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:
0000028625
FRN:
0003780202
Facility ID:
70852
Repack Channel:
20 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
04/24/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WAND(TV) PARTNERSHIP

Keith Wilkowski

624 W. MUHAMMAD ALI BLVD.

LOUISVILLE, KY 40203

United States

+1 (419) 277-6006 kwilkowski@blockcommunications.com Limited Partnership

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

Robert Gunther

Chief Engineer

WAND(TV) Partnership

Robert Gunther

904 Southside Drive

Decatur, IL 62521

United States

+1 (217) 424-2500 Robert.Gunther@wandtv.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 New transmitter will be placed in existing building. A side mount antenna will be placed on existing tower until time to shut down current transmitter and put new TX online and correct primary antenna placed on top of the tower.

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 Refurbished HP50DDW
Year 2006
Type Inductive Output Tube
IOT Power Type Two
Description  
Power capacity 50 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-90
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 50 kw
Other Transmitter Type  
Justification for New Transmitter Existing unit is outdated and can not be re-tuned to new specs.

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 300 kVA
Rigid Conduit and Wiring No
Size
Length
Other Electrical Service Yes
Description Parallel Surge Suppressor for 3PH WYE or DELTA (Lightning and surge protection).
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

Name Description

Building Electrical work

Install electrical system components in building by ALLTECH Electric

RF Accessories

RF system components necessary for the interim use and permanent install of the new transmitter

Shipping

Shipping charges for transmitter components

State and local sales tax on transmitter

State and Local Sales tax on the new transmitter.

Installation services

Fees for installing the transmitter and inside RF system.

State and local sales tax on materials needed for electrical service

State and Local Sales tax on materials relating to electrical installation

Mask Filter

Filter for preventing out of band emmisions

Transmitter Electrical Work

Electrical work for installation of GatesAir transmitter

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 Top-mount single
Antenna position in stack Not in Stack
Polarization Circular
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 TFU-31JTH/VP-R T110C
Year 2011

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? No
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 Circular
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-31JTH/VP-R T110/C150 CH 20
Year 2017
Justification for New Antenna Changing from channel 17 to channel 20. Current equipment cannot be used for the new 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 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

Reducer

Transmission line reducer-two needed

State and Local Sales Tax

State and local sales tax in the amount of 9.25% is calculated on the total cost, bringing the total amount to 627937.32

Transformer

Matching transformer for new transmission line-two needed

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? No
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 Slot
Number of Stations Supported 1
Number of Panels/Bays 16
Lower Limit 470.00 MHz
Upper Limit 695.00 MHz
Design power capacity in use 100.0 %
Other Antenna Type N/A
ERP: 435.30 kW
Manufacturer
Model TFU-16WB/VP-R S230
Year 2017
Justification for New Antenna Interim side mount antenna to be put in place while primary antenna and feedline is replaced to minimize loss of on air time.

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 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

Interim Antenna

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Other Antenna Cost Not Listed

Name Description

Transformer

Matching transformer for new transmission line.

Sales Tax

State and local sales tax is calculated at 9.25% on the amount of the total sale, bringing the total cost to 383011.38

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 8 3/16 inches
Segment Length 19 ¾ '
Other Segment Length
Number of parallel runs 1
Length 1350 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? Yes
Type Rigid
Diameter 8 3/16 inches
Segment Length 19 ¾ '
Other Segment Length
Number of parallel runs 1
Length 1200 feet per run
Justification for New Transmission Line Current equipment cannot be used for the new channel.

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 6 1/8 inches
Segment Length 19 ¾ '
Other Segment Length
Number of parallel runs 1
Length 1350 feet per run
Justification for New Transmission Line Current transmission line cannot be used with new channel assignment of channel 20

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? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
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 1009651
Coordinates (NAD83) Latitude (NAD83) 39° 57' 08.6" N-
Longitude (NAD83) 088° 49' 56.6" W-
Overall Structure Height 1313.96 feet
Support Structure Height 1243.10 feet
Ground Elevation Above Mean Sea Level (AMSL) 686.02 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner WAND(TV) Partnership
Date Constructed 10/01/1980


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: No 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? No
Number of Hours N/A
Explanation N/A
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 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 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 Yes
ASR Modification Yes
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations No
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 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)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? No
Does this relocation require Equipment Storage? No
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? No
Does this relocation require MVPD Notification of a Channel Change? No

Other Expenses

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Other Expenses Not Listed

Name Description

Rental of heavy equipment

rental of forklift or sky-jack to off load transmitter antennas and transmission line and other equipment.

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 $1,861,551.57 $1,751,173.73 N/A $1,745,863.88 N/A
Total for all systems $3,542,345.77 $3,195,206.43 N/A $1,745,863.88 N/A
Primary Transmitter ULXTE-90 $1,861,551.57 $1,751,173.73 $1,745,863.88
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,434,000.00 $1,359,472.16 N/A $1,359,472.16 N/A
State and local sales tax on transmitter $106,055.20 $106,055.20 N/A $100,745.35 N/A
Installation services $81,690.50 $81,690.50 N/A $81,690.50 N/A
Transmitter Electrical Work $12,101.82 $12,101.82 N/A $12,101.82 N/A
Mask Filter $56,125.88 $56,125.88 N/A $56,125.88 N/A
State and local sales tax on materials needed for electrical service $0.00 $0.00 N/A $0.00 N/A
Shipping $13,500.00 $13,500.00 N/A $13,500.00 N/A
Building Electrical work $0.00 $0.00 N/A $0.00 N/A
Transformer 3 phase/480v - 300 KVA $35,850.00 $0.00 N/A $0.00 N/A
Other Electrical Service: Parallel Surge Suppressor for 3PH WYE or DELTA (Lightning and surge protection). $0.00 $0.00 N/A $0.00 N/A
RF Accessories $122,228.17 $122,228.17 N/A $122,228.17 N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW

