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:
0000028570
FRN:
0010569705
Facility ID:
10265
Repack Channel:
31 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
01/07/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

SUNSHINE STATE TELEVISION NETWORKS, INC.

Doing Business As: SUNSHINE STATE TELEVISION NETWORKS, INC.

Jorge Rossi

3848 N. MACARTHUR BLVD.

WARR ACRES, OK 73122

United States

+1 (405) 639-2232 Jrossi08@bellsouth.net 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

Edward A. Maldonado , Esq. .

Regulatory Legal Counsel

Law Offices of Edward A. Maldonado, P.A.

Mr. Edward A. Maldonado, Esq.

2850 Douglas Road, Suite 303

Coral Gables, FL 33134

United States

+1 (305) 477-7580 eam@maldonado-group.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 Order antenna and transmitter designed to operate on Channel 31 (repack channel), install on tower.

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? No
Existing Transmitter Manufacturer and Type Manufacturer
Model 2000 watt
Year 2009
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 2000 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 TRN-5X-U-28C
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 2000 kw
Other Transmitter Type  
Justification for New Transmitter Old Transmitter is no longer supported and cannot be re tuned to new channel .

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 No
Size
Length
Other Electrical Service Yes
Description Electrical installation.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 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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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? Yes
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: 15.00 kW
Manufacturer
Model PSILP200I/45
Year 2009

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? No
Will antenna be located on or in close proximity to an antenna farm? Yes
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: 15.00 kW
Manufacturer
Model PSILP12OI-31
Year 2018
Justification for New Antenna Old antenna cannot be tuned to work on CH 31.

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? 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

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 Flexible Air
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 300 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 Flexible Air
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 300 feet per run
Justification for New Transmission Line In order to continue operation on CH 45, we will need install new transmission line to the new CH 31 antenna.

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? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 35° 21' 46.0" N-
Longitude (NAD83) 097° 26' 57.0" W-
Overall Structure Height 198.00 feet
Support Structure Height 198.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 1443.00 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Ronnie Tutor
Date Constructed 01/01/2000


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: Minor 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 25
Explanation Help with preparing the documents.
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 Yes
For Main Facility No
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 Yes
Quantity 1
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 Yes
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

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 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? No
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

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 $137,288.92 $136,838.92 N/A $68,722.62 N/A
Total for all systems $520,426.92 $507,573.92 N/A $104,679.12 N/A
Primary Transmitter TRN-5X-U-28C $137,288.92 $136,838.92 $68,722.62
5 Ton system $19,700.00 $19,250.00 N/A $0.00 N/A
Other Electrical Service: Electrical installation. $21,000.00 $21,000.00 N/A $20,459.00 N/A
UHF - Air Cooled Solid State Transmitter 2000 kW $96,588.92 $96,588.92 N/A $48,263.62 N/A

Components

Actual Information Description File Name
5 Ton system

Component Description:
Please reject this invoice for this category. Invoice added to wrong reimbursement category
Amount:
N/A
Other Electrical Service: Electrical installation.

Component Description:
Re-quoted Tutor Consulting Invoice on 08/05/2018 for $5,065.00 Accepted by Sunshine on 08/24/2018
Amount:
N/A

Component Description:
Cover Letter clarifying issue date of Aug 01 2018, acceptance on Aug 24 2018, and agreed and revised due date of Aug 28 2018.
Amount:
N/A

Component Description:
Re-statement of Quote originally given by Tutor Consulting for Station Air Conditioning upgrade for Repack resubmitted on 11/01/2018 for Invoice 29170111-01 for $15,394.00.
Amount:
N/A

Component Description:
Electrical upgrades including wiring, meter drop, installation and local permits for work
Amount:
$5,065.00

Component Description:
Station Air Conditioning upgrades for channel change equipment to be added to facilities.
Amount:
$15,394.00

Component Description:
Supporting Documentation of Vendor Description for Tutor Consulting
Amount:
N/A

Component Description:
Supporting Documentation - Quote for Electrical Upgrades
Amount:
N/A

Component Description:
Supporting Documentation Revised Invoice further detailing costs and labor from Tutor Consulting
Amount:
N/A
UHF - Air Cooled Solid State Transmitter 2000 kW

Component Description:
Transmitter, Air Cooled with Exciter, Hi-Eff PA (2.2kW). 100% of Total prepaid and Down in order to obtain discounted pricing. Correct Invoice and Quote is #7081-01-08-22-2018
Amount:
$48,263.62

Component Description:
Quote for Transmitter, Air Cooled with Exciter, Hi-Eff PA (2.2kW). 100% of Total prepaid and Down in order to obtain discounted pricing. Correct Invoice and Quote #7081-01-08-22-2018
Amount:
N/A

Component Description:
Cover Letter from Sunshine State regarding clarification of Proposal and Invoice number on submitted cost. Supporting non-financial information/detail.
Amount:
N/A

Component Description:
Supporting Documentation of Quote for Anywave Transmitter on 8/28/18
Amount:
N/A

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 $32,150.00 $31,400.00 N/A $13,312.22 N/A
Total for all systems $520,426.92 $507,573.92 N/A $104,679.12 N/A
Primary Antenna PSILP12OI-31 $32,150.00 $31,400.00 $13,312.22
Sweep test of existing antenna $6,550.00 $6,400.00 N/A $6,025.00 N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $25,600.00 $25,000.00 N/A $7,287.22 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
Invoice Number 1009 from Tutor Consulting for Sweep of Antenna, removal of old Antenna, and installation of new Antenna to be done in conjunction with transmitter installation
Amount:
$4,200.00

