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:
0000027251
FRN:
0005941323
Facility ID:
70536
Repack Channel:
18 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
10/31/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WEST CENTRAL ILLINOIS EDUCATIONAL TELECOMMUNICATIONS CORP.

Doing Business As: WMEC TV

Jerold Gruebel

PO Box 6248

Springfield, IL 62708

United States

+1 (217) 482-7887 jgruebel@wsec.tv Not-for-Profit

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 WSEC will be changing channel with a minimal amount of interruption to viewers. Purchasing new transmitter, mask filter & broadcast antenna plus required associated modules and components.

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 DCD20PL1
Year 2001
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 5 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-12R44
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 7.2 kw
Other Transmitter Type  
Justification for New Transmitter Existing Harris DiamondCD transmitter is not capable of producing the required TPO in order to achieve an ERP of 80.8kW as assigned.

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 50.0 feet
Other Electrical Service Yes
Description Install new circuit breaker(s) as required and install wiring to transmitter's physical location within the building.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 10 tons
Other Size  
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size
Channel 14 Costs Is an RF Consulting Engineer needed?
Is a channel 14 Mask Filer needed?
Is additional field engineering time needed?
Number of Days  

Primary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Antennas

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

Primary Antenna

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Add Antenna Information

Section Question Response
Existing Antenna Description Type of change 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? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Top-mount single
Antenna position in stack Not in Stack
Polarization Horizontal
Type Other Type
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 Slot Antenna - single channel tuned
ERP: 75.00 kW
Manufacturer
Model TFU-24GTH-R O4
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? No
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: 80.80 kW
Manufacturer
Model ATW22H3-HTO-10-18H
Year 2018
Justification for New Antenna Existing antenna will not function on the assigned frequency..

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

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? Yes

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change 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 4 1/16 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 1000 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 4 1/16 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 1050 feet per run
Justification for New Transmission Line Structure analyses found need for tower replacement. New tower will require transmission line be in place at the time transmission begins on new tower. Flexible line required from base of tower to transmitter location within building.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Four inch air DieElectric

Flexible transmission line from tower base to transmitter location within equipment enclosure.

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 Construct New
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) No
Others Types of Users Yes
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 1221865
Coordinates (NAD83) Latitude (NAD83) 39° 36' 09.2" N-
Longitude (NAD83) 090° 02' 47.4" W-
Overall Structure Height 976.04 feet
Support Structure Height 915.67 feet
Ground Elevation Above Mean Sea Level (AMSL) 672.89 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner West Central Illinois Educational Telecommunications Corporation
Date Constructed 09/23/2002


Other Types of Users

Users
W40CV-D

Primary Tower

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Tower Construction Costs

Section Question Response
Construct New Tower Use Primary (Main)
Description of Use N/A
Is this a request for upgraded equipment? No
Height 912.00 feet
Justification for New Tower Two structural analyses were conducted and both found that the existing structure and foundation do not meet ANSI/TIA - G Code. See attachment: WSEC Documentation for new tower.pdf (attached)

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

Name Description

STL-TSL Equipment

Please refer to file - WSEC-Microwave Justification.PDF This tower is the 2nd in a string of 7 towers sending programming, transmitter control & telemetry between master control and our three broadcast stations.

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 120
Explanation Forms review; onsite supervision during transmitter, antenna & tower work; coordination of involved entities in the project.
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 Yes
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations No
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study 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

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
FCC Special Temporary Authority Application No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? 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

Information not provided.

