Go to the Federal Communications Commission homepage at www.fcc.gov

FCC Form 399: Incentive Auction Relocation Reimbursement Fund System

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

(REFERENCE COPY - Not for submission)FCC Form 399: Incentive Auction Relocation Reimbursement Fund System

File Number:
0000028864
FRN:
0006551626
Facility ID:
415
Repack Channel:
36 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
11/27/2017

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WUTV LICENSEE, LLC

Doing Business As: WUTV LICENSEE, LLC

Harvey Arnold

10706 Beaver Dam Road

Cockeysville, MD 21030

United States

+1 (410) 568-1500 harnold@sbgtv.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

Paul A Cicelski , Esq. .

Lerman Senter PLLC

Paul Cicelski

2001 L Street, NW

Suite 400

Washington, DC 20036

United States

+1 (202) 429-8970 pcicelski@lermansenter.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan 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 60QXD2
Year 2004
Type Inductive Output Tube
IOT Power Type Two
Description  
Power capacity 60 kw
Solid State Cooling  
Solid State Power Capacity  
Other Transmitter Type  

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Description of Use  
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model ULXTE-40
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 23.3 kw
Other Transmitter Type  
Justification for New Transmitter Per the manufacturer, the current transmitter cannot be retuned. See Exhibit B.

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.

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Side-mount
Antenna position in stack Not in Stack
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: 1000.00 kW
Manufacturer
Model TFU16DSB-E-R-(C)
Year 2006

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? Yes
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 Type Class Full Power
Mounting Top-mount single
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 1000.00 kW
Manufacturer
Model TFU-24DSB-E
Year 2017
Justification for New Antenna Current antenna is a single channel antenna that cannot be used for the new post-auction channel.

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 4 1/16 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

Information not provided.

Interim Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Interim
Description of Use N/A
Change Type Purchase New
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? 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 Elliptical
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 8
Lower Limit 470.00 MHz
Upper Limit 598.00 MHz
Design power capacity in use 100.0 %
Other Antenna Type N/A
ERP: 100.00 kW
Manufacturer
Model TFU-8WB-1-R
Year 2017
Justification for New Antenna Interim antenna to be used to stay on the air while the main antenna undergoes construction for the post-auction channel change.

Interim Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 3 1/8 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

Interim Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Utilize Existing
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Dielectric
Type Rigid
Diameter 4 1/16 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 1500 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

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 3 1/8 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 600 feet per run
Justification for New Transmission Line Interim transmission line will feed the interim antenna.

Interim Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Owned
Is this tower consider Complex? Candelabra
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) No
Others Types of Users Yes
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1019110
Coordinates (NAD83) Latitude (NAD83) 43° 01' 32.2" N-
Longitude (NAD83) 078° 55' 42.1" W-
Overall Structure Height 1110.88 feet
Support Structure Height 1045.92 feet
Ground Elevation Above Mean Sea Level (AMSL) 588.90 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner SINCLAIR TELEVISION OF BUFFALO, INC.
Date Constructed 08/06/1998


Other Types of Users

Users
MediaFLO
FBI
Grand Is Fire D
Homeland Sec
US Customs

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 tower with candelabra
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 Candelabra
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 470
Explanation Outside consulting engineering, legal work, and accounting services, as well as project management for regional and comprehensive repack execution.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility N/A
For Main Facility Yes N/A
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 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 Yes
Environmental Assessment Yes
ASR Modification Yes
FAA Consultation (including preparation of FAA Form 7460) Yes
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 No
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

