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:
0000026619
FRN:
0006610976
Facility ID:
67190
Repack Channel:
23 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
07/03/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

LA CADENA DEL MILAGRO, INC.

Doing Business As: LA CADENA DEL MILAGRO, INC.

Esteban Paredes

P.O. BOX 949

CAMUY, PR 00627

United States

+1 (787) 262-5400 montero@fhhlaw.com Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

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 The main transmitter and the main and antenna wil be replaced according to the schedule of equipment delivery and tower modifications necessary.

Transmitters

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Section Question Response
Transmitter Related Expenses Do you have transmitter related expenses? Yes

Auxiliary Transmitter

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Add Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Auxiliary (Backup)
Description of Use Backup used when Main transmitter fail or needs repair/maintenace
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 Affinity
Year 2000
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 0.5 kw
Other Transmitter Type  

Auxiliary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Auxiliary (Backup)
Description of Use To be used when the main trasmitter fails or needs maintenance
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model EC702HP-BB
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 1 kw
Other Transmitter Type  
Justification for New Transmitter To be used when the main transmitter fails or needs maintenance.

Auxiliary 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) No
Power
Rigid Conduit and Wiring Yes
Size 1 inches
Length 30.0 feet
Other Electrical Service Yes
Description Panel breaker, ground system, connecting cables.
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  

Auxiliary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Shipping and Crating

Shipping and crating to San Juan

Transmitter

System, WVSN EC702HP

Installation of LPTV

Installation of EC702 HP

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 Ultimate TDU2 5K00
Year 2004
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 5 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? No
Manufacturer
Model Parallax
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 5 kw
Other Transmitter Type  
Justification for New Transmitter Existing transmitter manufacturer no longer on the market. We are requesting a replacement transmitter with the same "headroom" transmitter capacity as the existing transmitter.

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) No
Power
Rigid Conduit and Wiring Yes
Size 2 inches
Length 30.0 feet
Other Electrical Service Yes
Description Additional panel breaker, safety switches for liquid pumps, electrical conduits and cables, ground system, etc.
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? Yes
Size 400.0 square feet
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

Transmitter Installation

Installation of Parlax U4 D23

Shipping and Crating

Shipping of Paralax U4 D23

Transmitter Proof of Performance

Performance of Parlax U4 D23

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? 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: 46.00 kW
Manufacturer
Model JA/MS-AW-12
Year 2008

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 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: 27.40 kW
Manufacturer
Model PSILPD12AW-23-EP
Year 2017
Justification for New Antenna Existing antenna can't be frequency change. Upgrading to an elliptically polarized antenna to improve coverage due to the new reduced ERP.

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? No
Broadband or Single Channel? N/A
Feed Line Size N/A
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.

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 Horizontal
Type Broadband Slot
Number of Stations Supported 1
Number of Panels/Bays 1
Lower Limit 470.00 MHz
Upper Limit 806.00 MHz
Design power capacity in use 60.0 %
Other Antenna Type N/A
ERP: 10.00 kW
Manufacturer
Model PSILP8A W23
Year 2018
Justification for New Antenna This antenna will be used during new main antenna installation and could be used later with the new assigned frequency for backup purposes.

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? No
Broadband or Single Channel? N/A
Feed Line Size N/A
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

Name Description

Connectors Adapters

To be used to couple the antenna and transmission line

Transmission Line

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

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 Flexible Foam
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 250 feet per run
Justification for New Transmission Line Line to feed the interim antenna during main antenna installation.

Interim Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Connectors Adapters

Used to interconnect antenna, line and transmitter

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

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 160
Explanation It is a religious station with limited operating costs and do not have personnel with the expertise and qualifications to manage a complicated project like this.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 2
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 2
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations 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 No
RF exposure measurements Yes
Additional Field Engineering Service Yes
Number of Days 10
Justification Transmitter related RF components connections, test coordination with Arecibo Observatory and other local entities.

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 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

Station Personnel

Extra time incurred by station personnel and travel expenses.

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 $565,927.00 $449,997.00 N/A $181,173.50 N/A
Total for all systems $845,671.50 $722,970.69 N/A $193,699.38 N/A
Primary Transmitter Parallax $354,972.00 $322,042.00 $138,146.00
Transmitter Proof of Performance $13,100.00 $13,100.00 N/A $6,550.00 N/A
Shipping and Crating $11,457.00 $11,457.00 N/A $5,728.50 N/A
Transmitter Installation $18,635.00 $18,635.00 N/A $9,317.50 N/A
Other -- Building Addition Size: 400.0 $40,000.00 $40,000.00 $100 per foot $0.00 N/A
UHF - Liquid Cooled Solid State Transmitter 4.9 . 6.5 kW $266,000.00 $233,100.00 N/A $116,550.00 N/A
2" Rigid Conduit and Wiring (Cost per foot) $780.00 $750.00 N/A N/A N/A
Other Electrical Service: Additional panel breaker, safety switches for liquid pumps, electrical conduits and cables, ground system, etc. $5,000.00 $5,000.00 N/A N/A N/A
Auxiliary Transmitter EC702HP-BB $210,955.00 $127,955.00 $43,027.50
Installation of LPTV $13,549.00 $13,549.00 N/A $6,774.50 N/A
Transmitter $67,166.00 $67,166.00 N/A $33,583.00 N/A
Shipping and Crating $5,340.00 $5,340.00 N/A $2,670.00 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $123,000.00 $40,000.00 Amount adjusted according to an e-mail received : 2017-07-25 14:23:52 EDT by Geoffrey Mendenhall N/A N/A
1" Rigid Conduit and Wiring $400.00 $400.00 N/A N/A N/A
Other Electrical Service: Panel breaker, ground system, connecting cables. $1,500.00 $1,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Transmitter Proof of Performance