Cost Information

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Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $285,450.00 $282,500.00 N/A $0.00 N/A
Total for all systems $2,956,259.61 $2,807,814.66 N/A $1,536,346.12 N/A
Primary Transmitter UAXTE-12R44 $285,450.00 $282,500.00 $0.00
10 Ton system $37,900.00 $35,000.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 7.2 kW $245,000.00 $245,000.00 N/A N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $1,300.00 $1,250.00 N/A N/A N/A
Other Electrical Service: Install new circuit breaker(s) as required and install wiring to transmitter's physical location within the building. $1,250.00 $1,250.00 N/A N/A N/A

Components

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 $247,050.00 $134,750.00 N/A $94,325.00 N/A
Total for all systems $2,956,259.61 $2,807,814.66 N/A $1,536,346.12 N/A
Primary Antenna ATW22H3-HTO-10-18H $247,050.00 $134,750.00 $94,325.00
Sweep test of existing antenna $6,550.00 $6,250.00 ERI Proposal 20186018-491 Rev D $4,375.00 N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized $240,500.00 $128,500.00 ERI Proposal 20180618-491 Rev-D - Discounted $89,950.00 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
Line and antenna sweep. Please refer to uploaded ERI Invoice WSEC-001.PDF for explanation.
Amount:
$4,375.00
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized

Component Description:
ERI Antenna 70% down payment - Please refer to uploaded ERI Invoice WSEC-001.PDF for explanation.
Amount:
$89,950.00

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 $148,400.00 $100,905.05 N/A $68,183.53 N/A
Total for all systems $2,956,259.61 $2,807,814.66 N/A $1,536,346.12 N/A
Primary Transmission Line $148,400.00 $100,905.05 $68,183.53
Four inch air DieElectric $3,500.00 $3,500.00 Sixty feet of air dielectric 4" flexible line to reach from base of new tower to rigid line within the building receiving the signal from the filter and transmitter. N/A N/A
Rigid Transmission Line - copper, 4 1/16" $144,900.00 $97,405.05 ERi Proposal 20180618-491 Rev D - Discounted transmission line and air dryer $68,183.53 N/A

Components

Actual Information Description File Name
Four inch air DieElectric Information not provided.
Rigid Transmission Line - copper, 4 1/16"

Component Description:
Transmission line and air dryer for ERI antenna system. NOTE this is a percentage of the invoiced amount and pennies may be rounded. Please refer to uploaded ERI Invoice WSEC-001.PDF for explanation.
Amount:
$68,183.53

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 $2,187,759.61 $2,177,159.61 N/A $1,343,678.78 N/A
Total for all systems $2,956,259.61 $2,807,814.66 N/A $1,536,346.12 N/A
Primary Tower TOWER $0.00 $0.00 $0.00
Primary Tower $2,187,759.61 $2,177,159.61 $1,343,678.78
Tall Tower (greater than 500') $205,000.00 $200,000.00 Replacement antennae and waveguide for microwave on new tower plus rigging to remove old antennae and replaced tower structure once new structure is complete and online. $3,200.00 N/A
New tower $1,905,398.25 $1,905,398.25 ERI Proposal 20181618-491 Rev D Manufacture (discounted), construct and equip replacement 912' tower and decommission existing tower. $1,333,778.78 N/A
STL-TSL Equipment $65,061.36 $65,061.36 Please refer to file - WSEC - Microwave Justification ... and per quote from Heartland Video Systems - see file - WSEC - HVS Commscope Antennas Gear.PDF N/A N/A
Structural engineering tower load study for well documented tower $12,300.00 $6,700.00 ***System Notice: Estimate adjusted and locked because line has been superseded.*** $6,700.00 N/A

Components

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

Component Description:
Land survey for construction of new tall tower.
Amount:
$3,200.00
New tower

Component Description:
Tower portion of invoice. Refer to uploaded file ERI Invoice WSEC-001 Memo.pdf for explanation.
Amount:
$1,333,778.78
STL-TSL Equipment Information not provided.
Structural engineering tower load study for well documented tower

Component Description:
Structural analysis of WSEC Tower. Reg #1221865 For TIA/EIA 222-G standards. Valmont order #156273-2-1
Amount:
$3,500.00

Component Description:
Geotechnical and structural analysis of broadcast tower for the TIA-222-G standard
Amount:
$3,200.00

