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

FCC Form 399: Reimbursement Request

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

(REFERENCE COPY - Not for submission) FCC Form 399: Reimbursement Request

Facility ID:
23935
Service:
DTV
Call Sign:
WMUM-TV
Channel:
9 (High VHF)
File Number:
0000027593
FRN:
0001844976
Date Submitted:
08/02/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GEORGIA PUBLIC TELECOMMUNICATIONS COMMISSION

Doing Business As: GEORGIA PUBLIC TELECOMMUNICATIONS COMMISSION

260 14TH ST NW

ATLANTA, GA 30318

United States

+1 (404) 685-2410 apadgett@gpb.org Government Entity

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Robert Gehman

ConsultingEngineer

Kessler and Gehman Associates, Inc.

Robert Gehman

507 NW 60 Street

Suite D

Gainesville, FL 32607

United States

+1 (352) 332-3157 bob@kesslerandgehman.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan New transmitter and Main antenna using existing transmission line. Mapping, analysis, design of pre-EIA-222-G tower, and possible tower modifications. Interim antenna and line for use during Main antenna replacement and duration of assigned phase.

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 N/A
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model PTCD20P2
Year 2008
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 8 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model TBD
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 8 kW
Justification for New Transmitter Manufacturer of existing transmitter advises that the existing transmitter cannot be re-tuned to the assigned channel. See Attachment.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) Yes
Transformer (480V) Yes
Power 150 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 100.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Standby Exciter and Switch

Standby Exciter with Automatic Change Over Switch

Additional Interior RF System

Interior RF System Existing Transmitter to Interim Transmission line

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 28.0 kW
Manufacturer
Model TLS-V8
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? No
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? No
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types 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: 31.0 kW
Manufacturer
Model TBD
Year 2018
Justification for New Antenna The existing primary antenna is a single channel slotted coaxial which cannot accommodate the assigned channel.

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? 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 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: 28.0 kW
Manufacturer
Model TBD
Year 2018
Justification for New Antenna An interim antenna is necessary to keep station on the air during primary antenna replacement and for the duration of the assigned phase. Station will attempt to lease if leasing is available at time of acquisition.

Interim Antenna

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Other Antenna Costs

Section Question Response
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 an 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

Interim Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Utilize Existing
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer ERI
Type Flexible Air
Diameter 3 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 1120 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Sweep

Verify line performance on new channel

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 3 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 1000 feet per run
Justification for New Transmission Line An interim transmission line is necessary for the interim antenna to keep station on the air during primary antenna replacement and for the duration of the assigned phase.

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? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users Yes
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1018798
Coordinates (NAD83) Latitude (NAD83) 32° 28' 12.2" N-
Longitude (NAD83) 083° 15' 18.0" W-
Overall Structure Height 1168.95 feet
Support Structure Height 1109.89 feet
Ground Elevation Above Mean Sea Level (AMSL) 398.95 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner GEORGIA PUBLIC TELECOMMUNICATIONS COMMISSION
Date Constructed 03/02/2016

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID Call Sign Service
43212 WMAB-FM FM

Other Types of Users

Users
WMAB ICR

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 undocumented/poorly 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 60
Explanation It will be necessary to schedule and coordinate multiple vendors, complete progress reports, and update Schedule 399. Station does not have available personnel or personnel trained in project management for such complex projects.
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 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 No
Additional Field Engineering Service Yes
Number of Days 15
Justification It will be necessary to survey the site, plan the equipment, develop specifications for purchasing, and oversee multiple vendor RF projects. Station does not have available personnel or personnel trained in such services.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Other Legal Services

Legal services not already included in a pre-established OPS section.

Other Engineering Services

Engineering services not already included in a pre-established OPS section.

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 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

