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:
64048
Service:
DCA
Call Sign:
KNOV-CD
Channel:
31 (UHF)
File Number:
0000027971
FRN:
0004941621
Date Submitted:
01/18/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

BEACH TV PROPERTIES, INC.

Doing Business As: BEACH TV PROPERTIES, INC.

Byron J. Colley, Jr.

PO Box

SUITE 23

PANAMA CITY, FL 32407

United States

+1 (850) 234-2773 jud.colley@tripsmarter.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

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 KNOV will transition to channel 25, to maintain signal to head ends, a second antenna will be mounted near the current antenna and will become the main antenna. A new transmitter and mask filter are required. An interim transmitter is required.

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 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 ATSC-1.6 KW
Year 2017
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.6 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? No
Manufacturer
Model TMx9
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.2 kW
Justification for New Transmitter Transmitter is needed in order to maintain continuous service during the transition.

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 N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service Yes
Description 120/240
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

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Mask Filter

Rhode & Swartz UT6E7F-1.5K

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Class A
Mounting Top 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: 3.2 kW
Manufacturer
Model 770-881
Year 2003

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 Types Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
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: 3.2 kW
Manufacturer
Model ANT TLP6B
Year 2018
Justification for New Antenna Old antenna cannot be retuned.

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

Name Description

Combiner

Combines channels 31 and 41 so only one antenna will be needed for the transition

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 Foam
Diameter 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 100 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
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 100 feet per run
Justification for New Transmission Line Need transmission line for the new antenna.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Interim Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Flexible Air
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 100 feet per run
Justification for New Transmission Line Need transmission line for new antenna.

Interim 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

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 620
Explanation Have no ability to conduct internally.
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 Yes
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
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 Yes
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
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 No
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 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

Name Description

Thomaston Broadcasting

KNOV 8 hr. x $40/hr. 320. Preparation of 399.

Mike Minturn

MVPD property installs. 125 properties @ 3 hrs/property. 375 hrs. x $35/hr. $13,125.

Thomaston Broadcasting

Transmitter and antenna work. 80 hr x $40/hr. $3,200. MVPD property installs. 125 properties @ 3 hrs/property. 375hrs. x$40/hr. $15,000

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 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

Upgrade Hotels

Antennas and processors in each of 125 hotels have to be replaced.

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 $135,101.00 $67,296.00 N/A $47,897.47 N/A
Total for all systems $517,935.26 $435,455.00 N/A $81,751.58 N/A
Primary Transmitter TMx9 $135,101.00 $67,296.00 $47,897.47
Mask Filter $4,101.00 $4,101.00 N/A $3,832.48 N/A
Other Electrical Service: 120/240 $5,000.00 $5,000.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $58,195.00 N/A $44,064.99 N/A

Components

Actual Information Description File Name
Mask Filter

Component Description:
Mask filter
Amount:
$3,832.48
Other Electrical Service: 120/240 Information not provided.
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Second 1/3 due before shipping.
Amount:
$16,200.24

Component Description:
1/3 Down payment, invoice does not include tax and freight which are included in the attached quote.
Amount:
$14,700.24

Component Description:
Last 1/3 payment for Transmitter
Amount:
$13,164.51

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 $46,209.26 $38,989.00 N/A $11,666.14 N/A
Total for all systems $517,935.26 $435,455.00 N/A $81,751.58 N/A
Primary Antenna ANT TLP6B $46,209.26 $38,989.00 $11,666.14
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $2,880.00 N/A
Combiner $7,987.50 $7,987.50 N/A $3,594.38 N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $19,409.74 This estimated cost is equivalent to the previously approved budget amount of $24,601.50 less the previously reimbursed amount of $5,191.76. N/A N/A
UHF - Lower Power, Top Mount, Class A, basic slot antenna, 3 kW input, elliptically or circularly polarized $5,191.76 $5,191.76 ***System Notice: Estimate adjusted and locked because line has been superseded.*** $5,191.76 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
45% of sweep cost with order. See Dielectric quote.
Amount:
$2,880.00
Combiner

Component Description:
45% with order. See Dielectric proposal.
Amount:
$3,594.38
UHF - Lower Power Side Mount, Class A One Station antenna -- basic Information not provided.
UHF - Lower Power, Top Mount, Class A, basic slot antenna, 3 kW input, elliptically or circularly polarized

Component Description:
45% of antenna cost. See Dielectric quote. We have adjusted the request to match the Dielectric quote for an h.pol antenna. See attached explanation.
Amount:
$4,733.44

Component Description:
45% of Jumper with order. See Dielectric quote.
Amount:
$458.32