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 $44,850.00 $71,000.00 N/A $30,158.81 N/A
Total for all systems $2,956,259.61 $2,807,814.66 N/A $1,536,346.12 N/A
Outside Professional Services $44,850.00 $71,000.00 $30,158.81
ASR modification (prepare FCC Form 854) $2,050.00 $2,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,305.00 $4,500.00 Please refer to uploaded file "WSEC Legal Counsel Budget.PDF" -- Additional legal counsel costs incurred due to unanticipated need for a new tower at this site. $2,416.50 Additional legal counsel required due to problems with 'saving' the 399 schedule without losing tower work dollar amounts. Received numerous errors on "saving & exiting'. Required repeated contact with FCC I.T. personnel (Raphael) to rectify.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $30,000.00 Additional amount added to budget for legal counsel expenses due to legal complexities associated with unanticipated construction of a new tower at this site. $25,398.81 Additional legal fees due to unanticipated need to replace tower.
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 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 $2,343.50 N/A
Project management of the transition $18,480.00 $18,000.00 N/A N/A N/A

Components

Actual Information Description File Name
ASR modification (prepare FCC Form 854) Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Legal Counsel - WSEC repack issues June 2017
Amount:
$1,130.50

Component Description:
Legal Counsel - WSEC repack issues September 2017
Amount:
$56.00

Component Description:
Legal Counsel - WSEC repack issues August 2017
Amount:
$101.00

Component Description:
Legal Counsel - WSEC repack issues July 2017
Amount:
$1,129.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Legal Counsel - WSEC repack issues in October 2018, Amount due net 30
Amount:
$2,828.00

Component Description:
Legal Counsel for 12/2017
Amount:
$454.50

Component Description:
Legal Counsel for repack oriented work performed during September 2018
Amount:
$9,897.31

Component Description:
Legal Counsel - WSEC repack issues October 2017
Amount:
$431.00

Component Description:
Legal Counsel - WSEC Repack Issues May 2018
Amount:
$202.00

Component Description:
Legal Counsel - WSEC Repack April 2018
Amount:
$50.50

Component Description:
Legal Counsel - WSEC repack issues February 2018
Amount:
$168.00

Component Description:
Legal Counsel - WSEC repack issues November 2017
Amount:
$39.00

Component Description:
Line budget exceeded due to issues involved in awarding new tower manufacture and construction contract
Amount:
$1,414.00

Component Description:
Legal Counsel - 01/2018
Amount:
$622.50

Component Description:
PAYMENT DUE date is 30 days following the invoice date. LEGAL COUNSEL - WSEC repack issues - June - 2018
Amount:
$3,535.00

Component Description:
PAYMENT DUE date is 30 days following the invoice date. Legal Counsel - WSEC repack issues - August - 2018
Amount:
$5,757.00

Component Description:
WSEC's portion of this invoice for Legal Counsel for repack issues in 03/2017 split evenly between WSEC-TV (facility 70536) & WMEC-TV. (facility 70537)
Amount:
$101.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
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

Component Description:
Prepare WSEC engineering section of Form 2100 Construction Permit Application.
Amount:
$1,500.00

Component Description:
WSEC Portion of invoice for planning meeting to discuss assigned frequency for repack
Amount:
$742.50

Component Description:
REVISED Legal Counsel for WSEC repack issues during the month of March 2017
Amount:
$101.00
Project management of the transition 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 $42,750.00 $41,500.00 N/A $0.00 N/A
Total for all systems $2,956,259.61 $2,807,814.66 N/A $1,536,346.12 N/A
Other Expenses $42,750.00 $41,500.00 $0.00
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 $5,000.00 $5,000.00 N/A N/A N/A
Equipment Storage $2,500.00 $2,500.00 N/A N/A N/A
Equipment Delivery and Handling Charges $15,000.00 $15,000.00 Tx @ 5400 Antenna @ 7700 Misc @ 1900 N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $4,000.00 $4,000.00 Antenna, transmitter, packaging materials. N/A N/A
DTV Medical Facility Notification $11,250.00 $10,000.00 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 $2,956,259.61 $2,807,814.66 $1,536,346.12

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.

Richard Plotkin

Project Manager


10/31/2018

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.

Richard Plotkin

Project Manager


10/31/2018

Attachments

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