Component Description:
Transmitter
Amount:
$192,023.01

Component Description:
This invoice is for 2/3 of the transmitter cost and is now due. The final 1/3 will be due after installation.
Amount:
$1,167,449.15
State and local sales tax on transmitter

Component Description:
Tax
Amount:
$100,745.35
Installation services

Component Description:
This is the line item for installation of the transmitter shown on the invoice.
Amount:
$81,690.50
Transmitter Electrical Work

Component Description:
This is the electrical cost for the transmitter.
Amount:
$12,101.82
Mask Filter

Component Description:
This is the line item for the Mask Filter System on the invoice.
Amount:
$56,125.88
State and local sales tax on materials needed for electrical service Information not provided.
Shipping

Component Description:
This is the line item for freight for the attached invoice.
Amount:
$13,500.00
Building Electrical work Information not provided.
Transformer 3 phase/480v - 300 KVA Information not provided.
Other Electrical Service: Parallel Surge Suppressor for 3PH WYE or DELTA (Lightning and surge protection). Information not provided.
RF Accessories

Component Description:
This is the line item for RF accessories on the attached invoice.
Amount:
$122,228.17

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 $645,826.20 $590,731.70 N/A $0.00 N/A
Total for all systems $3,542,345.77 $3,195,206.43 N/A $1,745,863.88 N/A
Interim Antenna TFU-16WB/VP-R S230 $279,876.88 $274,696.88 $0.00
Sales Tax $32,428.88 $32,428.88 N/A $0.00 N/A
Transformer $7,898.00 $7,898.00 Two transformers are required for impedance matching for interim antenna, primary antenna and transmitter. $0.00 N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,000.00 $11,970.00 Price quoted by manufacturer, quote attached. $0.00 N/A
UHF - Lower Power Side Mount, One station antenna -- 200-500 kW, elliptically or circularly polarized $221,000.00 $216,000.00 N/A N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A $0.00 N/A
Primary Antenna TFU-31JTH/VP-R T110/C150 CH 20 $365,949.32 $316,034.82 $0.00
Transformer $7,897.00 $7,897.00 Two transformers are required for impedance matching for interim antenna, primary antenna and transmitter. $0.00 N/A
State and Local Sales Tax $53,166.32 $53,166.32 N/A $0.00 N/A
Reducer $4,836.00 $4,836.00 N/A $0.00 N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,000.00 $10,298.00 N/A $0.00 N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $281,500.00 $233,437.50 N/A $0.00 N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A $0.00 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 $671,550.00 $527,497.00 N/A $0.00 N/A
Total for all systems $3,542,345.77 $3,195,206.43 N/A $1,745,863.88 N/A
Interim Transmission Line $265,950.00 $215,595.00 $0.00
Rigid Transmission Line - copper, 6 1/8" $265,950.00 $215,595.00 N/A $0.00 N/A
Primary Transmission Line $405,600.00 $311,902.00 $0.00
Rigid Transmission Line - copper, 8 3/16" $405,600.00 $311,902.00 N/A $0.00 N/A

Components

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $217,300.00 $191,501.00 N/A $0.00 N/A
Total for all systems $3,542,345.77 $3,195,206.43 N/A $1,745,863.88 N/A
Primary Tower TOWER $217,300.00 $191,501.00 $0.00
Structural engineering tower load study for well documented tower $12,300.00 $8,000.00 N/A $0.00 N/A
Tall Tower (greater than 500') $205,000.00 $183,501.00 N/A $0.00 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 $131,840.00 $128,750.00 N/A $0.00 N/A
Total for all systems $3,542,345.77 $3,195,206.43 N/A $1,745,863.88 N/A
Outside Professional Services $131,840.00 $128,750.00 $0.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,305.00 $2,250.00 N/A $0.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A $0.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $1,500.00 N/A $0.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A $0.00 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,560.00 $2,500.00 N/A $0.00 N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A $0.00 N/A
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet $10,240.00 $10,000.00 N/A $0.00 N/A
ASR modification (prepare FCC Form 854) $2,050.00 $2,000.00 N/A $0.00 N/A
Comprehensive coverage verification via field study, if needed $81,900.00 $80,000.00 N/A $0.00 N/A
RF Exposure Measurements $20,500.00 $20,000.00 N/A $0.00 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 $14,278.00 $5,553.00 N/A $0.00 N/A
Total for all systems $3,542,345.77 $3,195,206.43 N/A $1,745,863.88 N/A
Other Expenses $14,278.00 $5,553.00 $0.00
Rental of heavy equipment $2,500.00 $2,500.00 N/A $0.00 N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A $0.00 N/A
FCC Filing Fees - Form 2100 license to cover application $333.00 $325.00 N/A $0.00 N/A
DTV Medical Facility Notification $11,250.00 $2,538.00 N/A $0.00 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 $3,542,345.77 $3,195,206.43 $1,745,863.88

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.

Keith Wilkowski

VP Legal & Govt Affairs


04/24/2018

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.

Keith Wilkowski

VP Legal & Govt Affairs


04/24/2018

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