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

FCC Form 399: Reimbursement Request

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

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

Facility ID:
19200
Service:
DTV
Call Sign:
WTNZ
Channel:
15 (UHF)
File Number:
0000025079
FRN:
0028123164
Date Submitted:
11/16/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WTNZ LICENSE SUBSIDIARY, LLC

Doing Business As: WTNZ LICENSE SUBSIDIARY, LLC

RSA TOWER, 20TH FLOOR

201 MONROE STREET

MONTGOMERY, AL 36104

United States

+1 (334) 206-1400 fcclms@raycommedia.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

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 Move station to another ATC tower facility. Install new main and backup transmitter

Transmitters

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

Auxiliary Transmitter

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Add Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Retune Existing
Use Auxiliary (Backup)
Ownership Owned
Owner N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer Harris
Model UAX
Year 2011
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.1 kW

Auxiliary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed N/A
New Mask Filter
Power 1.5 kW
Other Power N/A
New Exciter Is a new exciter needed? No

Auxiliary 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 N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Auxiliary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model DCX
Year 2005
Type Inductive Output Tube
IOT Power Type Single
Power Capacity 20 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model ULXTE-50
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 30.1 kW
Justification for New Transmitter Existing transmitter cannot be retuned Manufacturer data attached Headroom analysis attached

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 500 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 100.0 feet
Other Electrical Service Yes
Description Service panel and distribution for new ATC suite.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 10 tons
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 800.0 square feet
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

removal of existing equipment

Station must abandon existing ATC suite and remove its equipment

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 Leased
Owner American Tower
Site N/A
Is the existing antenna shared with another station or stations? Yes
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 Top Mount
Antenna position in stack Bottom
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 3
Number of Panels 10
Design power capacity in use 50.0 %
Lower Limit 470.00 MHz
Upper Limit 608.00 MHz
Other Antenna Type N/A
ERP: 460.0 kW
Manufacturer
Model TUD-O5-16/80H-2-B
Year 2003

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID Call Sign
52628 WPXK-TV
71082 WATE-TV

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? No
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types Class Full Power
Mounting Top 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: 280.0 kW
Manufacturer
Model TFU-24GTH-R 04
Year 2019
Justification for New Antenna Existing leased antenna will not meet spec for channel 15. Sweep data attached. Station must relocate.

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 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

Name Description

Antenna Pedestal

Required 10' pedestal for arbor arm installation

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 Leased
Owner American Tower
Site N/A
Is the existing transmission line shared with another station or stations? Yes
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 8 3/16 inches
Other Diameter N/A
Segment Length Broadband
Other Segment Length N/A
Number of parallel runs 2
Length 1600 feet per run

Facility ID's and Call Signs of all stations with whom the transmission line is shared.

Facility ID Call Sign
71082 WATE-TV
52628 WPXK-TV

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
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1500 feet per run
Justification for New Transmission Line Station is changing sites and is not able to lease.

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 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? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1222895
Coordinates (NAD83) Latitude (NAD83) 35° 59' 44.4" N-
Longitude (NAD83) 083° 57' 23.1" W-
Overall Structure Height 1534.10 feet
Support Structure Height 1399.92 feet
Ground Elevation Above Mean Sea Level (AMSL) 1314.94 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner American Towers LLC
Date Constructed 04/03/2003

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
69161 WUOT FM
35908 WVLT-TV DTV
18267 WKOP-TV 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: Minor 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? Yes

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 300
Explanation Pattern analysis Antenna Spec Transmitter Spec Building drawings Installation Supervision Accounting Internal Legal
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 No
Quantity N/A
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 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 Yes
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 Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 1
Justification system sweep

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 Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change Yes
FCC License to Cover Application Yes
FCC Special Temporary Authority Application No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Name Description

ATC Expenses

Defined American Tower charges attached

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 $1,330,330.00 $1,234,421.89 N/A $154,053.23 N/A
Total for all systems $2,970,335.00 $2,699,708.64 N/A $161,300.66 N/A
Primary Transmitter ULXTE-50 $1,222,100.00 $1,222,250.29 $151,267.85
removal of existing equipment $35,000.00 $35,000.00 N/A N/A N/A
Other -- Building Addition Size: 800.0 $45,000.00 $45,000.00 N/A N/A N/A
10 Ton system $38,900.00 $15,000.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW $947,000.00 $976,350.29 Quote attached $151,267.85 N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $13,700.00 N/A N/A N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A
Transformer 3 phase/480v - 500 KVA $48,400.00 $46,000.00 N/A N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $5,200.00 $4,900.00 N/A N/A N/A
Other Electrical Service: Service panel and distribution for new ATC suite. $50,000.00 $50,000.00 N/A N/A N/A
Auxiliary Transmitter UAX $108,230.00 $12,171.60 $2,785.38
UHF and VHF - minor banding issues $105,200.00 $12,171.60 Quote attached (GA-00021682 ) $2,785.38 N/A
1.5 kW mask filter $3,030.00 $0.00 included in tx quote N/A N/A

