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:
0000028746
FRN:
0001731298
Facility ID:
2175
Repack Channel:
19 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
07/19/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

SISTEMA UNIVERSITARIO ANA G. MENDEZ, INC.

Doing Business As: SISTEMA UNIVERSITARIO ANA G. MENDEZ, INC.

P.O. BOX 21345

SAN JUAN, PR 00928

United States

+1 (787) 766-2600 CA_ADIAZ@SUAGM.EDU Private Not-for-Profit Educational Institution

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

Ariel Diaz

Engineering VP

SISTEMA UNIVERSITARIO ANA G. MENDEZ INC

ARIEL DIAZ Sistema-TV

PO Box 21345

San Juan, PR 00928

United States

+1 (787) 766-2600 ca_adiaz@suagm.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. No
Briefly describe transition plan File CP, Perform Tower Reinforcement and Orders for equipment. File STA, Field Survey and Design. Install interim antenna. Remove present antenna. New equipment installation. Send notifications. File License. Narrative Attached

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 2
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model CU2TD-1400
Year 2013
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 1.4 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 EC702-HP BB DOH
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 1.7 kw
Other Transmitter Type  
Justification for New Transmitter Original Manufacturer is no longer at the market, The product is no longer produced by the new company UBS Axcera. The company is not responsive for service support and take 6 month for repairs of an amp. Never send certifications (emails attached)

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 100.0 feet
Other Electrical Service Yes
Description Surge Protector, Voltage Regulator and UPS are required for new transmitter installation. Distribution panel modification and rewiring for new transmitter
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size Other tons
Other Size 3 tons
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 80.0 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

Maritime Transportation

Due to the particular conditions of an island, special maritime transportation is required from port to port

System Design and Site Survey

System Design based on Site Survey to prepare an as built and present modifications to accommodate the new transmitters, Filters, RF components. Prepare electrical distribution based on the existing and new components associated with the transition

Crating for Ocean Shipment

Offloading the equipment and placement into the building

Upgraded Mask Filter from 6 to 8 poles

Charge to replace an included RF Mask Filter of 6 pole on the transmitter proposal with 8 pole filter

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 1
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model CTT-U DCX-1 Millenium
Year 2004
Type Inductive Output Tube
IOT Power Type Single
Description  
Power capacity 30 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 HPTV-PRLX-U14
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 19.4 kw
Other Transmitter Type  
Justification for New Transmitter Hitachi Kokusai Electric Comark LLC informed us that they will not be able to re-channel our DCX transmitter. Request for a solid state Txmter is because the cost of a new IOT DCX Txmter is higher than a S.S. (See Attch) One power-level step up in Txmter

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 3 inches
Length 100.0 feet
Other Electrical Service Yes
Description Surge Protector, Voltage Regulator and UPS are required for new transmitter installation. Distribution panel modification and rewiring for new transmitter.
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

Transmitter Motorized Switch Replacement

Extra cost for replace an included (3) port Manual Patch Panel on the transmitter proposal with a motorized Switch as the existing transmission system

Maritime transportation

Due to the particular conditions of an island, special maritime transportation is required from port to port.

Crating for Ocean Shipment

Equipment Crating required for Maritime Transportation

Upgraded RF Maks Filter

Charge to replace an included RF Mask Filter of 6 pole on the transmitter proposal with 8 pole filter

System Design and Site Survey

System Design based on Site Survey to prepare an as built and present modifications to accommodate the new transmitters, Filters, RF components. Prepare electrical distribution based on the existing and new components associated with the transition.

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 2
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? Yes
Existing Antenna Manufacturer and Type Class Full Power
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 15.00 kW
Manufacturer
Model TFU-16DSB/VP-R P270 SP
Year 2013

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and 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: 13.10 kW
Manufacturer
Model TFU-16DSB/VP-R P270 SP
Year 2017
Justification for New Antenna Narrowband Slotted coaxial antenna not suited for rechanneling from CH 25 to CH 19 according to Manufacturer specs

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? 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

Maritime Transportation

Due to the particular conditions of an island, special maritime transportation is required from port to port

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 1
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? Yes
Existing Antenna Manufacturer and Type Class Full Power
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization 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: 800.00 kW
Manufacturer
Model TFU-22DSC P230 DC
Year 2003

