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:
0000028011
FRN:
0002733764
Facility ID:
9913
Repack Channel:
20 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
01/15/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

CENTRAL MICHIGAN UNIVERSITY

Doing Business As: CENTRAL MICHIGAN UNIVERSITY

Wayne Henderson

PUBLIC BROADCASTING

1999 EAST CAMPUS DR.

MT. PLEASANT, MI 48859

United States

+1 (989) 774-3105 hende1ww@cmich.edu Government Entity

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

Wayne Henderson

Director of Technical Services

Central Michigan University

Wayne Henderson

Public Broadcasting Center

1999 E. Campus Drive

Mount Pleasant, MI 48859

United States

+1 (989) 774-6864 hende1ww@cmich.edu

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 Pre-install the replacement transmitter, Mask Filter, and test/proof system into a dummy load. During Replacement of the antenna and elbow complex the transmitter will be cut over to the new antenna. See uploaded attachment for thorough description.

Transmitters

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Section Question Response
Transmitter Related Expenses Do you have transmitter related expenses? Yes

Primary Transmitter

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Add 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 NV7250V
Year 2008
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 4.1 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-8
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 4.8 kw
Other Transmitter Type  
Justification for New Transmitter No longer supported, no field service available, This expense will save major building construction at another repack site, and many parts required for retune not available. See attached notice from Rohde & Schwarz. .

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 30.0 feet
Other Electrical Service Yes
Description 30 kVA Step Up Transformer from 208 VAC to 440 VAC, Circuit Breaker, Disconnects, and Electrical Wiring Needed for Solid State Transmitter.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
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? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class 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: 70.00 kW
Manufacturer
Model TFU-18JSC-R-C170
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? Yes
Will antenna be located on or in close proximity to an antenna farm? No
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: 68.30 kW
Manufacturer
Model TFU-18JSC-R C170
Year 2019
Justification for New Antenna Dielectric indicates by attempting to retune this antenna from ch 21 down to ch 20 would leave us with a beam tilt spec that's unknown and unpredictable. Gain of the antenna would be a guess; see attached support document.

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 3 1/8 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? Yes
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

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 Utilize Existing
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Dielectric
Type Rigid
Diameter 3 1/8 inches
Segment Length 19 ½ '
Other Segment Length
Number of parallel runs 1
Length 435 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Myat Inc. Line and Accessories

Qty 2 20.5" Unflanged Transmission Lines, Qty 4 Elbows, Qty 6 Adaptor Flanges, Qty 6 Coupling Assemblies, Qty 12 Anchor Insulators

Myat Inc. Coaxial Switch

Qty 1 Myat Part # 301-180-1 Motorized Coaxial Switch w/Controller.

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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Add Tower

Section Question Response
Existing Tower Description Type of change Move Equipment
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? 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? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1052328
Coordinates (NAD83) Latitude (NAD83) 44° 03' 57.0" N-
Longitude (NAD83) 086° 19' 58.3" W-
Overall Structure Height 427.16 feet
Support Structure Height 427.16 feet
Ground Elevation Above Mean Sea Level (AMSL) 717.84 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner CMU Public Broadcasting
Date Constructed 02/27/2009


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? No
Number of Hours N/A
Explanation N/A
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development No
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 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 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

Name Description

Tower Consultants, Inc.

Tower Consultants, Inc; Tower Analysis and tension Chart, Rigging Plan Review, and Oversight and Inspection.

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)? No
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

Name Description

Internal Project Management Expense Estimate

Director of Technical Services Project Management. CP, Form 399, Site Investigation, Bid Specs, Purchasing Activity, On Site during Construction, Prep License to Cover. See Detailed Doc Attached.

Internal Field Engineering Expense Estimate

Field Engineering Staff Initial Investigative Site Visits. Print workup, Manage Deliveries, On Site for Installations, Signal and Remote Control Wiring, Ice Bridge and RF Transmission Line Installation.

