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:
0000028206
FRN:
0005020243
Facility ID:
29715
Repack Channel:
18 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
09/21/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

JACKSONVILLE EDUCATORS BROADCASTING, INC.

PO Box 721800

HOUSTON, TX 77272

United States

+1 (281) 983-7109 cmmay@maylawoffices.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

The Preparer is same as the reimbursement contact.

 

 

 

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. Yes
Briefly describe transition plan Reduce TPO to 50% and remove 1/2 of the xmitter system. Install new SS xmitter system. Add AUX antenna & line to the tower & feed it with a reduced signal from the current xmitter. Remove & replace antenna. Test.

Question Response
Sharee Station Facility ID 70865
Call Sign WTCN-CA
Type
Licensee Name WTVX LICENSEE, LLC
Status LICENSED
DTS No
Community of License PALM BEACH, FL
Pre-auction RF Channel 43
Post-auction RF Channel 17
Neilsen DMA West Palm Beach-Ft. Pierce
Network Affiliation
Question Response
Sharee Station Facility ID 190603
Call Sign WMMF-LD
Type
Licensee Name VINIONS LLC
Status CP OFF AIR
DTS No
Community of License VERO BEACH, FL
Pre-auction RF Channel 39
Post-auction RF Channel
Neilsen DMA
Network Affiliation
Question Response
Sharee Station Facility ID 182904
Call Sign WDOX-LD
Type
Licensee Name DTV America Corporation
Status LICENSED AND SILENT
DTS No
Community of License SEBASTIAN, FL
Pre-auction RF Channel 24
Post-auction RF Channel
Neilsen DMA
Network Affiliation
Question Response
Sharee Station Facility ID 63557
Call Sign WWHB-CA
Type
Licensee Name WTVX LICENSEE, LLC
Status LICENSED
DTS No
Community of License STUART, FL
Pre-auction RF Channel 48
Post-auction RF Channel 33
Neilsen DMA West Palm Beach-Ft. Pierce
Network Affiliation

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Description of Use  
Ownership Owned
Owner  
Site  
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model DCX 2
Year 2006
Type Inductive Output Tube
IOT Power Type Two
Description  
Power capacity 50 kw
Solid State Cooling  
Solid State Power Capacity  
Other Transmitter Type  

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Description of Use  
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model HPTV-PRLX-U12
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 19 kw
Other Transmitter Type  
Justification for New Transmitter 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) No
Transformer (480V) No
Power
Rigid Conduit and Wiring No
Size
Length
Other Electrical Service Yes
Description disconnectes, labor
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

install

xmitter install

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting 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 ATW22H3-HTPX-38S
Year 2005

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? No
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: 649.00 kW
Manufacturer
Model ATW22H3-HTPX-18H
Year 2017
Justification for New Antenna The present antenna can not be tuned tio ch 18

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 6 1/8 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

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? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Type Class Full Power
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization 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: 240.00 kW
Manufacturer
Model RD12A 1424 M3sx
Year 2017
Justification for New Antenna Remain on the air while antenna & line are changed.

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? No

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 Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 6 1/8 inches
Segment Length 19 ½ '
Other Segment Length
Number of parallel runs 1
Length 1100 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 1100 feet per run
Justification for New Transmission Line flange reflection on old line

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 3 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 500 feet per run
Justification for New Transmission Line To remain on the air durring antenna and line change.

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 Leased
Is this tower consider Complex? Candelabra
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 No
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? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 27° 01' 32.0" N-
Longitude (NAD83) 080° 10' 41.9" W-
Overall Structure Height 1021.97 feet
Support Structure Height 940.93 feet
Ground Elevation Above Mean Sea Level (AMSL) 16.08 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner American Towers, LLC
Date Constructed 12/01/1996

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
70865 WTCN-CA DTV
63557 WWHB-CA DTV

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 tower with candelabra
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 Candelabra
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Name Description

management

Modification management

Ground Bldg

A E Permit drawing

Tower Permit Drawings

American Tower Drawing Package

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 95
Explanation AMerican Tower
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 2
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 2
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations 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 No
RF exposure measurements No
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

Name Description

Site Coordination

Meeting

Migratory Birds

Migratory Birds

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 Yes
Non-zoning permits Yes
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)? No
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? No
Does this relocation require MVPD Notification of a Channel Change? No

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 $796,000.00 $794,865.00 N/A $661,621.75 N/A
Total for all systems $2,443,435.00 $1,959,307.00 N/A $1,177,229.35 N/A
Primary Transmitter HPTV-PRLX-U12 $796,000.00 $794,865.00 $661,621.75
install $30,000.00 $30,000.00 quoted xmitter install $30,000.00 N/A
Other Electrical Service: disconnectes, labor $100,000.00 $100,000.00 quoted N/A N/A
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW $666,000.00 $664,865.00 See attached quote. Shipping is included in quote. $631,621.75 N/A

Components

Actual Information Description File Name
install

Component Description:
xmitter site prep
Amount:
$1,950.00

Component Description:
Balance due on xmitter installation
Amount:
$28,050.00
Other Electrical Service: disconnectes, labor Information not provided.
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW