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Type Class Full Power
Mounting Side-mount
Antenna position in stack Middle
Polarization Horizontal
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: 696.00 kW
Manufacturer
Model TFU-22DSC-R P230
Year 2017
Justification for New Antenna Narrowband Slotted coaxial antenna not suited for rechanneling from channel 25 to channel 19 according to the manufacturer specs

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? 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

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Maritime Transportation

Due to the particular conditions of an island, special maritime transportation is required from port to port

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? Yes
New 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/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 800.00 kW
Manufacturer
Model TFU-22DSC-R P230 DC
Year 2017
Justification for New Antenna Interim Antenna to operate at Site-1 while the existing antenna is removed and the final antenna for the new channel is installed on the tower.

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

Maritime Transportation

Due to the particular conditions of an island, special maritime transportation is required from port to port

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? Yes
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: 15.00 kW
Manufacturer
Model TFU-16DSB/VP-R P270 SP
Year 2017
Justification for New Antenna Interim Antenna to operate at Site-2 while the existing antenna is removed and the final antenna for the new channel is installed on the tower.

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

Maritime Transportation

Due to the particular conditions of an island, special maritime transportation is required from port to port

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 1
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 6 1/8 inches
Segment Length 19 ½ '
Other Segment Length
Number of parallel runs 1
Length 260 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Rigid
Diameter 6 1/8 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 260 feet per run
Justification for New Transmission Line Existing Transmission line can't be re-used because it have a prohibited length for the re-packed channel

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

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 2
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 Flexible Foam
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 175 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Foam
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 175 feet per run
Justification for New Transmission Line Existing Transmission Line will be relocated with the existing antenna to remain on the air during the transition

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 Flexible Air
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 150 feet per run
Justification for New Transmission Line Interim transmission Line for the Interim antenna, to operate at Site-2 while the existing antenna and transmission line are removed and the final antenna with its transmission line for the new channel are installed on the tower

Interim 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 Flexible Air
Diameter 5 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 240 feet per run
Justification for New Transmission Line Interim transmission Line for the Interim antenna, to operate at Site-1 while the existing antenna and transmission line are removed and the final antenna with its transmission line for the new channel are installed on the tower

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? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1231838
Coordinates (NAD83) Latitude (NAD83) 18° 04' 41.0" N-
Longitude (NAD83) 066° 44' 54.0" W-
Overall Structure Height 243.11 feet
Support Structure Height 197.18 feet
Ground Elevation Above Mean Sea Level (AMSL) 2018.02 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Sistema Universitario Ana G. Mendez
Date Constructed 06/30/2003


Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

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? No
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 18° 18' 58.8" N-
Longitude (NAD83) 067° 10' 47.6" W-
Overall Structure Height 200.00 feet
Support Structure Height 200.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 1148.00 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Aureo Matos
Date Constructed 01/10/1999


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 N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 859
Explanation External resource are required for management this project. The technical and administrative personnel are occupied in daily operations of the station. The Budgeting's constrains of the NCE (PBS) TV station prevent reassign functions or increase personnel
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 1
Do you have Distributed Transmission System engineering services? Yes
Critical Facility 1
Terrain-Shielded Facility 1
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 1
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 No
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 No
FCC Special Temporary Authority Application No
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

Local Sales and Use Taxes

Sales taxes based on 11.5 percent and service taxes based on 4 percent This amount corresponds to a sales and use tax to be paid by any who imports tangible personal property into Puerto Rico or provides services in relation to any property from abroad