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 $500,450.00 $480,500.00 N/A $0.00 N/A
Total for all systems $1,782,670.00 $1,720,450.00 N/A $10,867.50 N/A
Primary Transmitter TBD $500,450.00 $480,500.00 $0.00
High VHF - Air Cooled Solid State Transmitter 6.5 . 12.5 kW $331,500.00 $315,000.00 N/A N/A N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $24,300.00 N/A N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $5,200.00 $4,900.00 N/A N/A N/A
Additional Interior RF System $75,000.00 $75,000.00 N/A N/A N/A
Standby Exciter and Switch $25,000.00 $25,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $430,280.00 $426,800.00 N/A $0.00 N/A
Total for all systems $1,782,670.00 $1,720,450.00 N/A $10,867.50 N/A
Interim Antenna TBD $215,140.00 $213,400.00 $0.00
High VHF - High Power Side Mount One Station horizontally polarized $180,000.00 $180,000.00 N/A N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $22,000.00 N/A N/A N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,260.00 $5,000.00 N/A N/A N/A
Primary Antenna TBD $215,140.00 $213,400.00 $0.00
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,260.00 $5,000.00 N/A N/A N/A
High VHF - High Power Side Mount One Station horizontally polarized $180,000.00 $180,000.00 N/A N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $22,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $65,400.00 $62,400.00 N/A $0.00 N/A
Total for all systems $1,782,670.00 $1,720,450.00 N/A $10,867.50 N/A
Interim Transmission Line $59,000.00 $56,000.00 $0.00
Flexible Air Transmission Line - dielectric, 3" $59,000.00 $56,000.00 N/A N/A N/A
Primary Transmission Line $6,400.00 $6,400.00 $0.00
Sweep $6,400.00 $6,400.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $657,800.00 $625,000.00 N/A $0.00 N/A
Total for all systems $1,782,670.00 $1,720,450.00 N/A $10,867.50 N/A
Primary Tower GTOWER $657,800.00 $625,000.00 $0.00
Tall Tower (greater than 500') $210,500.00 $200,000.00 N/A N/A N/A
Major tower reinforcement/modifications $421,000.00 $400,000.00 N/A N/A N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $25,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $100,190.00 $97,750.00 N/A $10,867.50 N/A
Total for all systems $1,782,670.00 $1,720,450.00 N/A $10,867.50 N/A
Outside Professional Services $100,190.00 $97,750.00 $10,867.50
Project management of the transition $9,480.00 $9,000.00 Fewer Project Management tasks are required & Other Engineering Services "OES" are required, therefore the PM total has been reduced and a new OES category has been created and funded with the money removed from PM. $750.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $2,500.00 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $3,500.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,000.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $1,732.50 N/A
Other Engineering Services $20,000.00 $20,000.00 Fewer Project Management tasks are required & Other Engineering Services "OES" are required, therefore the PM total has been reduced and a new OES category has been created and funded with the money removed from PM. N/A N/A
Other Legal Services $10,000.00 $10,000.00 N/A $385.00 N/A
Additional Field Engineering Service, 15 Days $30,000.00 $30,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project management Bob Gehman
Amount:
$225.00

Component Description:
Project management Bob Gehman
Amount:
$225.00

Component Description:
Project management Bob Gehman
Amount:
$300.00
Prepare and or review reimbursement form

Component Description:
Prepare and review reimbursement form
Amount:
$2,500.00
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:
Perform engineering study for new channel assignment
Amount:
$3,500.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Prepare engineering section of FCC Form 2100 (main) construction permit
Amount:
$2,000.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
WMUM amount. Refer to GMP master summary invoice WMUM with attached invoice. Refer to letter and attachments uploaded by GPB 8.2.18
Amount:
$385.00

Component Description:
WMUM amount. Refer to GMP master summary invoice WMUM with attached invoice. Refer to letter and attachments uploaded by GPB 8.2.18
Amount:
$1,347.50
Other Engineering Services Information not provided.
Other Legal Services

Component Description:
WMUM amount. Refer to Jan-April GMP matter summary. Refer to letter and attachments uploaded from GPB 8.2.18
Amount:
$38.50

Component Description:
WMUM amount. Refer to GMP matter summary May 2018. Refer to letter and attachments uploaded from GPB 8.2.18
Amount:
$154.00

Component Description:
WMUM amount.Refer to GMP master summary invoice WMUM with attached invoice.
Amount:
$38.50

Component Description:
WMUM amount. Refer to GMP master summary invoice WMUM with attached invoice.
Amount:
$115.50

Component Description:
WMUM amount.Refer to GMP master summary invoice WMUM with attached invoice.
Amount:
$38.50
Additional Field Engineering Service, 15 Days Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization 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 $28,550.00 $28,000.00 N/A $0.00 N/A
Total for all systems $1,782,670.00 $1,720,450.00 N/A $10,867.50 N/A
Other Expenses $28,550.00 $28,000.00 $0.00
MVPD Notification of Channel Change $2,000.00 $2,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $0.00 $0.00 N/A N/A N/A
Equipment Storage $5,000.00 $5,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $5,000.00 $5,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 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 $1,782,670.00 $1,720,450.00 $10,867.50

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
Construction of final facilities or all necessary modifications are complete. No
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator. 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.

Elizabeth Laprade

CFO


08/02/2018

Attachments

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