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:
0000027984
FRN:
0002914638
Facility ID:
6568
Repack Channel:
22 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
01/18/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

BOWLING GREEN STATE UNIVERSITY

Anthony Short, General Manager

245 TROUP STREET

BOWLING GREEN, OH 43402

United States

+1 (419) 372-2700 ashort@bgsu.edu 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

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. No
Briefly describe transition plan Purchase/install an aux antenna, a new transmitter (current one cannot be re-used) and we will use a spare transmission line to test our new channel (22) during the phase one testing period. Upon cutover we'll transition the above to permanent antenna.

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 Ultimate
Year 2003
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 10 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 UXLTE-20
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 7.5 kw
Other Transmitter Type  
Justification for New Transmitter Our old Comark transmitter could not be retuned for the new channel (22).

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) Yes
Power 300 kVA
Rigid Conduit and Wiring Yes
Size 2 inches
Length 100.0 feet
Other Electrical Service No
Description  
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

Information not provided.

Antennas

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

Primary Antenna

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Add Antenna Information

Section Question Response
Existing Antenna Description Type of change Retune Existing
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this antenna currently shared with any other stations? No
Is this 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 Top-mount single
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 56
Design power capacity in use 40.0 %
Lower Limit 470.00 MHz
Upper Limit 728.00 MHz
Other Antenna Type N/A
ERP: 153.00 kW
Manufacturer Dielectric
Model TUF-04-14/56 H-I-T-R
Year 2003

Primary Antenna

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Adjustment to Existing Antenna

Section Question Response
Sweep Test of Existing Antenna Do you need a sweep test of existing antenna? Yes

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

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

retune elbox complex

retuning elbox complex for new channel

Auxiliary Antenna

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Add Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Auxiliary (Backup)
Description of Use Backup antenna
Ownership Owned
Owner N/A
Site N/A
Is this antenna currently shared with any other stations? No
Is this 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 Class A
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: 61.00 kW
Manufacturer
Model AL8PLUS
Year 2002

Auxiliary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Auxiliary (Backup)
Description of Use Aux/backup antenna to replace existing. Will be used for testing new channel prior to cutover
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 Type Class Class A
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: 137.00 kW
Manufacturer
Model ATC-BCH216M-22
Year 2018
Justification for New Antenna Current auxiliary antenna is not capable of new channel. Will install new auxiliary antenna for testing in phase 1 while not interrupting current channel/service

Auxiliary 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

Auxiliary 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 Dielectric
Type Rigid
Diameter 6 1/8 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 2
Length 1000 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Primary Line sweep and tuning bullets

Current transmission line is compatible with new channel, just needs swept and tuned

Auxiliary Transmission Line

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Add Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Utilize Existing
Use Auxiliary (Backup)
Description of Use Backup transmission line to side mount antenna
Ownership Owned
Owner N/A
Site N/A
Is this transmission currently shared with any other stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Andrew
Type Flexible Air
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 560 feet per run

Auxiliary 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 Move Equipment
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? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1016071
Coordinates (NAD83) Latitude (NAD83) 41° 08' 12.0" N-
Longitude (NAD83) 083° 54' 24.0" W-
Overall Structure Height 1089.55 feet
Support Structure Height 1030.83 feet
Ground Elevation Above Mean Sea Level (AMSL) 727.03 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner BOWLING GREEN STATE UNIVERSITY
Date Constructed 08/13/2004


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? No
Number of Hours N/A
Explanation N/A
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 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 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? No
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 $425,510.00 $425,510.00 N/A $354,008.45 N/A
Total for all systems $1,461,718.19 $1,052,421.82 N/A $753,945.27 N/A
Primary Transmitter UXLTE-20 $425,510.00 $425,510.00 $354,008.45
UHF - Liquid Cooled Solid State Transmitter 7.5 kW $387,060.00 $387,060.00 N/A $354,008.45 N/A
2" Rigid Conduit and Wiring (Cost per foot) $2,600.00 $2,600.00 N/A N/A N/A
Transformer 3 phase/480v - 300 KVA $35,850.00 $35,850.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 7.5 kW