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 $302,868.00 $254,825.00 N/A $0.00 N/A
Total for all systems $612,425.00 $601,857.00 N/A $4,152.00 N/A
Primary Transmitter UAXTE-8 $302,868.00 $254,825.00 $0.00
10 Ton system $58,900.00 $16,387.00 N/A $0.00 N/A
Other Electrical Service: 30 kVA Step Up Transformer from 208 VAC to 440 VAC, Circuit Breaker, Disconnects, and Electrical Wiring Needed for Solid State Transmitter. $12,688.00 $12,688.00 Electrical Firm Initial Site Visit to obtain all detail for Transmitter Electrical Connection. 2nd Site Visit to Install Circuit Breaker, 2 Disconnects, 1 30 kVA Transformer, conduit, and wiring to Transmitter. N/A N/A
UHF - Air Cooled Solid State Transmitter 4 - 6 kW $230,500.00 $225,000.00 N/A $0.00 N/A
2" Rigid Conduit and Wiring (Cost per foot) $780.00 $750.00 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 $128,800.00 $168,825.00 N/A $0.00 N/A
Total for all systems $612,425.00 $601,857.00 N/A $4,152.00 N/A
Primary Antenna TFU-18JSC-R C170 $128,800.00 $168,825.00 $0.00
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
UHF - Lower Power Side Mount, One station antenna - medium power (50-200 kW), horizontally polarized $87,000.00 $128,025.00 Dielectric Quote is attached pricing the same antenna on channel 20 that we currently are using for channel 21. Existing antenna can not be retuned as the beam tilt and power gain specifications can not be determined. See attached letter from Dielectric N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $22,550.00 $22,000.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 3 1/8. feedline (if needed) $7,580.00 $7,400.00 N/A N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $12,340.00 $12,340.00 N/A $0.00 N/A
Total for all systems $612,425.00 $601,857.00 N/A $4,152.00 N/A
Primary Transmission Line $12,340.00 $12,340.00 $0.00
Myat Inc. Coaxial Switch $5,700.00 $5,700.00 Transmitter needs to have RF Coaxial System pre-installed to the station power load for testing, proof, and alignment. Switch needed in order to flash cut to new channel on date and time assigned. N/A N/A
Myat Inc. Line and Accessories $6,640.00 $6,640.00 Qty 2 Line Sections, coupling assemblies, various elbows, flange adaptors, and anchor insulators for the complete RF transmission line installation so proof, testing, and we are ready to switch to Channel 20 at the push of a button. 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 $81,900.00 $80,000.00 N/A $0.00 N/A
Total for all systems $612,425.00 $601,857.00 N/A $4,152.00 N/A
Primary Tower TOWER $81,900.00 $80,000.00 $0.00
Short Tower (less than 500') $81,900.00 $80,000.00 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 $50,330.00 $49,930.00 N/A $4,000.50 N/A
Total for all systems $612,425.00 $601,857.00 N/A $4,152.00 N/A
Outside Professional Services $50,330.00 $49,930.00 $4,000.50
Tower Consultants, Inc. $33,180.00 $33,180.00 Tower Consultants, Inc. Quote for Installation Project Management, Structural Analysis, and Inspection. TCI conducts all of our Tower Structural Analysis, Inspections after Installations, and this tower has not been Analyzed to the G Standard. N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,305.00 $2,250.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A $1,000.50 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 $3,000.00 N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,560.00 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Tower Consultants, Inc. 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:
Work on FCC minor modification repack construction permit
Amount:
$961.50

Component Description:
Analysis and review FCC re-pack transition quarterly progress report.
Amount:
$39.00
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

Component Description:
Prepare and upload Engineering Section of FCC Form 2100 Construction Permit Application
Amount:
$3,000.00
Prepare and or review reimbursement form Information not provided.
Address transition timing and coordination issues w/ other stations and wireless 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 $36,187.00 $35,937.00 N/A $151.50 N/A
Total for all systems $612,425.00 $601,857.00 N/A $4,152.00 N/A
Other Expenses $36,187.00 $35,937.00 $151.50
Internal Field Engineering Expense Estimate $10,909.00 $10,909.00 Field Engineering Staff Initial Investigative Site Visits. Print workup, Manage Deliveries; On Site for Installations of Transmitter, Signal and Remote Control Wiring, HVAC Units, and RF Transmission Line. N/A N/A
Internal Project Management Expense Estimate $10,524.00 $10,524.00 Internal Expense Estimate for Director of Technical Services Project Management. CP, Form 399, Site Investigation, Bid Specs, Purchasing Activity, On Site during Construction, License to Cover. See Detailed Doc Attached. N/A N/A
MVPD Notification of Channel Change $619.00 $619.00 Initial Work Up of Addresses and Contact Info for MVPD and Satellite Companies; then Preparation and Certified Mailing of Notices, Phone Time Working with Reception and Specifics of Receiving Station. See spreadsheet for internal expense estimates. $151.50 N/A
Develop and air announcement of upcoming channel change $385.00 $385.00 Set Up Scope of Effort, Make Assignments, Write and record copy; shoot, edit, export, and ingest the spot. Traffic and Programming staff efforts of spot placement and ensure FCC compliance. N/A N/A
Equipment Delivery and Handling Charges $2,500.00 $2,500.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Internal Field Engineering Expense Estimate Information not provided.
Internal Project Management Expense Estimate Information not provided.
MVPD Notification of Channel Change

Component Description:
Work on MVPD Notification Issues for repack and channel change.
Amount:
$151.50
Develop and air announcement of upcoming channel change Information not provided.
Equipment Delivery and Handling Charges Information not provided.
DTV Medical Facility Notification Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $612,425.00 $601,857.00 $4,152.00

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.

Shannon Peak

Manager Business Operations


01/15/2019

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.

Shannon Peak

Manager Business Operations


01/15/2019

Attachments

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