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 $6,600.00 $6,200.00 N/A $0.00 N/A
Total for all systems $517,935.26 $435,455.00 N/A $81,751.58 N/A
Interim Transmission Line $3,300.00 $3,100.00 $0.00
Flexible Air Transmission Line - dielectric, 1 5/8" $3,300.00 $3,100.00 N/A N/A N/A
Primary Transmission Line $3,300.00 $3,100.00 $0.00
Flexible Air Transmission Line - dielectric, 1 5/8" $3,300.00 $3,100.00 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 $0.00 $0.00 N/A $0.00 N/A
Total for all systems $517,935.26 $435,455.00 N/A $81,751.58 N/A
Primary Tower BANT $0.00 $0.00 $0.00

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 $159,530.00 $153,075.00 N/A $20,433.25 N/A
Total for all systems $517,935.26 $435,455.00 N/A $81,751.58 N/A
Outside Professional Services $159,530.00 $153,075.00 $20,433.25
Mike Minturn $13,125.00 $13,125.00 N/A N/A N/A
Thomaston Broadcasting $18,200.00 $18,200.00 N/A $1,040.00 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
Attorney Fees - Aux Antenna, prepare and File Form 2100 Construction Permit or License Application $4,210.00 $4,000.00 N/A $1,740.00 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
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $0.00 N/A
Project management of the transition $97,960.00 $93,000.00 N/A $16,073.25 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $80.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $0.00 N/A
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, Construction Permit Application $2,105.00 $2,000.00 N/A $0.00 N/A
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, License to Cover Application $1,580.00 $1,500.00 N/A $1,500.00 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

Components

Actual Information Description File Name
Mike Minturn Information not provided.
Thomaston Broadcasting

Component Description:
Getting quotes for equipment and assisting 399 filing.
Amount:
$640.00

Component Description:
Contract Labor
Amount:
$400.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Aux Antenna, prepare and File Form 2100 Construction Permit or License Application

Component Description:
Prepare minor change application
Amount:
$1,740.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for new channel assignment and antenna development Information not provided.
Project management of the transition

Component Description:
Project Management
Amount:
$2,559.30

Component Description:
Project Management
Amount:
$2,788.40

Component Description:
Project Management
Amount:
$2,154.00

Component Description:
Project Management
Amount:
$2,394.50

Component Description:
Project Management
Amount:
$1,677.00

Component Description:
Review initial FCC notification. Email time with client reviewing the FCC filing process.
Amount:
$337.50

Component Description:
Project management
Amount:
$1,807.10

Component Description:
FCC 387 Form prep
Amount:
$175.00

Component Description:
Project Management
Amount:
$2,180.45
Prepare and or review reimbursement form

Component Description:
Complete processing of 399 Forms.
Amount:
$80.00

Component Description:
Form 399 research.
Amount:
$740.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Review FCC filing process.
Amount:
$337.50
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, Construction Permit Application

Component Description:
Prepare Form 387.
Amount:
$175.00
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, License to Cover Application

Component Description:
Review antenna and system data.
Amount:
$1,500.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application 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 $170,495.00 $169,895.00 N/A $1,754.72 N/A
Total for all systems $517,935.26 $435,455.00 N/A $81,751.58 N/A
Other Expenses $170,495.00 $169,895.00 $1,754.72
MVPD Notification of Channel Change $5,000.00 $5,000.00 Must notify 125 hotels who receive our signal in their SMATV systems. N/A N/A
Develop and air announcement of upcoming channel change $2,500.00 $2,500.00 N/A N/A N/A
Equipment Storage $5,000.00 $5,000.00 N/A $1,754.72 N/A
Upgrade Hotels $125,000.00 $125,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $5,000.00 $5,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $15,000.00 $15,000.00 N/A N/A N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage

Component Description:
Rent & Insurance (9/19-10/18)
Amount:
$191.56

Component Description:
Insurance & Rent (3/19-4/18), Administrative Fee
Amount:
$211.56

Component Description:
Receipt for rent and insurance
Amount:
$191.56

Component Description:
Rent & Insurance (6/19-7/18)
Amount:
$191.56

Component Description:
Rent & Insurance (4/19-5/18)
Amount:
$191.56

Component Description:
Rent & Insurance (5/19-6/18)
Amount:
$191.56

Component Description:
Rent & Insurance (11/19-12/18)
Amount:
$202.24

Component Description:
Rent & Insurance (8/19-9/18)
Amount:
$191.56

Component Description:
Rent & Insurance (7/19-8/18)
Amount:
$191.56
Upgrade Hotels Information not provided.
DTV Medical Facility Notification Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Equipment Delivery and Handling Charges Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $517,935.26 $435,455.00 $81,751.58

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.

Jud Colley

Owner


01/18/2019

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.

Jud Colley

Owner


01/18/2019

Attachments

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