Component Description:
RF load
Amount:
$13,785.91

Component Description:
Blackmagic Desing Smartview
Amount:
$1,256.30

Component Description:
Sencore receiver
Amount:
$2,031.60

Component Description:
Heat exchanger
Amount:
$4,417.40

Component Description:
Stabiline Automatic Voltage regulator
Amount:
$22,561.28

Component Description:
Streamscope ATSC1.0 Analyzer
Amount:
$29,900.00

Component Description:
Transmitter RF plumbing
Amount:
$20,773.63

Component Description:
Cmask 20kw UHF ATSC tuned
Amount:
$16,065.00

Component Description:
ULXTE-20 High Efficiency Transmitter
Amount:
$243,217.33
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Transformer 3 phase/480v - 300 KVA 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 $333,142.00 $92,342.00 N/A $67,842.00 N/A
Total for all systems $1,461,718.19 $1,052,421.82 N/A $753,945.27 N/A
Primary Antenna TUF-04-14/56 H-I-T-R $258,750.00 $18,100.00 $0.00
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized $240,500.00 $0.00 Do not need a new antenna, just retuning elbox complex of existing and line sweep N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A
retune elbox complex $11,700.00 $11,700.00 estimated cost of elbow complex retuning N/A N/A
Auxiliary Antenna ATC-BCH216M-22 $74,392.00 $74,242.00 $67,842.00
UHF - Lower Power, Side Mount, Class A, basic slot antenna, 60 - 65 kW input, horizontally polarized $44,796.00 $44,796.00 ***System Notice: Estimate adjusted and locked because line has been superseded.***Cost of new aux antenna as current aux antenna isn't compatible with new channel 6-6-18 - added $500 to the $45,000 to cover extra shipping charges - see attached Alive Telecom quote $44,796.00 N/A
UHF - Lower Power, Side Mount, Class A, basic slot antenna, 137 kW input, horizontally polarized $23,046.00 $23,046.00 Auxilliary antenna from Alive Telecom, plus freight charges - 2nd payment. First payment was approved under wrong item $23,046.00 N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized Information not provided.
Sweep test of existing antenna Information not provided.
retune elbox complex Information not provided.
UHF - Lower Power, Side Mount, Class A, basic slot antenna, 60 - 65 kW input, horizontally polarized

Component Description:
Balance due for antenna
Amount:
$23,046.00

Component Description:
This is for the 50% down payment for the new auxiliary antenna
Amount:
$21,750.00
UHF - Lower Power, Side Mount, Class A, basic slot antenna, 137 kW input, horizontally polarized

Component Description:
2nd payment for antenna - the first payment was approved under the wrong item
Amount:
$23,046.00
Sweep test of existing antenna Information not provided.

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $5,000.00 $5,000.00 N/A $950.00 N/A
Total for all systems $1,461,718.19 $1,052,421.82 N/A $753,945.27 N/A
Primary Transmission Line $5,000.00 $5,000.00 $950.00
Primary Line sweep and tuning bullets $5,000.00 $5,000.00 N/A $950.00 N/A
Auxiliary Transmission Line $0.00 $0.00 $0.00

Components

Actual Information Description File Name
Primary Line sweep and tuning bullets

Component Description:
Primary line sweep test
Amount:
$950.00

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 $205,000.00 $80,000.00 N/A $8,500.00 N/A
Total for all systems $1,461,718.19 $1,052,421.82 N/A $753,945.27 N/A
Primary Tower TOWER $205,000.00 $80,000.00 $8,500.00
Tall Tower (greater than 500') $205,000.00 $80,000.00 N/A $8,500.00 N/A

Components

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

Component Description:
Perform tower structural analysis to test for loading conditions and de-rated ice conditions
Amount:
$8,500.00

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 $131,840.00 $128,750.00 N/A $3,025.00 N/A
Total for all systems $1,461,718.19 $1,052,421.82 N/A $753,945.27 N/A
Outside Professional Services $131,840.00 $128,750.00 $3,025.00
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 -Prepare and File FCC Form 2100 (main), License to Cover Application $2,305.00 $2,250.00 N/A N/A N/A
RF Exposure Measurements $20,500.00 $20,000.00 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
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A $900.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A $2,125.00 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
Address transition timing and coordination issues w/ other stations and wireless $2,560.00 $2,500.00 N/A N/A N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
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 -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
RF Exposure Measurements Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
Perform engineering evaluation for new Channel 22
Amount:
$900.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Preparation of engineering portion of construction permit
Amount:
$2,125.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Address transition timing and coordination issues w/ other stations and wireless 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 $12,450.00 $3,650.00 N/A $2,450.00 N/A
Total for all systems $1,461,718.19 $1,052,421.82 N/A $753,945.27 N/A
Other Expenses $12,450.00 $3,650.00 $2,450.00
Disposal Costs (for equipment and other waste, net of any salvage value) $500.00 $500.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $500.00 $500.00 N/A N/A N/A
MVPD Notification of Channel Change $200.00 $200.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $2,450.00 N/A $2,450.00 N/A

Components

Actual Information Description File Name
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
MVPD Notification of Channel Change Information not provided.
DTV Medical Facility Notification

Component Description:
Medical Notification mailing
Amount:
$2,450.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,461,718.19 $1,052,421.82 $753,945.27

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.

Tina Simon

General Manager


01/18/2019

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.

Tina Simon

General Manager


01/18/2019

Attachments

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