Component Description:
30% due prior to shipment
Amount:
$199,459.50

Component Description:
30% due after 60 days.
Amount:
$199,459.50

Component Description:
35% deposit on U12 xmitter
Amount:
$232,702.75

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 $466,100.00 $291,250.00 N/A $219,740.00 N/A
Total for all systems $2,443,435.00 $1,959,307.00 N/A $1,177,229.35 N/A
Interim Antenna RD12A 1424 M3sx $207,050.00 $60,000.00 $0.00
Side mount brackets for high power antennas (if not included in antenna base cost) $22,550.00 $10,000.00 N/A N/A N/A
UHF - Lower Power Side Mount, One station - 200-500 kW, horizontally polarized $184,500.00 $50,000.00 N/A N/A N/A
Primary Antenna ATW22H3-HTPX-18H $259,050.00 $231,250.00 $219,740.00
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized $240,500.00 $215,000.00 N/A $209,490.00 N/A
Sweep test of existing antenna $6,550.00 $6,000.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,000.00 $10,250.00 N/A $10,250.00 N/A

Components

Actual Information Description File Name
Side mount brackets for high power antennas (if not included in antenna base cost) Information not provided.
UHF - Lower Power Side Mount, One station - 200-500 kW, horizontally polarized Information not provided.
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized

Component Description:
deposit
Amount:
$209,490.00
Sweep test of existing antenna Information not provided.
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
deposit
Amount:
$10,250.00

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 $245,200.00 $220,000.00 N/A $161,649.60 N/A
Total for all systems $2,443,435.00 $1,959,307.00 N/A $1,177,229.35 N/A
Interim Transmission Line $28,500.00 $20,000.00 $0.00
Flexible Air Transmission Line - dielectric, 3" $28,500.00 $20,000.00 N/A N/A N/A
Primary Transmission Line $216,700.00 $200,000.00 $161,649.60
Rigid Transmission Line - copper, 6 1/8" $216,700.00 $200,000.00 N/A $161,649.60 N/A

Components

Actual Information Description File Name
Flexible Air Transmission Line - dielectric, 3" Information not provided.
Rigid Transmission Line - copper, 6 1/8"

Component Description:
deposit
Amount:
$161,649.60

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 $857,250.00 $587,800.00 N/A $131,168.00 N/A
Total for all systems $2,443,435.00 $1,959,307.00 N/A $1,177,229.35 N/A
Primary Tower GTOWER $857,250.00 $587,800.00 $131,168.00
Structural engineering tower load study for a documented tower with candelabra $19,450.00 $19,000.00 N/A $19,000.00 N/A
Major tower reinforcement/modifications $409,500.00 $200,000.00 N/A $24,800.00 N/A
Ground Bldg $4,700.00 $4,700.00 American Tower N/A N/A
management $9,400.00 $9,400.00 Ametrican Tower N/A N/A
Tower Permit Drawings $4,700.00 $4,700.00 American Tower N/A N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $409,500.00 $350,000.00 N/A $87,368.00 N/A

Components

Actual Information Description File Name
Structural engineering tower load study for a documented tower with candelabra

Component Description:
Broadcast structural
Amount:
$19,000.00
Major tower reinforcement/modifications

Component Description:
tower mapping
Amount:
$24,800.00
Ground Bldg Information not provided.
management Information not provided.
Tower Permit Drawings Information not provided.
Complex Tower (includes, for example, those with candelabras and/or stacked antennas)

Component Description:
deposit
Amount:
$87,368.00

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 $65,035.00 $58,480.00 N/A $3,050.00 N/A
Total for all systems $2,443,435.00 $1,959,307.00 N/A $1,177,229.35 N/A
Outside Professional Services $65,035.00 $58,480.00 $3,050.00
Migratory Birds $1,750.00 $1,750.00 N/A N/A N/A
Site Coordination $10,000.00 $10,000.00 American Tower N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $7,170.00 $7,000.00 N/A N/A N/A
Attorney Fees - 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
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $3,070.00 $3,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A $1,750.00 N/A
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A $1,300.00 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
Project management of the transition $14,630.00 $9,480.00 N/A N/A N/A
Prepare and or review reimbursement form $2,560.00 $2,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Migratory Birds Information not provided.
Site Coordination 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.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Engineering for FCC 2100 CP
Amount:
$1,750.00
Perform engineering study for new channel assignment and antenna development

Component Description:
second interference study for repack CP
Amount:
$650.00

Component Description:
interference analysis for repack
Amount:
$650.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Project management of the transition Information not provided.
Prepare and or review reimbursement form 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 $13,850.00 $6,912.00 N/A $0.00 N/A
Total for all systems $2,443,435.00 $1,959,307.00 N/A $1,177,229.35 N/A
Other Expenses $13,850.00 $6,912.00 $0.00
Equipment Delivery and Handling Charges $2,000.00 $2,000.00 crane N/A N/A
Non-zoning permits $100.00 $100.00 American Tower N/A N/A
DTV Medical Facility Notification $11,250.00 $4,312.00 N/A N/A N/A
Local Zoning $500.00 $500.00 American Tower 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 $2,443,435.00 $1,959,307.00 $1,177,229.35

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.

John B. Casoria , ESQ. .

Assistant Secretary


09/21/2018

Attachments

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