M N/A N/A
Transportation Services $5,000.00 $5,000.00 1/8 shared cost. To be used for inclement weather. N/A N/A
Temporary Storage $4,000.00 $4,000.00 1/8 shared cost. Staging warehouse. See exhibit P N/A N/A
Temporary Sanitation $3,000.00 $3,000.00 1/8 shared cost. See exhibit S. Estimate based on experience at site. N/A N/A
Road Maintenance $10,000.00 $10,000.00 1/8 shared cost. See exhibit R N/A N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 N/A N/A N/A
Equipment Storage $4,000.00 $4,000.00 1/8 shared cost. On site storage. Total based on bids and experience at site. See exhibit Q N/A N/A
Equipment Delivery and Handling Charges $8,125.00 $8,125.00 1/8 shared cost. See exhibit P N/A N/A
Non-zoning permits $1,875.00 $1,875.00 1/8 shared cost. County will not provide estimates. Cost estimated based on experience at site. N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,070.00 $1,070.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $25,000.00 $25,000.00 Production plus air time. Will include radio time. N/A N/A
KSTU Mask Filter $6,756.25 $6,756.25 Mask filter to remedy adjacent channel problem with KSTU - See exhibit N - 1/8 shared cost. N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $25,000.00 $25,000.00 1/8 shared cost on common equipment. Individual station cost for transmitter. Based on experience. N/A N/A
Garbage Disposal $1,500.00 $1,500.00 1/8 shared cost. Not related to equipment disposal. Billed as used, estimate based on experience at site. N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $333.00 $325.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $3,417,340.25 $1,609,078.25 $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.

Matthew Richardson

Advancement Vice President


04/09/2018

Certification

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Section Question Response
Submission of Actual Cost Documentation 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 and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material.

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

  3. 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).

  4. 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.

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

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

  7. 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.

Matthew Richardson

Advancement Vice President


04/09/2018

Attachments

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