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 $953,664.81 $960,264.81 N/A $832,098.60 N/A
Total for all systems $3,133,110.92 $3,109,986.92 N/A $1,192,382.10 N/A
Primary Transmitter EC702-HP BB DOH $201,709.81 $154,409.81 $118,128.60
System Design and Site Survey $15,300.00 $15,300.00 System Design based on Site Survey to prepare an as built and present modifications to accommodate the new transmitters, Filters, RF components. Prepare electrical distribution based on the existing and new components associated with the transition $13,770.00 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $123,000.00 $75,800.00 Quote P2987-AEC702-061917R2 $68,220.00 N/A
2" Rigid Conduit and Wiring (Cost per foot) $2,600.00 $2,500.00 N/A N/A N/A
Other Electrical Service: Surge Protector, Voltage Regulator and UPS are required for new transmitter installation. Distribution panel modification and rewiring for new transmitter $36,300.00 $36,300.00 To protect the integrity of the new equipment is required to provide the surge protection, voltage regulation an Uninterrupted Power System UPS adequate for the new load. Attached quotes: P2987AEC702-06191R2 Opt T4 , S3Y, Clary Corp for DTS-2 $25,782.00 N/A
Other -- HVAC Service Type: C Size:3 (Other) $3,000.81 $3,000.81 Present air conditioning system is 2 Tons, as consequence of the building expansion for the new transmitter, the air conditioning system have to be changed from 2 tons to 3 tons. Attached quote from MFS Corp. N/A N/A
Other -- Building Addition Size: 80.0 $10,000.00 $10,000.00 N/A N/A N/A
Crating for Ocean Shipment $4,500.00 $4,500.00 Equipment Crating required for Maritime Transportation Attached Quote P2987-AEC702-061917R2 OPT NS1 $4,050.00 N/A
Upgraded Mask Filter from 6 to 8 poles $1,989.00 $1,989.00 Charge to replace an included RF Mask Filter of 6 pole on the transmitter proposal with 8 pole filter $1,788.60 N/A
Maritime Transportation $5,020.00 $5,020.00 Due to the particular conditions of an island, special maritime transportation is required from port to port $4,518.00 N/A
Primary Transmitter HPTV-PRLX-U14 $751,955.00 $805,855.00 $713,970.00
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW $666,000.00 $720,000.00 Solid state transmitter’s request, the cost of a new IOT transmitter is higher than a SS (attached). Unavailability for IOT adjustments (DA 16-1164 MB Docket No. 16-306 GN Docket No. 12-268). One power-level step up in transmitter (P2987-R2 WQTO prop.) $648,000.00 N/A
3" Rigid Conduit and Wiring (Cost per foot) $5,000.00 $4,900.00 N/A N/A N/A
Other Electrical Service: Surge Protector, Voltage Regulator and UPS are required for new transmitter installation. Distribution panel modification and rewiring for new transmitter. $36,300.00 $36,300.00 To protect the integrity of the new equipment is required to provide the surge protection, voltage regulation an Uninterrupted Power System UPS adequate for the new load. Attached quotes: P2987-R2 Opt T4 , S3Y, Clary Corp for DTS-1 $25,780.50 N/A
Crating for Ocean Shipment $4,500.00 $4,500.00 Equipment Crating required for Maritime Transportation Attached Quote P2987-R2 OPT NS1, Item 2.5 $4,050.00 N/A
Maritime transportation $5,020.00 $5,020.00 Due to the particular conditions of an island, special maritime transportation is required from port to port $4,518.00 N/A
Upgraded RF Maks Filter $15,000.00 $15,000.00 Charge to replace an included RF Mask Filter of 6 pole on the transmitter proposal with 8 pole filter $13,500.00 N/A
System Design and Site Survey $15,300.00 $15,300.00 System Design based on Site Survey to prepare an as built and present modifications to accommodate the new transmitters, Filters, RF components. Prepare electrical distribution based on the existing and new components associated with the transition $13,770.00 N/A
Transmitter Motorized Switch Replacement $4,835.00 $4,835.00 Extra cost for replace an included (3) port Manual Patch Panel on the transmitter proposal with a motorized Switch as the existing transmission system $4,351.50 N/A

Components

Actual Information Description File Name
System Design and Site Survey

Component Description:
40% for system design and site survey
Amount:
$6,120.00

Component Description:
50% for system design and site survey
Amount:
$7,650.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
50% for uhf air cooled solid state transmitter
Amount:
$37,900.00

Component Description:
40% for uhf air cooled solid state transmitter
Amount:
$30,320.00
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Other Electrical Service: Surge Protector, Voltage Regulator and UPS are required for new transmitter installation. Distribution panel modification and rewiring for new transmitter

Component Description:
50% for surge suppressor and automatic voltage regulator and bypass switching
Amount:
$14,324.00

Component Description:
40% for surge suppressor $2100 and automatic voltage regulator and bypass switching $6120
Amount:
$11,458.00
Other -- HVAC Service Type: C Size:3 (Other) Information not provided.
Other -- Building Addition Size: 80.0 Information not provided.
Crating for Ocean Shipment

Component Description:
50% for crating for ocean shipment
Amount:
$2,250.00

Component Description:
40% for crating for ocean shipment
Amount:
$1,800.00
Upgraded Mask Filter from 6 to 8 poles