Component Description:
Supporting Documentation Vendor Description Tutor Consulting
Amount:
N/A

Component Description:
Supporting Documentation -Quote for Sweeps, Removal and Installation of Antenna
Amount:
N/A

Component Description:
Quote for Sweeps, Removal and Installation of UHF Transmitter
Amount:
N/A

Component Description:
Invoice from Tutor Consulting for Sweeps, Removal and Installation of Transmitter in conjunction with Antenna
Amount:
$1,825.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
Antenna Manufacturing and Delivery: 50% of the Total Down, Balance due upon completion of manufacturing. Delivery 6-8 weeks.
Amount:
$7,287.22

Component Description:
Supporting Documentation of Final Invoice for 50% order from PSI for Basic UHF - Lower Power Side Mount, Class A One Station antenna to match August 2018 PO and contract
Amount:
N/A

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 $9,600.00 $14,000.00 N/A $13,144.28 N/A
Total for all systems $520,426.92 $507,573.92 N/A $104,679.12 N/A
Primary Transmission Line $9,600.00 $14,000.00 $13,144.28
Flexible Air Transmission Line - dielectric, 1 5/8" $9,600.00 $14,000.00 Actual costs higher than first estimated due to physical layout of facilities of station. See attached letter from Sunshine State Television Network. $13,144.28 Invoice includes shipping and handling as a part of the services to be rendered. Amount $1,227.00. Vender included this in quote and invoice to avoid separate invoice for this cost for purposes of work management of the particular item.

Components

Actual Information Description File Name
Flexible Air Transmission Line - dielectric, 1 5/8"

Component Description:
Cover letter to clarify the dates of Tutor Consulting Invoice 1005 issued Aug 01. Sunshine acceptance, Aug 24, and the final due date of the Invoice with agreed payment due immediately, Aug 28.
Amount:
N/A

Component Description:
Detailed Quote for Invoice 1005.
Amount:
N/A

Component Description:
Costs of transmission line 220ft. Auto Debydrator, hangers, grips, ground kits, adapters, elbows,tower crew installation and Engineering services plus shipping and handling of installation components.
Amount:
$13,144.28

Component Description:
Supporting Documentation - Vendor Description for Tutor Consulting
Amount:
N/A

Component Description:
Supporting Documentation - Quote from Tutor Consulting for labor and equipment for Transmission Line work.
Amount:
N/A

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 $261,000.00 $255,000.00 N/A $0.00 N/A
Total for all systems $520,426.92 $507,573.92 N/A $104,679.12 N/A
Primary Tower TOWER $261,000.00 $255,000.00 $0.00
Short Tower (less than 500') $81,900.00 $80,000.00 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
Minor tower reinforcement/modifications $153,500.00 $150,000.00 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 $53,790.00 $52,500.00 N/A $9,500.00 N/A
Total for all systems $520,426.92 $507,573.92 N/A $104,679.12 N/A
Outside Professional Services $53,790.00 $52,500.00 $9,500.00
Attorney Fees - Negotiation of lease and other matters for shared locations $4,095.00 $4,000.00 N/A $2,100.00 N/A
RF Exposure Measurements $20,500.00 $20,000.00 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 $0.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A $5,000.00 N/A
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, 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
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A $0.00 N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A $2,400.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,585.00 $3,500.00 N/A N/A N/A
Project management of the transition $3,850.00 $3,750.00 N/A N/A N/A

Components

Actual Information Description File Name
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
Legal Services attributable to Negotiations with vendors for discounts, lease for facilities, and other commercial matters.
Amount:
$2,100.00

Component Description:
Line item for $4,068.75 USD on Invoice #925 can be disregarded at this time. STA not sought at this time. Invoice 925 line item for preparation and review of FCC Form 399 negotiated down from $5,006.25 USD to $5,000.00. SUPPORTING DOCUMENTATION
Amount:
N/A
RF Exposure Measurements Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Legal services attributable to Form 2100 Construction Permit application, included liaison work with FCC.
Amount:
$5,000.00

Component Description:
Line item for $4,068.75 USD on Invoice #925 can be disregarded at this time. STA not sought at this time. Invoice 925 line item for preparation and review of FCC Form 399 negotiated down from $5,006.25 USD to $5,000.00. SUPPORTING DOCUMENTATION
Amount:
N/A
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
Please disregard this invoice at this time.
Amount:
N/A
Prepare and or review reimbursement form

Component Description:
Negotiated portion of services for final line item of attorney fees is allocated to preparation, and submission of form 399.
Amount:
$2,400.00

Component Description:
Line item for $4,068.75 USD on Invoice #925 can be disregarded at this time. STA not sought at this time. Invoice 925 line item for preparation and review of FCC Form 399 negotiated down from $5,006.25 USD to $5,000.00. SUPPORTING DOCUMENTATION
Amount:
N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
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 $26,598.00 $17,835.00 N/A $0.00 N/A
Total for all systems $520,426.92 $507,573.92 N/A $104,679.12 N/A
Other Expenses $26,598.00 $17,835.00 $0.00
Develop and air announcement of upcoming channel change $1,000.00 $1,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $2,000.00 $2,000.00 N/A 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 $2,500.00 N/A N/A N/A
MVPD Notification of Channel Change $750.00 $750.00 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 $520,426.92 $507,573.92 $104,679.12

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.

Jorge Rossi

President


01/06/2019

Attachments

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