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:
0000027054
FRN:
0003828712
Facility ID:
49157
Repack Channel:
18 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
08/31/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

NORTH CAROLINA BROADCASTING PARTNERS

Doing Business As: NORTH CAROLINA BROADCASTING PARTNERS

Beverly B. Poston

ONE TELEVISION PLACE

CHARLOTTE, NC 28205

United States

+1 (704) 372-4434 BPoston@bahakel.com General Partnership

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

M. Anne Swanson

Legal Counsel

Wilkinson Barker Knauer LLP

M. Anne Swanson

1800 M Street NW

Suite 800N

Washington, DC 20036

United States

+1 (202) 383-3342 ASwanson@wbklaw.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 Install new primary transmitter. Re-purpose legacy Ch.18 antenna and transmission line to operate on reassigned channel. See Exhibit A Revised 2-8-18 and WCCB Form 399 Amendment 2-23-18.

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-3H(IOX/DCX Product Family)
Year 2002
Type Inductive Output Tube
IOT Power Type Three
Description  
Power capacity 60 kw
Solid State Cooling  
Solid State Power Capacity  
Other Transmitter Type  

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Description of Use  
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model HPTV-PRLX-U32
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 55 kw
Other Transmitter Type  
Justification for New Transmitter Manufacturer is not able to re-tune existing transmitter. New transmitter is required to operate on reassigned channel. New transmitter is upgrade to solid state with non-reimbursable cost increase of $2070.30. See Exhibit B.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power
Rigid Conduit and Wiring Yes
Size 2 inches
Length 500.0 feet
Other Electrical Service Yes
Description Circuit breakers and disconnects for transmitter, pumps, and heat exchangers. Cost estimate is based upon previous projects experience of a similar nature. See Exhibit I.
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

Site Design and Survey by Manufacturer

Cost for site design and survey by manufacturer to determine electrical, HVAC, and space considerations for new primary transmitter and RF system. See Exhibit C.(Survey itself is in Exhibit B.)

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 Purchase New
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? 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 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: 1000.00 kW
Manufacturer
Model TFU-24DSC-R 3C130
Year 2002

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? Yes
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: 1000.00 kW
Manufacturer
Model TFU-24G
Year 1979
Justification for New Antenna This is a legacy top mount Ch.18 antenna which is currently installed on tower. It will be re-purposed to operate on reassigned channel. See WCCB Form 399 Amendment 2-23-18.

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? 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

Slot Covers

Replacement slot covers for re-purposed top mount Ch.18 antenna. See Exhibit L.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? No

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1037877
Coordinates (NAD83) Latitude (NAD83) 35° 16' 02.0" N-
Longitude (NAD83) 080° 44' 04.0" W-
Overall Structure Height 1214.55 feet
Support Structure Height 1140.73 feet
Ground Elevation Above Mean Sea Level (AMSL) 779.85 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner WCCB-TV, Inc.
Date Constructed 01/01/1966


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: No 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 480
Explanation Reassigned station does not have sufficient qualified internal personnel for project management. It is estimated that outside project management will be required for 60 days while new antennas, transmission line, and transmitter are installed.
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 Yes
FAA Consultation (including preparation of FAA Form 7460) Yes
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 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

WCCB Additional Repack Related Legal Services

Attorneys Fees - Repack requirements (vendor contracts, refinancing, tax, affiliation agreements, equipment selection/justification). See Exhibit H

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 Yes
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

Name Description

Wireless Microphones

To replace station's wireless microphones that will be displaced because existing channels are eliminated due to repack. See Exhibit F.

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 $1,776,800.00 $1,390,773.70 N/A $488,370.10 N/A
Total for all systems $2,449,940.04 $1,629,990.74 N/A $542,830.54 N/A
Primary Transmitter HPTV-PRLX-U32 $1,776,800.00 $1,390,773.70 $488,370.10
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW $1,741,000.00 $1,355,473.70 N/A $473,070.10 N/A
2" Rigid Conduit and Wiring (Cost per foot) $13,000.00 $12,500.00 N/A N/A N/A
Other Electrical Service: Circuit breakers and disconnects for transmitter, pumps, and heat exchangers. Cost estimate is based upon previous projects experience of a similar nature. See Exhibit I. $7,500.00 $7,500.00 N/A N/A N/A
Site Design and Survey by Manufacturer $15,300.00 $15,300.00 N/A $15,300.00 N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW

Component Description:
WCCB Transmitter Deposit Invoice
Amount:
$473,070.10
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Other Electrical Service: Circuit breakers and disconnects for transmitter, pumps, and heat exchangers. Cost estimate is based upon previous projects experience of a similar nature. See Exhibit I. Information not provided.
Site Design and Survey by Manufacturer

Component Description:
Final payment for Site Survey and Design.
Amount:
$13,300.00

Component Description:
Down payment for Site Survey and Design.
Amount:
$2,000.00

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 $256,971.90 $16,321.90 N/A $0.00 N/A
Total for all systems $2,449,940.04 $1,629,990.74 N/A $542,830.54 N/A
Primary Antenna TFU-24G $256,971.90 $16,321.90 $0.00
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized $240,500.00 $0.00 N/A N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A
Slot Covers $9,921.90 $9,921.90 N/A N/A N/A

Components

Information not provided.

