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:
0000028244
FRN:
0016216061
Facility ID:
50182
Repack Channel:
19 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
10/02/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

TRIBUNE BROADCASTING OKLAHOMA CITY LICENSE,LLC

Doing Business As: TRIBUNE BROADCASTING OKLAHOMA CITY LICENSE,LLC

Nick Thompson

444 EAST BRITTON ROAD

OKLAHOMA, OK 73114

United States

+1 (405) 478-6290 nick.thompson@kfor.com Limited Liability Company

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

Bill Vanduynhoven , Vanduynhov .

Director of Engineering operations

Tribune Broadcasting

Bill Vanduynhoven

2211 Rabbit Hill Cir

Dacula, GA 30019

United States

+1 (404) 312-8693 BillV@Tribunemedia.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. Yes
Briefly describe transition plan Move KAUT to a an existing Tribune owned site and install a Broadband antenna. Site requires renovation to support the operation. KOPX also repacked will be a tenant on the new 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 Sigma CD P3
Year 2006
Type Inductive Output Tube
IOT Power Type Three
Description  
Power capacity 90 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 ULXTE-60
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 38 kw
Other Transmitter Type  
Justification for New Transmitter Current transmitter has be stated by Manufacturer as not re-tunable. KAUT is moving to another tower and will install replacement transmitter at new site.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) Yes
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring No
Size
Length
Other Electrical Service Yes
Description New electrical distribution
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size 30 tons
Other Size  
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 2000.0 square feet
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

Ice protection

Ice shield over critical equipment

Removal Disposal

Clear Suite at current site

Asbestos abatement

Clean building and make safe for new system

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: 1000.00 kW
Manufacturer
Model TFU-30DSC-R 03
Year 2006

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? Yes
Is antenna directional? No
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Type Class Full Power
Mounting Top-mount single
Antenna position in stack Not in Stack
Polarization Elliptical
Type Broadband Panel
Number of Stations Supported 2
Number of Panels/Bays 25
Lower Limit 490.00 MHz
Upper Limit 590.00 MHz
Design power capacity in use 60.0 %
Other Antenna Type N/A
ERP: 2000.00 kW
Manufacturer
Model TUM25-04-16/64H-2-R-T
Year 2018
Justification for New Antenna Current antenna will not work on assigned channel. Moving to different site

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? Yes
Type New
Number of channels supported 2
Frequencies of channels supported RF channel
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? No
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Broadband
Feed Line Size 8 3/16 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

Enter a list of RF channel numbers.

RF Channel Number
18
19

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

KAUT Combiner install

Install of KAUT combiner

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 7 3/16 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 1600 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 8 3/16 inches
Segment Length Broadband
Other Segment Length
Number of parallel runs 1
Length 1900 feet per run
Justification for New Transmission Line Moving to different site. Current line would not support power required

Primary 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 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? Yes
ASR Number 1045226
Coordinates (NAD83) Latitude (NAD83) 35° 35' 52.1" N-
Longitude (NAD83) 097° 29' 23.2" W-
Overall Structure Height 1646.96 feet
Support Structure Height 1549.85 feet
Ground Elevation Above Mean Sea Level (AMSL) 1102.02 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner American Towers, LLC.
Date Constructed 02/01/1999

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
25382 KWTV-DT DTV
2566 KOPX-TV DTV
38214 KSBI DTV
58389 KXXY-FM FM
58390 KTST FM
66222 KFOR-TV DTV
84225 KOCM DTV
11964 KBRU FM
11918 KJYO FM

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? Yes

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Removal of current

Lease requirement to remove the current antenna and line

Primary Tower

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Add 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 No
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 1043710
Coordinates (NAD83) Latitude (NAD83) 35° 34' 07.0" N-
Longitude (NAD83) 097° 29' 21.0" W-
Overall Structure Height 1602.01 feet
Support Structure Height 1508.84 feet
Ground Elevation Above Mean Sea Level (AMSL) 1146.97 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Local TV Oklahoma, LLC
Date Constructed 04/06/1965

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
69175 KROU FM

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: Serious 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 1000
Explanation Construction supervision by Manhattan construction. Extensive site work required
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 No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare and file Form FCC License to Cover Application No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare request for Special Temporary Authority No
Quantity N/A
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 No
Address transition timing and coordination issues w/ other stations and wireless providers No
RF Field Engineering Services Comprehensive coverage verification via field study No
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

Name Description

Binding and insurance

Insurance for the construction

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 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? No
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Name Description

Design fees

Architectural design fees

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 $2,543,050.00 $2,360,700.00 N/A $765,141.16 N/A
Total for all systems $6,397,945.00 $5,118,050.00 N/A $1,917,187.06 N/A
Primary Transmitter ULXTE-60 $2,543,050.00 $2,360,700.00 $765,141.16
Asbestos abatement $100,000.00 $100,000.00 N/A N/A N/A
Removal Disposal $25,000.00 $25,000.00 N/A N/A N/A
Ice protection $300,000.00 $300,000.00 N/A N/A N/A
30 Ton system $162,000.00 $162,000.00 N/A N/A N/A
Other Electrical Service: New electrical distribution $285,000.00 $285,000.00 N/A N/A N/A
Transformer 3 phase/480v - 300 KVA $35,850.00 $30,000.00 N/A N/A N/A
Switchgear - industrial 800 amp $37,150.00 $20,000.00 N/A N/A N/A
Service entrance 3 phase/800 amp/208 volt $14,050.00 $13,700.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,434,000.00 $1,275,000.00 N/A $765,141.16 N/A
Other -- Building Addition Size: 2000.0 $150,000.00 $150,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Asbestos abatement Information not provided.
Removal Disposal Information not provided.
Ice protection Information not provided.
30 Ton system Information not provided.
Other Electrical Service: New electrical distribution Information not provided.
Transformer 3 phase/480v - 300 KVA Information not provided.
Switchgear - industrial 800 amp Information not provided.
Service entrance 3 phase/800 amp/208 volt Information not provided.
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW

Component Description:
ULXTE-60 Primary Transmitter - 3rd payment
Amount:
$182,433.72

Component Description:
ULXTE-60 Primary Transmitter - 2nd payment
Amount:
$291,353.72

Component Description:
ULXTE-60 Primary Transmitter - deposit
Amount:
$291,353.72
Other -- Building Addition Size: 2000.0 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 $913,000.00 $870,850.00 N/A $725,346.90 N/A
Total for all systems $6,397,945.00 $5,118,050.00 N/A $1,917,187.06 N/A
Primary Antenna TUM25-04-16/64H-2-R-T $913,000.00 $870,850.00 $725,346.90
New combiner, cost per channel (without antenna) $80,000.00 $96,000.00 CIF Combiner with Mask Filter $86,321.70 N/A
KAUT Combiner install $60,000.00 $60,000.00 N/A N/A N/A
Elbow complex, broadband, at antenna input, per 8 3/16. feedline (if needed) $18,450.00 $18,450.00 N/A $16,650.00 N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A $5,760.00 N/A
UHF - High Power Top Mount (200-1000 kW), Two Station broadband panel antenna, elliptically or circularly polarized $748,000.00 $690,000.00 N/A $616,615.20 N/A

Components

Actual Information Description File Name
New combiner, cost per channel (without antenna)

Component Description:
2 channel combiner
Amount:
$43,160.85

Component Description:
2 channel combiner 2nd payment
Amount:
$43,160.85
KAUT Combiner install Information not provided.
Elbow complex, broadband, at antenna input, per 8 3/16. feedline (if needed)

Component Description:
Elbow complex 8-3/16" 75 OHM
Amount:
$14,985.00

Component Description:
Elbow complex 8-3/16" 75 OHM
Amount:
$1,665.00
Sweep test of existing antenna

Component Description:
Eng on site
Amount:
$2,880.00

Component Description:
Eng on site
Amount:
$2,880.00
UHF - High Power Top Mount (200-1000 kW), Two Station broadband panel antenna, elliptically or circularly polarized

Component Description:
TUM25-O4-16/64H-2-R-T Omni antenna
Amount:
$308,307.60

Component Description:
TUM25-O4-16/64H-2-R-T Omni antenna
Amount:
$308,307.60

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 $737,200.00 $550,000.00 N/A $426,699.00 N/A
Total for all systems $6,397,945.00 $5,118,050.00 N/A $1,917,187.06 N/A
Primary Transmission Line $737,200.00 $550,000.00 $426,699.00
Rigid Transmission Line - copper, 8 3/16" broadband $737,200.00 $550,000.00 N/A $426,699.00 N/A

Components

Actual Information Description File Name
Rigid Transmission Line - copper, 8 3/16" broadband

Component Description:
8-3/16" 75 OHM EIA Digit Dual Lines
Amount:
$360,032.85

Component Description:
TLSCR'S T/L8-75 EIA 15'to 20' fixed flg
Amount:
$13,331.25

Component Description:
8-3/16" 75 OHM EIA Digit Dual Lines
Amount:
$40,003.65

Component Description:
TLSCR'S T/L8-75 EIA 15'to 20' fixed flg
Amount:
$13,331.25

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 $1,844,100.00 $990,000.00 N/A $0.00 N/A
Total for all systems $6,397,945.00 $5,118,050.00 N/A $1,917,187.06 N/A
Primary Tower GTOWER $589,500.00 $305,000.00 $0.00
Tower Helicopter Lift $80,000.00 $80,000.00 Only if joint operation with other stations N/A N/A
Removal of current $100,000.00 $100,000.00 N/A N/A N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $409,500.00 $125,000.00 N/A N/A N/A
Primary Tower TOWER $1,254,600.00 $685,000.00 $0.00
Tall Tower (greater than 500') $205,000.00 $100,000.00 N/A N/A N/A
Serious tower reinforcement/modifications $1,024,000.00 $560,000.00 N/A N/A N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $25,600.00 $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 $249,345.00 $235,500.00 N/A $0.00 N/A
Total for all systems $6,397,945.00 $5,118,050.00 N/A $1,917,187.06 N/A
Outside Professional Services $249,345.00 $235,500.00 $0.00
Binding and insurance $60,000.00 $60,000.00 Required by Manhattan construction N/A N/A
RF Exposure Measurements $20,500.00 $11,000.00 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 N/A N/A
Project management of the transition $154,000.00 $150,000.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A N/A N/A

Components

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 $111,250.00 $111,000.00 N/A $0.00 N/A
Total for all systems $6,397,945.00 $5,118,050.00 N/A $1,917,187.06 N/A
Other Expenses $111,250.00 $111,000.00 $0.00
Disposal Costs (for equipment and other waste, net of any salvage value) $25,000.00 $25,000.00 N/A N/A N/A
Local Zoning $10,000.00 $10,000.00 N/A N/A N/A
Design fees $25,000.00 $25,000.00 N/A N/A N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 N/A N/A N/A
Equipment Storage $25,000.00 $25,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $11,000.00 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 $6,397,945.00 $5,118,050.00 $1,917,187.06

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.

Teri Ann Guillory

Broadcasting Operations


10/02/2018

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.

Teri Ann Guillory

Broadcasting Operations


10/02/2018

Attachments

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