Component Description:
First 50 % Payment of TV Transmitter Proof Performance
Amount:
$6,550.00
Shipping and Crating

Component Description:
First 50 % Payment of Shipping and Crating TV transmitter
Amount:
$5,728.50
Transmitter Installation

Component Description:
First 50 % Payment of TV transmitter Installation
Amount:
$9,317.50
Other -- Building Addition Size: 400.0 Information not provided.
UHF - Liquid Cooled Solid State Transmitter 4.9 . 6.5 kW

Component Description:
first 50% Payment of UHF TV transmitter
Amount:
$116,550.00
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Other Electrical Service: Additional panel breaker, safety switches for liquid pumps, electrical conduits and cables, ground system, etc. Information not provided.
Installation of LPTV

Component Description:
First 50% payment of Auxiliary TV Transmitter installation
Amount:
$6,774.50
Transmitter

Component Description:
First 50% Payment of Auxilary TV Transmitter
Amount:
$33,583.00
Shipping and Crating

Component Description:
First Payment of 50% of shipping and crating
Amount:
$2,670.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW Information not provided.
1" Rigid Conduit and Wiring Information not provided.
Other Electrical Service: Panel breaker, ground system, connecting cables. 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 $100,096.50 $98,576.50 N/A $11,538.49 N/A
Total for all systems $845,671.50 $722,970.69 N/A $193,699.38 N/A
Interim Antenna PSILP8A W23 $41,637.50 $40,937.50 $3,458.83
Side mount brackets for high power antennas (if not included in antenna base cost) $22,550.00 $22,000.00 N/A $0.00 N/A
UHF - High Power, Side Mount, basic slot antenna, 1 bay,, 8 - 10 kW input, horizontally polarized $10,037.50 $10,037.50 N/A $3,458.83 N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A
Connectors Adapters $2,500.00 $2,500.00 N/A N/A N/A
Primary Antenna PSILPD12AW-23-EP $58,459.00 $57,639.00 $8,079.66
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,120.00 $5,000.00 N/A N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $22,550.00 $22,000.00 N/A N/A N/A
UHF - High Power, Side Mount, basic slot antenna, 27 kW input, directional,, elliptically or circularly polarized $24,239.00 $24,239.00 N/A $8,079.66 N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A

Components

Actual Information Description File Name
Side mount brackets for high power antennas (if not included in antenna base cost) Information not provided.
UHF - High Power, Side Mount, basic slot antenna, 1 bay,, 8 - 10 kW input, horizontally polarized

Component Description:
First 1/3 payment of the cost of the antenna that is due now
Amount:
$3,458.83
Sweep test of existing antenna Information not provided.
Connectors Adapters Information not provided.
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) Information not provided.
UHF - High Power, Side Mount, basic slot antenna, 27 kW input, directional,, elliptically or circularly polarized

Component Description:
First 1/3 Payment of the cost of the antenna.
Amount:
$8,079.66
Sweep test of existing antenna 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 $8,500.00 $5,462.19 N/A $987.39 N/A
Total for all systems $845,671.50 $722,970.69 N/A $193,699.38 N/A
Interim Transmission Line $8,500.00 $5,462.19 $987.39
Flexible Foam Transmission Line - dielectric, 1 5/8" $6,000.00 $2,962.19 N/A $987.39 N/A
Connectors Adapters $2,500.00 $2,500.00 N/A $0.00 N/A

Components

Actual Information Description File Name
Flexible Foam Transmission Line - dielectric, 1 5/8"

Component Description:
Firs 1/3 payment of the cost of the transmission line
Amount:
$987.39
Connectors Adapters 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 $0.00 $0.00 N/A $0.00 N/A
Total for all systems $845,671.50 $722,970.69 N/A $193,699.38 N/A
Primary Tower $0.00 $0.00 $0.00

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 $84,700.00 $82,750.00 N/A $0.00 N/A
Total for all systems $845,671.50 $722,970.69 N/A $193,699.38 N/A
Outside Professional Services $84,700.00 $82,750.00 $0.00
Additional Field Engineering Service, 10 Days $5,000.00 $5,000.00 $500 per day (10 days) N/A N/A
RF Exposure Measurements $20,500.00 $20,000.00 N/A 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 -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 - 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
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $1,500.00 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
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 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
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A N/A N/A
Project management of the transition $24,640.00 $24,000.00 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 $86,448.00 $86,185.00 N/A $0.00 N/A
Total for all systems $845,671.50 $722,970.69 N/A $193,699.38 N/A
Other Expenses $86,448.00 $86,185.00 $0.00
Station Personnel $21,100.00 $21,100.00 See attachment N/A N/A
MVPD Notification of Channel Change $10,000.00 $10,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $2,500.00 $2,500.00 N/A N/A N/A
Equipment Storage $5,000.00 $5,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $15,000.00 $15,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $20,000.00 $20,000.00 N/A 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
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

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $845,671.50 $722,970.69 $193,699.38

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.

Esteban Paredes

General Manager


07/03/2018

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.

Esteban Paredes

General Manager


07/03/2018

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