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

Other Expenses

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Other Expenses Not Listed

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 $991,300.00 $991,300.00 N/A $0.00 N/A
Total for all systems $2,630,381.00 $2,633,102.00 N/A $3,955.98 N/A
Primary Transmitter ULXTE-40 $991,300.00 $991,300.00 $0.00
2" Rigid Conduit and Wiring (Cost per foot) $20,000.00 $20,000.00 N/A N/A N/A
Transformer 3 phase/480v - 300 KVA $35,000.00 $35,000.00 N/A N/A N/A
Switchgear - industrial 800 amp $36,300.00 $36,300.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW $900,000.00 $900,000.00 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 $424,300.00 $427,021.00 N/A $0.00 N/A
Total for all systems $2,630,381.00 $2,633,102.00 N/A $3,955.98 N/A
Interim Antenna TFU-8WB-1-R $133,800.00 $133,800.00 $0.00
UHF - Lower Power Side Mount, One Station antenna . medium power (50-200 kW), elliptically or circularly polarized $98,000.00 $98,000.00 N/A N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $22,000.00 $22,000.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 3 1/8. feedline (if needed) $7,400.00 $7,400.00 N/A N/A N/A
Sweep test of existing antenna $6,400.00 $6,400.00 N/A N/A N/A
Primary Antenna TFU-24DSB-E $290,500.00 $293,221.00 $0.00
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $275,000.00 $277,721.00 See Response to August 8 Inquiry. N/A N/A
Sweep test of existing antenna $6,400.00 $6,400.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed) $9,100.00 $9,100.00 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 $59,400.00 $59,400.00 N/A $0.00 N/A
Total for all systems $2,630,381.00 $2,633,102.00 N/A $3,955.98 N/A
Interim Transmission Line $59,400.00 $59,400.00 $0.00
Rigid Transmission Line - copper, 3 1/8" $59,400.00 $59,400.00 N/A N/A N/A
Primary Transmission Line $0.00 $0.00 $0.00

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 $819,000.00 $819,000.00 N/A $0.00 N/A
Total for all systems $2,630,381.00 $2,633,102.00 N/A $3,955.98 N/A
Primary Tower TOWER $819,000.00 $819,000.00 $0.00
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $400,000.00 $400,000.00 N/A N/A N/A
Major tower reinforcement/modifications $400,000.00 $400,000.00 N/A N/A N/A
Structural engineering tower load study for a documented tower with candelabra $19,000.00 $19,000.00 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 $208,250.00 $208,250.00 N/A $3,955.98 N/A
Total for all systems $2,630,381.00 $2,633,102.00 N/A $3,955.98 N/A
Outside Professional Services $208,250.00 $208,250.00 $3,955.98
Project management of the transition $70,500.00 $70,500.00 N/A $3,803.97 N/A
Prepare and or review reimbursement form $2,500.00 $2,500.00 N/A $152.01 N/A
Comprehensive coverage verification via field study, if needed $80,000.00 $80,000.00 N/A N/A N/A
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase $2,000.00 $2,000.00 N/A N/A N/A
ASR modification (prepare FCC Form 854) $2,000.00 $2,000.00 N/A N/A N/A
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet $10,000.00 $10,000.00 N/A N/A N/A
NEPA Section 106 environmental review, if needed $6,000.00 $6,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $7,000.00 $7,000.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,000.00 $4,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,250.00 $2,250.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,000.00 $5,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $3,000.00 $3,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,500.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,000.00 $3,000.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,000.00 $7,000.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,500.00 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$32.35

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$43.72

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$912.82

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$731.71

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$1,954.93

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$20.91

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$107.53
Prepare and or review reimbursement form

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$152.01
Comprehensive coverage verification via field study, if needed Information not provided.
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase Information not provided.
ASR modification (prepare FCC Form 854) Information not provided.
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet Information not provided.
NEPA Section 106 environmental review, if needed Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization 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.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for new channel assignment and antenna development 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 $128,131.00 $128,131.00 N/A $0.00 N/A
Total for all systems $2,630,381.00 $2,633,102.00 N/A $3,955.98 N/A
Other Expenses $128,131.00 $128,131.00 $0.00
MVPD Notification of Channel Change $5,000.00 $5,000.00 See Exhibit J. N/A N/A
Develop and air announcement of upcoming channel change $28,050.00 $28,050.00 See Response to August 8 Inquiry. N/A N/A
Equipment Storage $15,000.00 $15,000.00 See Exhibit J. N/A N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 See Exhibit J. N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $28,566.00 $28,566.00 See Response to August 8 Inquiry. N/A N/A
Non-zoning permits $10,000.00 $10,000.00 See Exhibit J. N/A N/A
Local Zoning $20,000.00 $20,000.00 See Exhibit J. N/A N/A
FCC Filing Fees - Special Temporary Authorization request $190.00 $190.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $325.00 $325.00 N/A N/A N/A
DTV Medical Facility Notification $11,000.00 $11,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $2,630,381.00 $2,633,102.00 $3,955.98

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.

David Amy

Secretary, Sinclair Broadcast Group, Inc.


11/27/2017

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.

David Amy

Secretary, Sinclair Broadcast Group, Inc.


11/27/2017

Attachments

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