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:
0000028062
FRN:
0013697719
Facility ID:
70419
Repack Channel:
36 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
10/25/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

BELO TV, INC.

Doing Business As: BELO TV, INC.

Law Department

TEGNA Inc.

7950 Jones Branch Drive

McLean, VA 22107

United States

+1 (703) 873-6600 lawdept@tegna.com Corporation

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

Jeffrey Johnson

TEGNA, Inc.

TEGNA, Inc.

Jeffrey Johnson

7950 Jones Branch Drive

McLean, VA 22102

United States

+1 (703) 873-6736 jsjohnson@tegna.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 Change WBXN antenna and transmitter to new assignment

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 MX1501U
Year 2013
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity .15 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 UAXTE-2R37
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 1.2 kw
Other Transmitter Type  
Justification for New Transmitter Current transmitter manufacturer is out of business. Transmitter cannot be re-tuned.

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 100.0 feet
Other Electrical Service Yes
Description Additional electrical services required for transmitter installation.
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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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class 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: 4.00 kW
Manufacturer
Model PSILP24BF
Year 2004

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Type Class 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: 5.92 kW
Manufacturer
Model TFU-12SB-300BNT
Year 2019
Justification for New Antenna Licensed side-mount antenna cannot be re-tuned for new post-transition frequency and must be replaced.

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 3 1/8 inches
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? Yes
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

Shipping

$5,400

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 Flexible Air
Diameter 3 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 950 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

TX Line Sweep

Sweep required to verify post-transition channel measures well on existing line.

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? 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 Yes
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 1220144
Coordinates (NAD83) Latitude (NAD83) 29° 54' 22.9" N-
Longitude (NAD83) 090° 02' 22.1" W-
Overall Structure Height 1047.89 feet
Support Structure Height 1047.89 feet
Ground Elevation Above Mean Sea Level (AMSL) 0.98 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner WWL-TV, Inc.
Date Constructed 12/14/2001

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
74192 WWL-TV DTV

Other Types of Users

Users
WWL TV

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: Major 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 300
Explanation It will be necessary to schedule and coordinate multiple vendors, complete progress reports, and update Schedule 399s. Station does not have available personnel or personnel trained in project management for such complex projects.
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 Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements Yes
Additional Field Engineering Service Yes
Number of Days 5
Justification $2,500 per site visit including expenses x 5 days. It is necessary to survey the site, plan the equipment, develop specifications for purchasing, & oversee multiple vendor RF projects. Station does not have available personnel trained in such services.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Other Legal Services

Other Legal Services related to the DTV Repack

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning Yes
Non-zoning permits Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change Yes
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? 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