Component Description:
40% for upgraded mask filter
Amount:
$795.60

Component Description:
50% for upgraded mask filter
Amount:
$993.00
Maritime Transportation

Component Description:
40% for maritime transportation
Amount:
$2,008.00

Component Description:
50% for maritime transportation
Amount:
$2,510.00
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW

Component Description:
40% for uhf - liquid cooled solid state transmitter
Amount:
$288,000.00

Component Description:
50% for uhf - liquid cooled solid state transmitter
Amount:
$360,000.00
3" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Other Electrical Service: Surge Protector, Voltage Regulator and UPS are required for new transmitter installation. Distribution panel modification and rewiring for new transmitter.

Component Description:
50% for surge suppressor and automatic voltage regulator and bypass switching
Amount:
$14,322.50

Component Description:
40% for surge suppressor $2100 and automatic voltage regulator and bypass switching $9358
Amount:
$11,458.00
Crating for Ocean Shipment

Component Description:
40% for crating for ocean shipment
Amount:
$1,800.00

Component Description:
50% for crating for ocean shipment
Amount:
$2,250.00
Maritime transportation

Component Description:
50% for maritime transportation
Amount:
$2,510.00

Component Description:
40% for maritime transportation
Amount:
$2,008.00
Upgraded RF Maks Filter

Component Description:
40% for upgraded rf maks filter
Amount:
$6,000.00

Component Description:
50% for upgraded rf maks filter
Amount:
$7,500.00
System Design and Site Survey

Component Description:
50% for system design and site survey
Amount:
$7,650.00

Component Description:
40% for system design and site survey
Amount:
$6,120.00
Transmitter Motorized Switch Replacement

Component Description:
50% for transmitter motorized swith replacement
Amount:
$2,417.50

Component Description:
40% for transmitter motorized swith replacement
Amount:
$1,934.00

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 $759,410.00 $756,310.00 N/A $305,541.00 N/A
Total for all systems $3,133,110.92 $3,109,986.92 N/A $1,192,382.10 N/A
Interim Antenna TFU-22DSC-R P230 DC $190,480.00 $189,780.00 $147,960.00
Maritime Transportation $14,500.00 $14,500.00 Due to the particular conditions of an island, special maritime transportation is required from port to port. Quote includes the transmission line volume and weight 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 $15,768.00 N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A
UHF - High Power, Side Mount, basic slot antenna, 800 kW input, directional,, horizontally polarized $146,880.00 $146,880.00 Interim antenna included here is the same model of the permanent proposed antenna because the immediate unavailability of a directional auxiliary antenna, once the manufacturer indicate the correspondent model it will be amended $132,192.00 N/A
Interim Antenna TFU-16DSB/VP-R P270 SP $183,225.00 $182,525.00 $0.00
UHF - High Power, Side Mount, basic slot antenna, 15 kW input, directional,, elliptically or circularly polarized $146,625.00 $146,625.00 Interim antenna included here is the same model of the permanent proposed antenna because the immediate unavailability of a directional auxiliary antenna, once the manufacturer indicate the correspondent model it will be amended $0.00 N/A
Sweep test of existing antenna $6,550.00 $6,400.00 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 $0.00 N/A
Maritime Transportation $7,500.00 $7,500.00 Due to the particular conditions of an island, special maritime transportation is required from port to port. Quote includes the transmission line volume and weight N/A N/A
Primary Antenna TFU-16DSB/VP-R P270 SP $183,225.00 $182,525.00 $0.00
UHF - High Power, Side Mount, basic slot antenna, 13 kW input, directional,, elliptically or circularly polarized $146,625.00 $146,625.00 Estimated cost by Dielectric the antenna manufacturer with equivalent parameters to the present Directional Antenna, (proposal attached) N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 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
Maritime Transportation $7,500.00 $7,500.00 Due to the particular conditions of an island, special maritime transportation is required from port to port. Quote includes the transmission line volume and weight N/A N/A
Primary Antenna TFU-22DSC-R P230 $202,480.00 $201,480.00 $157,581.00
UHF - High Power, Side Mount, basic slot antenna, 696 kW input, directional,, horizontally polarized $146,880.00 $146,880.00 Estimated cost by Dielectric the antenna manufacturer with equivalent parameters to the present Directional Antenna, (proposal attached) $131,962.50 N/A
Sweep test of existing antenna $6,550.00 $6,400.00 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 $15,732.90 N/A
Maritime Transportation $14,500.00 $14,500.00 Due to the particular conditions of an island, special maritime transportation is required from port to port. Quote includes the transmission line volume and weight N/A N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,000.00 $11,700.00 N/A $9,885.60 N/A

