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:
0000027785
FRN:
0020176533
Facility ID:
83946
Repack Channel:
17 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
01/22/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

CHRISTIAN TELEVISION NETWORK OF MISSISSIPPI, INC.

Doing Business As: CHRISTIAN TELEVISION NETWORK OF MISSISSIPPI, INC.

PO BOX 6922

CLEARWATER, FL 33758

United States

+1 (727) 535-5622 soneal@ctntv.net 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

Joseph C. Chautin III

Hardy, Carey, Chautin & Balkin, LLP

1080 West Causeway Approach

Mandeville, LA 70471

United States

+1 (985) 629-0777 jchautin@hardycarey.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. Yes
Briefly describe transition plan WEPH will install temp low power antenna & line. Then, existing xmtr will feed temp LP antenna thru mask filter. Removal of old antenna & line. Then, installation of new line, antenna, new xmtr, and mask filter to begin.

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 CST II
Year 2010
Type Inductive Output Tube
IOT Power Type Single
Description  
Power capacity 15 kw
Solid State Cooling  
Solid State Power Capacity  
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? Yes
Manufacturer
Model Parallax
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 20 kw
Other Transmitter Type  
Justification for New Transmitter Manufacturer (ABS) no longer in business. Transmitter no longer field supported.

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 additional breakers in panel, EMT or flexible metal conduit, misc wiring
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

Name Description

anti-freeze

coolant for transmitter

TRANSMISSION LINE

transmitter building interior transmission line components for transmitter interconnects

plumbing

plumbing for heat exchanger

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? Yes
Existing Antenna Manufacturer and Type Class Full Power
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: 1000.00 kW
Manufacturer
Model ATW28H3-HSC4-49H
Year 2010

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? Yes
New Antenna Manufacturer and Type Class Full Power
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: 517.00 kW
Manufacturer
Model TFU-18DSC-R C250
Year 2017
Justification for New Antenna Existing antenna not capable of operating on new channel.

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? 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

Temporary antenna

A temporary low power antenna & line will be needed during the re-channeling process to keep WEPH on the air.

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 6 1/8 inches
Segment Length 19 ¾ '
Other Segment Length
Number of parallel runs 1
Length 1350 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 6 1/8 inches
Segment Length 19 ½ '
Other Segment Length
Number of parallel runs 1
Length 1350 feet per run
Justification for New Transmission Line Existing line section length is not compatible with new channel frequency.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Temporary transmission line

1 5/8" Heliax needed to feed temporary antenna which will keep WEPH on the air during modification of facility.

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 Move Equipment
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 No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1040183
Coordinates (NAD83) Latitude (NAD83) 33° 47' 40.0" N-
Longitude (NAD83) 089° 05' 16.0" W-
Overall Structure Height 1559.69 feet
Support Structure Height 1501.95 feet
Ground Elevation Above Mean Sea Level (AMSL) 579.72 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner Mississippi TV, LLC
Date Constructed 08/06/2013

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
74148 WTVA DTV

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 605
Explanation Project management (Invoice processing, progress reporting, daisy chain monitoring and analysis, program management, and site visits as required)
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 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 Yes
Number of Days 2
Justification optimization of new transmission line to operated on new channel

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Structural Analysis

Broadcast Tower Structural Analysis

Tower Mapping

Broadcast Tower Mapping

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 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 $680,200.00 $760,919.83 N/A $746,719.83 N/A
Total for all systems $1,532,832.00 $1,598,226.83 N/A $1,065,764.62 N/A
Primary Transmitter Parallax $680,200.00 $760,919.83 $746,719.83
plumbing $2,000.00 $2,000.00 needed for installation of liquid heat exchanger N/A N/A
TRANSMISSION LINE $5,000.00 $5,000.00 interconnect transmission line components within transmitter building N/A N/A
anti-freeze $200.00 $200.00 needed coolant for heat exchanger N/A N/A
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW $666,000.00 $746,719.83 Price includes miscellaneous equipment & services; see attached quote. $746,719.83 N/A
Other Electrical Service: additional breakers in panel, EMT or flexible metal conduit, misc wiring $7,000.00 $7,000.00 interconnect needed from existing electrical service to new transmitter components N/A N/A

Components

Actual Information Description File Name
plumbing Information not provided.
TRANSMISSION LINE Information not provided.
anti-freeze Information not provided.
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW

Component Description:
System, WEPH PRLX U12 D17
Amount:
$74,671.98

Component Description:
Transmitter system - PRLX U12 D17
Amount:
$373,359.92

Component Description:
Transmitter system - PRLX U12 D17
Amount:
$298,687.93
Other Electrical Service: additional breakers in panel, EMT or flexible metal conduit, misc wiring 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 $166,387.00 $166,117.00 N/A $35,363.47 N/A
Total for all systems $1,532,832.00 $1,598,226.83 N/A $1,065,764.62 N/A
Primary Antenna TFU-18DSC-R C250 $166,387.00 $166,117.00 $35,363.47
UHF - High Power, Side Mount, basic slot antenna, 517 kW input, directional,, horizontally polarized $133,792.00 $133,792.00 N/A $34,035.89 N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A $1,327.58 N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,120.00 $5,000.00 N/A N/A N/A
Temporary antenna $20,925.00 $20,925.00 N/A $0.00 N/A