Internal Labor

Local and Corporate labor

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 $150,600.00 $117,330.00 N/A $26,466.96 N/A
Total for all systems $1,180,257.00 $771,684.25 N/A $30,211.38 N/A
Primary Transmitter UAXTE-2R37 $150,600.00 $117,330.00 $26,466.96
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $123,000.00 $89,830.00 per Gates Air Quote $26,466.96 N/A
2" Rigid Conduit and Wiring (Cost per foot) $2,600.00 $2,500.00 N/A N/A N/A
Other Electrical Service: Additional electrical services required for transmitter installation. $25,000.00 $25,000.00 Additional electrical services required for transmitter installation. N/A N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Inv JW30004452-1 WBXN Primary Transmitter 1 3rd dp UL20180719jg v1
Amount:
$26,466.96
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Other Electrical Service: Additional electrical services required for transmitter installation. 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 $45,130.00 $62,175.25 N/A $0.00 N/A
Total for all systems $1,180,257.00 $771,684.25 N/A $30,211.38 N/A
Primary Antenna TFU-12SB-300BNT $45,130.00 $62,175.25 $0.00
Elbow complex, single channel, at antenna input, per 3 1/8. feedline (if needed) $7,580.00 $6,585.00 N/A N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 Per Widelity estimate N/A N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $25,600.00 $43,790.25 Required peanut pattern IS NOT an off-the-shelf antenna. N/A N/A
Shipping $5,400.00 $5,400.00 N/A 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 $6,400.00 $6,400.00 N/A $0.00 N/A
Total for all systems $1,180,257.00 $771,684.25 N/A $30,211.38 N/A
Primary Transmission Line $6,400.00 $6,400.00 $0.00
TX Line Sweep $6,400.00 $6,400.00 N/A 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 $640,100.00 $312,500.00 N/A $0.00 N/A
Total for all systems $1,180,257.00 $771,684.25 N/A $30,211.38 N/A
Primary Tower TOWER $640,100.00 $312,500.00 $0.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $25,600.00 $12,500.00 Shared expense with WWL N/A N/A
Major tower reinforcement/modifications $409,500.00 $200,000.00 Shared expense with WWL N/A N/A
Tall Tower (greater than 500') $205,000.00 $100,000.00 Shared expense with WWL 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 $208,735.00 $144,250.00 N/A $474.42 N/A
Total for all systems $1,180,257.00 $771,684.25 N/A $30,211.38 N/A
Outside Professional Services $208,735.00 $144,250.00 $474.42
Other Legal Services $10,000.00 $10,000.00 Other Legal Services related to the DTV Repack $174.42 N/A
Additional Field Engineering Service, 5 Days $12,500.00 $12,500.00 $2,500 per site visit including expenses x 5 days. It is necessary to survey the site, plan the equipment, develop specifications for purchasing, & oversee multiple vendor RF projects. Station does not have available personnel trained in such services. N/A N/A
ASR modification (prepare FCC Form 854) $2,050.00 $2,000.00 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
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $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
Attorney Fees - Negotiation of lease and other matters for shared locations $4,095.00 $4,000.00 N/A N/A N/A
Project management of the transition $46,200.00 $45,000.00 It will be necessary to schedule and coordinate multiple vendors, complete progress reports, and update Schedule 399s. Station does not have available personnel or personnel trained in project management for such complex projects. $300.00 N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 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
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 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
RF Exposure Measurements $20,500.00 $20,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $81,900.00 $20,000.00 Add to WWL test. N/A 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

Components

Actual Information Description File Name
Other Legal Services

Component Description:
Covington inv #60796723 Various Legal UL20181024jgv1
Amount:
$174.42
Additional Field Engineering Service, 5 Days Information not provided.
ASR modification (prepare FCC Form 854) 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.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Project management of the transition

Component Description:
Inv 29220 WBXN Proj Mgt 180428-180525 UL20180706jg v1
Amount:
$300.00
Prepare and or review reimbursement form Information not provided.
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Perform engineering study for new channel assignment and antenna development Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase 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 $129,292.00 $129,029.00 N/A $3,270.00 N/A
Total for all systems $1,180,257.00 $771,684.25 N/A $30,211.38 N/A
Other Expenses $129,292.00 $129,029.00 $3,270.00
Internal Labor $21,744.00 $21,744.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $25,000.00 $25,000.00 N/A N/A N/A
Non-zoning permits $25,000.00 $25,000.00 N/A N/A N/A
Local Zoning $200.00 $200.00 Building permit. 3 cents per 100 dollars of construction cost N/A 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
FCC Filing Fees - Form 2100 minor change CP application $1,070.00 $1,070.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A N/A N/A
MVPD Notification of Channel Change $6,000.00 $6,000.00 Prepare notification for all MVPD's of upcoming changes and testing windows. N/A N/A
Equipment Storage $7,500.00 $7,500.00 Per dielectric rate card. 6 months of storage. N/A N/A
Equipment Delivery and Handling Charges $25,000.00 $25,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $6,000.00 $6,000.00 40 hours at $150 per hour to shoot, write, produce and edit informational spot. $3,270.00 N/A

Components

Actual Information Description File Name
Internal Labor Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Non-zoning permits Information not provided.
Local Zoning Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
DTV Medical Facility Notification Information not provided.
MVPD Notification of Channel Change Information not provided.
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Develop and air announcement of upcoming channel change

Component Description:
2C Media inv #203806 Creation of channel change announcement UL20181016jgv1
Amount:
$3,270.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,180,257.00 $771,684.25 $30,211.38

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.

Jeffrey C Gehman

Engineering Associate


10/25/2018

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.

Jeffrey C Gehman

Engineering Associate


10/25/2018

Attachments

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