Components

Actual Information Description File Name
Maritime Transportation Information not provided.
Side mount brackets for high power antennas (if not included in antenna base cost)

Component Description:
45% of the order confirmation for the side mount brackets
Amount:
$7,884.00

Component Description:
45% for the side mount brackets
Amount:
$7,884.00

Component Description:
45% of the order confirmation for the side mount brackets
Amount:
N/A
Sweep test of existing antenna Information not provided.
UHF - High Power, Side Mount, basic slot antenna, 800 kW input, directional,, horizontally polarized

Component Description:
45% of the order confirmation for antenna
Amount:
N/A

Component Description:
45% for antenna one station horizontally polarized
Amount:
$66,096.00

Component Description:
45% for antenna one station horizontally polarized
Amount:
$66,096.00
UHF - High Power, Side Mount, basic slot antenna, 15 kW input, directional,, elliptically or circularly polarized

Component Description:
45 % of the order confirmation for lower power side mount elliptically polarized
Amount:
N/A

Component Description:
45% of the invoice
Amount:
N/A
Sweep test of existing antenna Information not provided.
Side mount brackets for high power antennas (if not included in antenna base cost)

Component Description:
45% of the invoice
Amount:
N/A

Component Description:
45% of the order confirmation for side mount brackets for antenna
Amount:
N/A
Maritime Transportation Information not provided.
UHF - High Power, Side Mount, basic slot antenna, 13 kW input, directional,, elliptically or circularly polarized Information not provided.
Sweep test of existing antenna Information not provided.
Side mount brackets for high power antennas (if not included in antenna base cost) Information not provided.
Maritime Transportation Information not provided.
UHF - High Power, Side Mount, basic slot antenna, 696 kW input, directional,, horizontally polarized

Component Description:
45% for Primary lower power side mount antenna
Amount:
$65,981.25

Component Description:
45% for Primary lower power side mount antenna
Amount:
$65,981.25
Sweep test of existing antenna Information not provided.
Side mount brackets for high power antennas (if not included in antenna base cost)

Component Description:
45% for side mount brackets, reducer and adapter
Amount:
$7,866.45

Component Description:
45% for side mount brackets, reducer and adapter
Amount:
$7,866.45
Maritime Transportation Information not provided.
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
45% of the order confirmation for elbow complex single channel at antenna input for 3-1/8
Amount:
$4,942.80

Component Description:
45% for elbow complex single channel at antenna input for 3-1/8
Amount:
$4,942.80

Component Description:
45% of the order confirmation for elbow complex single channel at antenna input for 3-1/8
Amount:
N/A

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 $84,700.00 $82,597.00 N/A $43,222.50 N/A
Total for all systems $3,133,110.92 $3,109,986.92 N/A $1,192,382.10 N/A
Interim Transmission Line $4,800.00 $4,650.00 $0.00
Flexible Air Transmission Line - dielectric, 1 5/8" $4,800.00 $4,650.00 N/A N/A N/A
Interim Transmission Line $24,480.00 $24,000.00 $0.00
Flexible Air Transmission Line - dielectric, 5" $24,480.00 $24,000.00 N/A N/A N/A
Primary Transmission Line $51,220.00 $49,920.00 $43,222.50
Rigid Transmission Line - copper, 6 1/8" $51,220.00 $49,920.00 N/A $43,222.50 N/A
Primary Transmission Line $4,200.00 $4,027.00 $0.00
Flexible Foam Transmission Line - dielectric, 1 5/8" $4,200.00 $4,027.00 This cost is accordingly to the adjust requested by the TV Broadcaster Relocation Fund Administrator on his communication of 10/12/2017. The original amount requested was $4,370 and the verified amount established on the letter is $4,027. Letter attached N/A N/A

Components

Actual Information Description File Name
Flexible Air Transmission Line - dielectric, 1 5/8" Information not provided.
Flexible Air Transmission Line - dielectric, 5" Information not provided.
Rigid Transmission Line - copper, 6 1/8"

