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:
0000027784
FRN:
0013774344
Facility ID:
17625
Repack Channel:
14 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
10/09/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

CHRISTIAN TELEVISION NETWORK OF IOWA, INC.

Doing Business As: KFXB-TV

Tamie Cook

744 Main St

Dubuque, IA 52001

United States

+1 (563) 690-1704 tamiec@mchsi.com Not-for-Profit

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Joseph C. Chautin III

Hardy, Carey, Chautin & Balkin, LLP

1080 West Causeway Approach

Mandeville, LA 70471

United States

+1 (985) 629-0777 jchautin@hardycarey.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 KFXB will install temp low power antenna & line. Then, existing xmtr will feed temp LP antenna thru mask filter. Removal of old antenna. Then, installation of new xmtr, mask filter and antenna to begin.

Transmitters

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

Primary Transmitter

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Add 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 Visionary
Year 2004
Type Inductive Output Tube
IOT Power Type Single
Description  
Power capacity 29 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 P3221
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 27.5 kw
Other Transmitter Type  
Justification for New Transmitter Manufacturer (Axcera) no longer in business. Existing transmitter not supported.

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 No
Size
Length
Other Electrical Service Yes
Description additional breakers in panel, EMT or flexible metal conduit, misc wiring
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? Yes
Is a channel 14 Mask Filer needed? Yes
Is additional field engineering time needed? Yes
Number of Days 10

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

transmission line

transmitter building interior transmission line components for transmitter interconnects

anti-freeze

coolant anti-freeze

Motorized Switch

4 way motorized switch this is for transferring the output of the transmitter into the station load.

plumbing

plumbing for heat exchanger

Equipment Rental

Heavy equipment rental to off-load the transmitter

Factory Training

Factory training of the new transmitter for the station engineers

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? Yes
Existing Antenna Manufacturer and Type Class Full Power
Mounting Top-mount single
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 1000.00 kW
Manufacturer
Model ATW16H3-HTC4-43S
Year 2009

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 Top-mount single
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: 580.00 kW
Manufacturer
Model TFU 12GTH-R C250
Year 2017
Justification for New Antenna Existing antenna cannot be re-channeled.

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? 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

temporary antenna

A temporary low power antenna & line will be needed during the re-channeling process to keep KFXB on the air.

Transmission Line

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

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Utilize Existing
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer ERI
Type Rigid
Diameter 6 1/8 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 900 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Interim Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Flexible Air
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 750 feet per run
Justification for New Transmission Line to feed interim antenna which will keep KFXB on the air during modification of facility

Interim Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

misc hardware

connectors, hanging brackets, etc.

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 Leased
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 1055265
Coordinates (NAD83) Latitude (NAD83) 42° 31' 09.0" N-
Longitude (NAD83) 090° 37' 11.0" W-
Overall Structure Height 836.93 feet
Support Structure Height 789.03 feet
Ground Elevation Above Mean Sea Level (AMSL) 859.90 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Second Generation Realty of Iowa
Date Constructed 01/01/1976


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 595
Explanation KFXB-TV does not have sufficient resource capacity and expertise in-house to handle all of the reimbursement filings by the construction deadline for Phase 1 of Nov 30, 2018. KFXB-TV will hire an outside firm o ensure a timely transition.
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? 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 1
NEPA Section 106 environmental review Yes
Environmental Assessment Yes
ASR Modification Yes
FAA Consultation (including preparation of FAA Form 7460) Yes
Negotiation of Lease and other Matter for Shared Locations Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 3
Justification optimization of existing transmission line to operate on new channel

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)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? No
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Information not provided.

Cost Information

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Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $1,201,180.00 $1,120,143.00 N/A $975,119.70 N/A
Total for all systems $2,396,228.00 $2,284,643.00 N/A $1,226,833.04 N/A
Primary Transmitter P3221 $1,201,180.00 $1,120,143.00 $975,119.70
Motorized Switch $4,835.00 $4,835.00 N/A $4,351.50 N/A
plumbing $2,000.00 $2,000.00 N/A N/A N/A
anti-freeze $200.00 $200.00 N/A N/A N/A
transmission line $5,000.00 $5,000.00 N/A N/A N/A
Additional field engineering time, 10-30 days $61,400.00 $60,000.00 N/A N/A N/A
RF Consulting Engineer $5,120.00 $5,000.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW $922,000.00 $846,983.00 N/A $798,305.70 N/A
Channel 14 Mask Filter $184,500.00 $180,000.00 N/A $162,000.00 N/A
Other Electrical Service: additional breakers in panel, EMT or flexible metal conduit, misc wiring $7,125.00 $7,125.00 P#3221PRLXU16-072417-R2 $6,412.50 N/A
Equipment Rental $4,500.00 $4,500.00 N/A N/A N/A
Factory Training $4,500.00 $4,500.00 N/A $4,050.00 N/A

Components

Actual Information Description File Name
Motorized Switch

Component Description:
Motorized Switch (40% Due Prior to Shipment)
Amount:
$1,934.00

Component Description:
Motorized Switch (50% Down Payment)
Amount:
$2,417.50
plumbing Information not provided.
anti-freeze Information not provided.
transmission line Information not provided.
Additional field engineering time, 10-30 days Information not provided.
RF Consulting Engineer Information not provided.
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW

Component Description:
Transmitter
Amount:
$354,802.20

Component Description:
transmitter system
Amount:
$443,503.50
Channel 14 Mask Filter