Components

Actual Information Description File Name
UHF - High Power, Side Mount, basic slot antenna, 517 kW input, directional,, horizontally polarized

Component Description:
UHF high power side mount antenna
Amount:
$34,035.89
Sweep test of existing antenna

Component Description:
Sweep - repack
Amount:
$1,327.58
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) Information not provided.
Temporary antenna

Component Description:
side mount brackets for lower antenna
Amount:
$3,634.26

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 $290,950.00 $284,200.00 N/A $54,582.81 N/A
Total for all systems $1,532,832.00 $1,598,226.83 N/A $1,065,764.62 N/A
Primary Transmission Line $290,950.00 $284,200.00 $54,582.81
Temporary transmission line $25,000.00 $25,000.00 N/A $17,269.68 N/A
Rigid Transmission Line - copper, 6 1/8" $265,950.00 $259,200.00 N/A $37,313.13 N/A

Components

Actual Information Description File Name
Temporary transmission line

Component Description:
Tower Service- MS
Amount:
$10,969.68

Component Description:
Tower Service- MS
Amount:
$6,300.00
Rigid Transmission Line - copper, 6 1/8"

Component Description:
Rigid transmission line
Amount:
$37,313.13

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 $205,000.00 $200,000.00 N/A $181,002.07 N/A
Total for all systems $1,532,832.00 $1,598,226.83 N/A $1,065,764.62 N/A
Primary Tower GTOWER $205,000.00 $200,000.00 $181,002.07
Tall Tower (greater than 500') $205,000.00 $200,000.00 N/A $181,002.07 N/A

Components

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

Component Description:
WEPH-410-Primary Tower - Tower Equipment and Rigging Costs - Tall Tower over 500'
Amount:
$18,055.07

Component Description:
Customer Deposit for Repack Side mount TV antenna system replacement services.
Amount:
$58,990.00

Component Description:
Tower Service- MS
Amount:
$35,000.00

Component Description:
Tower Service- MS
Amount:
$50,000.00

Component Description:
Tower Service
Amount:
$16,337.00

Component Description:
Tower Service- MS
Amount:
$2,620.00

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 $140,950.00 $137,900.00 N/A $33,972.19 N/A
Total for all systems $1,532,832.00 $1,598,226.83 N/A $1,065,764.62 N/A
Outside Professional Services $140,950.00 $137,900.00 $33,972.19
Additional Field Engineering Service, 2 Days $4,000.00 $4,000.00 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
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 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 N/A N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A $0.00 N/A
Project management of the transition $93,170.00 $90,750.00 N/A $17,072.19 N/A
Structural Analysis $9,000.00 $9,000.00 N/A $9,000.00 N/A
Tower Mapping $7,900.00 $7,900.00 Invoices received $7,900.00 N/A
Prepare request for Special Temporary Authorization $1,535.00 $1,500.00 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

Components

Actual Information Description File Name
Additional Field Engineering Service, 2 Days 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.
Prepare engineering section of FCC Form 2100 (main), 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 Information not provided.
Prepare and or review reimbursement form Information not provided.
Project management of the transition

Component Description:
Project Management
Amount:
$3,584.10

Component Description:
WEPH MVPD Notification
Amount:
$1,500.00

Component Description:
WEPH Medical Notification
Amount:
$2,130.49

Component Description:
Project Management
Amount:
$1,609.35

Component Description:
Project Management
Amount:
$2,473.00

Component Description:
Project Management
Amount:
$2,436.95

Component Description:
Project Management
Amount:
$1,832.70

Component Description:
Project Management
Amount:
$1,505.60
Structural Analysis

Component Description:
Engineering Evaluation, Corrosion Risk Analysis,
Amount:
$4,500.00

Component Description:
Engineering Evaluation, Corrosion Risk Analysis, Tower Mapping
Amount:
$4,500.00
Tower Mapping

Component Description:
Tower Mapping
Amount:
$3,950.00

Component Description:
Tower Mapping
Amount:
$3,950.00
Prepare request for Special Temporary Authorization Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit 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 $49,345.00 $49,090.00 N/A $14,124.25 N/A
Total for all systems $1,532,832.00 $1,598,226.83 N/A $1,065,764.62 N/A
Other Expenses $49,345.00 $49,090.00 $14,124.25
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
MVPD Notification of Channel Change $1,500.00 $1,500.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $400.00 $400.00 N/A N/A N/A
Equipment Delivery and Handling Charges $30,000.00 $30,000.00 N/A $9,736.75 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $6,000.00 $6,000.00 N/A $4,387.50 N/A

Components

Actual Information Description File Name
DTV Medical Facility Notification Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Delivery and Handling Charges

Component Description:
WEPH-610-Equipment Delivery and Handling Charges
Amount:
$9,736.75
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
WEPH-610-Disposal Costs
Amount:
$4,387.50

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,532,832.00 $1,598,226.83 $1,065,764.62

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.

CHRIS L MAVROS

Director of Engineering


01/19/2019

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.

CHRIS L MAVROS

Director of Engineering


01/19/2019

Attachments

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