Component Description:
45% for rigid transmission line copper 6-1/8" 75 ohm and tlscr's tbd t/l 6-75
Amount:
$21,611.25

Component Description:
45% for rigid transmission line copper 6-1/8" 75 ohm and tlscr's tbd t/l 6-75
Amount:
$21,611.25
Flexible Foam Transmission Line - dielectric, 1 5/8" 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 $751,400.00 $734,000.00 N/A $5,760.00 N/A
Total for all systems $3,133,110.92 $3,109,986.92 N/A $1,192,382.10 N/A
Primary Tower TOWER $503,700.00 $492,000.00 $5,760.00
Structural engineering tower load study for well documented tower $12,300.00 $12,000.00 N/A $5,760.00 N/A
Short Tower (less than 500') $81,900.00 $80,000.00 N/A N/A N/A
Major tower reinforcement/modifications $409,500.00 $400,000.00 N/A N/A N/A
Primary Tower TOWER $247,700.00 $242,000.00 $0.00
Minor tower reinforcement/modifications $153,500.00 $150,000.00 N/A N/A N/A
Structural engineering tower load study for well documented tower $12,300.00 $12,000.00 N/A N/A N/A
Short Tower (less than 500') $81,900.00 $80,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Structural engineering tower load study for well documented tower

Component Description:
45% for one field engineer on site for one day, travel, expenses and report
Amount:
$2,880.00

Component Description:
45% for one field engineer on site for one day, travel, expenses and report
Amount:
$2,880.00

Component Description:
45% of invoice for engineer expenses
Amount:
N/A
Short Tower (less than 500') Information not provided.
Major tower reinforcement/modifications Information not provided.
Minor tower reinforcement/modifications Information not provided.
Structural engineering tower load study for well documented tower Information not provided.
Short Tower (less than 500') 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 $278,971.00 $272,100.00 N/A $5,760.00 N/A
Total for all systems $3,133,110.92 $3,109,986.92 N/A $1,192,382.10 N/A
Outside Professional Services $278,971.00 $272,100.00 $5,760.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A N/A N/A
DTS Site RF Consulting Engineer - Terrain-shielded Facility $2,560.00 $2,500.00 N/A N/A N/A
DTS Site RF Consulting Engineer - Critical Facility $8,190.00 $8,000.00 N/A N/A N/A
Project management of the transition $132,286.00 $128,850.00 Proposal from RGB Corporation HMDRQ2924 and Detailed estimate attached for DTS-1 and DTS-2 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 $5,760.00 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
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 request for Special Temporary Authorization $1,535.00 $1,500.00 N/A N/A N/A
RF Exposure Measurements $20,500.00 $20,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $81,900.00 $80,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,585.00 $3,500.00 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

Components

Actual Information Description File Name
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
DTS Site RF Consulting Engineer - Terrain-shielded Facility Information not provided.
DTS Site RF Consulting Engineer - Critical Facility Information not provided.
Project management of the transition Information not provided.
Prepare and or review reimbursement form Information not provided.
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
45% for one field engineer on-site for one day, travel, expenses and report
Amount:
$2,880.00

Component Description:
45% for one field engineer on-site for one day, travel, expenses and report
Amount:
$2,880.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, 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.

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 $304,965.11 $304,715.11 N/A $0.00 N/A
Total for all systems $3,133,110.92 $3,109,986.92 N/A $1,192,382.10 N/A
Other Expenses $304,965.11 $304,715.11 $0.00
Equipment Storage $7,000.00 $7,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $10,500.00 $10,500.00 N/A N/A N/A
Local Sales and Use Taxes $239,215.11 $239,215.11 PR Sales Use Taxes and Use Tax 11.5% for all the imported equipment or 4% for all the services from abroad. Attached Excel Worksheet with detailed calculations, Translated copy of the state law 25-2017, Copy of the DA 15-17 and translated Indirect Tax Alert N/A N/A
MVPD Notification of Channel Change $12,000.00 $12,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $5,000.00 $5,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $20,000.00 $20,000.00 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 $3,133,110.92 $3,109,986.92 $1,192,382.10

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.

GINIA E HERNANDEZ

Sponsored Program Director


07/19/2018

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.

Ariel Diaz

Engineer


07/19/2018

Attachments

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