Component Description:
Mask Filter System (40% Due Prior to Shipment)
Amount:
$72,000.00

Component Description:
Mask Filter System (50% Down Payment)
Amount:
$90,000.00
Other Electrical Service: additional breakers in panel, EMT or flexible metal conduit, misc wiring

Component Description:
Surge Suppressor (40% Due Prior to Shipment)
Amount:
$2,850.00

Component Description:
Surge Suppressor (50% Down Payment)
Amount:
$3,562.50
Equipment Rental Information not provided.
Factory Training

Component Description:
Factory Training (40% Due Prior to Shipment)
Amount:
$1,800.00

Component Description:
Factory Training (50% Down Payment)
Amount:
$2,250.00

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 $254,025.00 $248,375.00 N/A $170,413.34 N/A
Total for all systems $2,396,228.00 $2,284,643.00 N/A $1,226,833.04 N/A
Primary Antenna TFU 12GTH-R C250 $254,025.00 $248,375.00 $170,413.34
temporary antenna $6,975.00 $6,975.00 to minimize "off air" time while main antenna and transmitter are replaced. N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A $5,826.30 N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized $240,500.00 $235,000.00 N/A $164,587.04 N/A

Components

Actual Information Description File Name
temporary antenna Information not provided.
Sweep test of existing antenna

Component Description:
Primary Antenna - Sweep Test
Amount:
$3,586.30

Component Description:
Primary Antenna - Sweep Test
Amount:
$2,240.00
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized

Component Description:
Primary Antenna - UHF High Power Top Mount
Amount:
$100,805.70

Component Description:
Primary Antenna - UHF High Power Top Mount
Amount:
$63,781.34

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 $31,000.00 $30,250.00 N/A $0.00 N/A
Total for all systems $2,396,228.00 $2,284,643.00 N/A $1,226,833.04 N/A
Interim Transmission Line $31,000.00 $30,250.00 $0.00
misc hardware $7,000.00 $7,000.00 connectors, hanging brackets, etc. needed for installation of temporary transmission line which will feed the temporary antenna N/A N/A
Flexible Air Transmission Line - dielectric, 1 5/8" $24,000.00 $23,250.00 N/A N/A N/A
Primary Transmission Line $0.00 $0.00 $0.00

Components

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $626,800.00 $608,500.00 N/A $81,300.00 N/A
Total for all systems $2,396,228.00 $2,284,643.00 N/A $1,226,833.04 N/A
Primary Tower TOWER $626,800.00 $608,500.00 $81,300.00
Tall Tower (greater than 500') $205,000.00 $200,000.00 N/A $72,800.00 N/A
Major tower reinforcement/modifications $409,500.00 $400,000.00 N/A N/A N/A
Structural engineering tower load study for well documented tower $12,300.00 $8,500.00 N/A $8,500.00 N/A

Components

Actual Information Description File Name
Tall Tower (greater than 500')

Component Description:
Repack top mount TV antenna system replacement services
Amount:
$72,800.00
Major tower reinforcement/modifications Information not provided.
Structural engineering tower load study for well documented tower

Component Description:
Tower structural review
Amount:
$4,250.00

Component Description:
Engineering Services for KFXB-TV per contract CS188-011
Amount:
$4,250.00

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 $233,545.00 $228,285.00 N/A $0.00 N/A
Total for all systems $2,396,228.00 $2,284,643.00 N/A $1,226,833.04 N/A
Outside Professional Services $233,545.00 $228,285.00 $0.00
Additional Field Engineering Service, 3 Days $6,000.00 $6,000.00 Work performed by on-site engineering assistant - includes but is not limited to equipment relocation, running control wiring, and assembling connectors. N/A N/A
Comprehensive coverage verification via field study, if needed $81,900.00 $81,900.00 N/A N/A N/A
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase $2,050.00 $2,050.00 N/A N/A N/A
ASR modification (prepare FCC Form 854) $2,050.00 $2,050.00 N/A N/A N/A
NEPA Section 106 environmental review, if needed $6,140.00 $6,140.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,095.00 $4,095.00 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 $1,535.00 $500.00 N/A N/A N/A
Project management of the transition $91,630.00 $90,750.00 Price quote 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 $2,560.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $1,500.00 N/A N/A N/A
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet $10,240.00 $10,240.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,585.00 $750.00 N/A N/A N/A

Components

Actual Information Description File Name
Additional Field Engineering Service, 3 Days Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase Information not provided.
ASR modification (prepare FCC Form 854) Information not provided.
NEPA Section 106 environmental review, if needed Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Project management of the transition

Component Description:
Project Management
Amount:
$1,458.20

Component Description:
Project Management
Amount:
$1,693.10

Component Description:
Project Management
Amount:
$3,358.20
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 Information not provided.
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.
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization 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 $49,678.00 $49,090.00 N/A $0.00 N/A
Total for all systems $2,396,228.00 $2,284,643.00 N/A $1,226,833.04 N/A
Other Expenses $49,678.00 $49,090.00 $0.00
MVPD Notification of Channel Change $1,500.00 $1,500.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $333.00 $0.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $6,000.00 $6,000.00 disposal of old transmitter equipent N/A N/A
Equipment Delivery and Handling Charges $30,000.00 $30,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $400.00 $400.00 production time N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $2,396,228.00 $2,284,643.00 $1,226,833.04

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.

CHRIS L MAVROS

Director of Engineering


10/08/2018

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.

CHRIS L MAVROS

Director of Engineering


10/08/2018

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