Cost Information

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Transmission Line

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 $217,300.00 $27,000.00 N/A $19,100.00 N/A
Total for all systems $2,449,940.04 $1,629,990.74 N/A $542,830.54 N/A
Primary Tower GTOWER $217,300.00 $27,000.00 $19,100.00
Tall Tower (greater than 500') $205,000.00 $15,000.00 See Exhibit M N/A N/A
Structural engineering tower load study for well documented tower $12,300.00 $12,000.00 N/A $19,100.00 See Exhibit K

Components

Actual Information Description File Name
Tall Tower (greater than 500') Information not provided.
Structural engineering tower load study for well documented tower

Component Description:
WCCB Tower Structural Analysis Invoice (revised)
Amount:
$6,600.00

Component Description:
WCCB Ultrasound Testing Invoice
Amount:
$4,500.00

Component Description:
WCCB Tower Wind and Ice Analysis (revised)
Amount:
$1,250.00

Component Description:
WCCB Utrasonic Testing Invoice
Amount:
$5,500.00

Component Description:
WCCB Corrosion Risk Analysis Invoice
Amount:
$1,250.00

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 $119,460.00 $116,750.00 N/A $26,926.34 N/A
Total for all systems $2,449,940.04 $1,629,990.74 N/A $542,830.54 N/A
Outside Professional Services $119,460.00 $116,750.00 $26,926.34
WCCB Additional Repack Related Legal Services $12,000.00 $12,000.00 N/A $11,850.90 N/A
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase $2,050.00 $2,000.00 N/A N/A N/A
ASR modification (prepare FCC Form 854) $2,050.00 $2,000.00 N/A $168.00 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
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A $1,278.00 N/A
Prepare request for Special Temporary Authorization $1,535.00 $1,500.00 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 N/A N/A
Project management of the transition $73,920.00 $72,000.00 N/A N/A N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A $11,316.94 See Exhibit J
Address transition timing and coordination issues w/ other stations and wireless $2,560.00 $2,500.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A $2,312.50 N/A

Components

Actual Information Description File Name
WCCB Additional Repack Related Legal Services

Component Description:
WCCB Post-Auction Repack Legal Services
Amount:
$2,164.90

Component Description:
WCCB Post-Auction Repack Legal Services
Amount:
$819.00

Component Description:
WCCB Post-Auction Repack Legal Services
Amount:
$8,867.00
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)

Component Description:
WCCB Antenna Structure Registration Legal Issues (revised)
Amount:
$168.00
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.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
WCCB Construction Permit Legal Issues (revised)
Amount:
$498.00

Component Description:
WCCB Construction Permit Legal Issues (revised)
Amount:
$780.00
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 Information not provided.
Project management of the transition Information not provided.
Prepare and or review reimbursement form

Component Description:
WCCB Post-Auction Repack Legal Issues
Amount:
$1,057.44

Component Description:
WCCB Post-Auction Repack Legal Issues.
Amount:
$1,003.00

Component Description:
WCCB Post-Auction Repack Legal Issues
Amount:
$1,521.00

Component Description:
WCCB Post-Auction Repack Legal Issues (revised)
Amount:
$3,198.00

Component Description:
WCCB Post-Auction Repack Legal Issues (revised)
Amount:
$4,362.00

Component Description:
WCCB Post-Auction Repack Legal Services
Amount:
$175.50
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:
WCCB Eng Study Invoice
Amount:
$250.00

Component Description:
WCCB Eng Study Invoice
Amount:
$312.50

Component Description:
WCCB Eng Study Invoice
Amount:
$1,500.00

Component Description:
WCCB Eng Study Invoice (revised)
Amount:
$250.00

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 $79,408.14 $79,145.14 N/A $8,434.10 N/A
Total for all systems $2,449,940.04 $1,629,990.74 N/A $542,830.54 N/A
Other Expenses $79,408.14 $79,145.14 $8,434.10
Wireless Microphones $10,988.14 $10,988.14 N/A N/A N/A
MVPD Notification of Channel Change $1,000.00 $1,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $1,000.00 $1,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $41,642.00 $41,642.00 See Exhibit B and Form 399 Amendment. $8,434.10 N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $333.00 $325.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A N/A N/A
Non-zoning permits $500.00 $500.00 N/A N/A N/A
Equipment Delivery and Handling Charges $12,500.00 $12,500.00 N/A N/A N/A

Components

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

Component Description:
WCCB Coolant Testing Invoice
Amount:
$500.00

Component Description:
WCCB Coolant Disposal Invoice
Amount:
$6,934.10

Component Description:
WCCB Coolant TCLP Testing Invoice
Amount:
$500.00

Component Description:
WCCB Coolant TCLP Testing Invoice
Amount:
$500.00
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
DTV Medical Facility Notification Information not provided.
Non-zoning permits Information not provided.
Equipment Delivery and Handling Charges Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $2,449,940.04 $1,629,990.74 $542,830.54

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.

Beverly Poston

President


08/31/2018

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.

Beverly Poston

President


08/31/2018

Attachments

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