Components

Actual Information Description File Name
removal of existing equipment Information not provided.
Other -- Building Addition Size: 800.0 Information not provided.
10 Ton system Information not provided.
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW

Component Description:
Transmitter, Mask Filter Saystem, RF Accessories, Electrical, Installation & Proof
Amount:
$90,739.11

Component Description:
ULXTE-24-E
Amount:
$60,528.74
Service entrance 3 phase/800 amp/208 volt Information not provided.
Switchgear - industrial 800 amp Information not provided.
Transformer 3 phase/480v - 500 KVA Information not provided.
3" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Other Electrical Service: Service panel and distribution for new ATC suite. Information not provided.
UHF and VHF - minor banding issues

Component Description:
Channel Change & Proof
Amount:
$1,671.23

Component Description:
Channel Change UAX-1000AT per quote GA-00021682
Amount:
$1,114.15
1.5 kW mask filter 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 $286,030.00 $253,838.05 N/A $0.00 N/A
Total for all systems $2,970,335.00 $2,699,708.64 N/A $161,300.66 N/A
Primary Antenna TFU-24GTH-R 04 $286,030.00 $253,838.05 $0.00
Antenna Pedestal $20,000.00 $20,000.00 estimated until ATC provides quote N/A N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,300.00 $10,298.00 quote attached N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized $247,000.00 $217,140.05 quote attached N/A N/A

Components

Information not provided.

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $303,000.00 $205,548.70 N/A $0.00 N/A
Total for all systems $2,970,335.00 $2,699,708.64 N/A $161,300.66 N/A
Primary Transmission Line $303,000.00 $205,548.70 $0.00
Rigid Transmission Line - copper, 6 1/8" $303,000.00 $205,548.70 Quote attached N/A N/A

Components

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $799,000.00 $769,000.00 N/A $0.00 N/A
Total for all systems $2,970,335.00 $2,699,708.64 N/A $161,300.66 N/A
Primary Tower GTOWER $799,000.00 $769,000.00 $0.00
Tower Helicopter Lift $200,000.00 $200,000.00 estimated until quote is obtained N/A N/A
Minor tower reinforcement/modifications $158,000.00 $150,000.00 estimated pending structural analysis completion N/A N/A
Structural engineering tower load study for a documented tower with candelabra $20,000.00 $19,000.00 ATC RFP attached N/A N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $421,000.00 $400,000.00 estimated 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 $160,530.00 $153,375.00 N/A $5,834.95 N/A
Total for all systems $2,970,335.00 $2,699,708.64 N/A $161,300.66 N/A
Outside Professional Services $160,530.00 $153,375.00 $5,834.95
Additional Field Engineering Service, 1 Days $5,000.00 $5,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,625.00 Per invoices submitted $3,625.00 N/A
Project management of the transition $47,400.00 $45,000.00 N/A $2,084.95 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $125.00 N/A

Components

Actual Information Description File Name
Additional Field Engineering Service, 1 Days Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Preparation of the engineering portion of FCC Form 2100
Amount:
$2,000.00

Component Description:
Preparation of the engineering portion of FCC Form 2100
Amount:
$1,625.00
Project management of the transition

Component Description:
Project Management
Amount:
$2,084.95
Prepare engineering section of 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.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
Engineering study work for new channel assignment and antenna development.
Amount:
$125.00

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 $91,445.00 $83,525.00 N/A $1,412.48 N/A
Total for all systems $2,970,335.00 $2,699,708.64 N/A $161,300.66 N/A
Other Expenses $91,445.00 $83,525.00 $1,412.48
Disposal Costs (for equipment and other waste, net of any salvage value) $25,000.00 $25,000.00 N/A $1,412.48 N/A
ATC Expenses $19,630.00 $19,630.00 ATC document attached N/A N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $2,850.00 $2,850.00 estimate for on air rescan announcement production Quote attached N/A N/A
Equipment Storage $20,000.00 $20,000.00 Dielectric letter attached N/A N/A
Equipment Delivery and Handling Charges $2,970.00 $2,970.00 On site forklift rental estimate Representative quote attached N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $3,750.00 Group quote attached N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,000.00 N/A N/A N/A
Non-zoning permits $3,000.00 $3,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
Fee, Fuel Surcharge
Amount:
$1,412.48
ATC Expenses Information not provided.
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
DTV Medical Facility Notification Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
Non-zoning permits Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $2,970,335.00 $2,699,708.64 $161,300.66

Reimbursement Status

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

Certification

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Section Question Response
Submission of Estimated Expenses Statements

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.

  1. The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  3. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  4. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).

  5. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  6. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.

  7. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  8. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Robert Thurber

VP, Engineering


11/16/2018

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (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 AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).

  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.

  2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

  3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  4. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  5. 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 (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .

  6. 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.

  7. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

  8. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  9. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite 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.

Robert Thurber

VP, Engineering


11/16/2018

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