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:
46753
Service:
DCA
Call Sign:
KDAO-CD
Channel:
17 (UHF)
File Number:
0000028046
FRN:
0003769270
Date Submitted:
03/25/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

MTN BROADCASTING, INC.

Doing Business As: MTN BROADCASTING, INC.

Mark Osmundson

1930 N. CENTER STREET ROAD

MARSHALLTOWN, IA 50158

United States

+1 (641) 752-4122 MARK@KDAO.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

Jeremy D Ruck , PE .

Consulting Engineer

Jeremy Ruck & Associates, Inc.

PO Box 415

Canton, IL 61520

United States

+1 (309) 647-1200 jeremy@jeremyruck.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 KDAO-CD will change channel from 44 to 17 using the existing site. A change in the antenna will be required. The existing transmitter will be retuned. KDAO-CD does not share equipment with other stations.

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 TRN-5X
Year 2015
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 0.5 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? Yes
Manufacturer
Model TRN-5X-4-UC
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity .5 kW
Justification for New Transmitter Manufacturer indicates that the existing transmitter can't be re-tuned from channel 44 to channel 17 - see attachment with letter.

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 Electrical connector by a licensed electrician.
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

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? 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: 1.38 kW
Manufacturer
Model B4UO
Year 1998

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? No
New Antenna Manufacturer and Types Class Class A
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Other
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 Superturnstile
ERP: 0.78 kW
Manufacturer
Model 75010272
Year 2017
Justification for New Antenna Current antenna is Bogner model BU4O. This antenna is specifically tuned for the current channel of operation. It cannot be re-tuned to change channel from 44 to 17.

Primary Antenna

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Other Antenna Costs

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

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Foam
Diameter Other
Other Diameter 1 1/4 inches
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 332 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 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 335 feet per run
Justification for New Transmission Line Transmission line requires extension due to change of antenna. Current line size of 1 1/4 inch foam LDF6-50 is no longer available. Replacement allows for continuous run as is the current case.

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 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? 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? Unknown
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 42° 04' 17.3" N-
Longitude (NAD83) 092° 55' 19.3" W-
Overall Structure Height 199.00 feet
Support Structure Height 192.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 863.00 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner MTN Broadcasting, Inc.
Date Constructed 12/01/1978

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
90503 KRFH FM
46754 KDAO AM

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Swap out of mount and antenna

Labor to rig tower, remove mount and antenna, modify mount, install new mount and antenna, reconnectorize line, and derig tower

Design and fabrication of antenna mounting plate

Design & fabrication of antenna mounting plate for a Kathrein Low Power Top Mount, Class A, Basic Slot TV Antenna for mounting on a Rohn 45G Tower. 1/2" Steel plate and welding materials

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 Yes
Number of Days 2
Justification Antenna system for KDAO-CD is located on an AM structure. Change in antenna and transmission line will necessitated impedance measurements and direct measurement of power application.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Preparation of engineering portion of direct measurement of power application for KDAO

Preparation of Direct Measurement of Power Application for co-located KDAO

KDAO direct measurement of power application legal review and filing

Review and filing of KDAO direct measurement of power application by attorney.

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? No
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 $23,175.91 $23,175.91 N/A $17,622.57 N/A
Total for all systems $182,026.25 $175,701.25 N/A $35,235.63 N/A
Primary Transmitter TRN-5X-4-UC $23,175.91 $23,175.91 $17,622.57
UHF - Air Cooled Solid State Transmitter .5 kW $21,175.91 $21,175.91 Base on the quote for a new transmitter from the manufacturer, plus Iowa Sales Tax. $17,622.57 Transmitter Reimbursement
Other Electrical Service: Electrical connector by a licensed electrician. $2,000.00 $2,000.00 Electrician to provide hookup services and proper connector. N/A N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter .5 kW

Component Description:
Reimbursement for Sales Tax for 280 watt Transmitter
Amount:
$1,153.00

Component Description:
Reimbursement for 280 Watt Transmitter
Amount:
$16,469.57
Other Electrical Service: Electrical connector by a licensed electrician. 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 $14,390.84 $14,060.84 N/A $7,660.66 N/A
Total for all systems $182,026.25 $175,701.25 N/A $35,235.63 N/A
Primary Antenna 75010272 $14,390.84 $14,060.84 $7,660.66
UHF - Lower Power, Top Mount, Class A, basic slot antenna, 1 kW input, horizontally polarized $7,660.84 $7,660.84 Actual cost of UHF antenna with jumper cable. Please see Actual Cost attachment with Quote, P.O. and Invoice. Also 7% Iowa Sales Tax which will be requested for reimbursement after payment is made to the State of Iowa. $7,660.66 Antenna invoice includes a jumper cable to connect the antenna to feed line. Additional Iowa Sales Tax payment will also be submitted when paid.
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF - Lower Power, Top Mount, Class A, basic slot antenna, 1 kW input, horizontally polarized

Component Description:
Sales Tax for UHF Omni Antenna
Amount:
$501.00

Component Description:
UHF Omni Antenna & Jumper Cable.
Amount:
$7,159.66
Sweep test of existing antenna 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 $8,040.00 $7,705.00 N/A $0.00 N/A
Total for all systems $182,026.25 $175,701.25 N/A $35,235.63 N/A
Primary Transmission Line $8,040.00 $7,705.00 $0.00
Flexible Foam Transmission Line - dielectric, 1 5/8" $8,040.00 $7,705.00 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 $90,804.50 $86,604.50 N/A $6,604.50 N/A
Total for all systems $182,026.25 $175,701.25 N/A $35,235.63 N/A
Primary Tower TOWER $90,804.50 $86,604.50 $6,604.50
Swap out of mount and antenna $5,855.50 $5,855.50 N/A $5,855.50 N/A
Design and fabrication of antenna mounting plate $749.00 $749.00 N/A $749.00 N/A
Short Tower (less than 500') $84,200.00 $80,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Swap out of mount and antenna

Component Description:
Swap out of mount and antenna
Amount:
$5,855.50
Design and fabrication of antenna mounting plate

Component Description:
Antenna Mounting Plate
Amount:
$749.00
Short Tower (less than 500') 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 $28,620.00 $27,750.00 N/A $2,835.00 N/A
Total for all systems $182,026.25 $175,701.25 N/A $35,235.63 N/A
Outside Professional Services $28,620.00 $27,750.00 $2,835.00
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $585.00 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
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $2,250.00 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
Additional Field Engineering Service, 2 Days $5,000.00 $5,000.00 Cost estimate based on labor and expenses. N/A N/A
Preparation of engineering portion of direct measurement of power application for KDAO $2,000.00 $2,000.00 N/A N/A N/A
KDAO direct measurement of power application legal review and filing $4,000.00 $4,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Prepare and or review reimbursement form Information not provided.
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Engineering Fees for Preparation of Repack Construction Permit
Amount:
$585.00

Component Description:
Engineering Fees for Preparation of Repack Construction Permit Application
Amount:
$585.00
Prepare engineering section of 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 Fees for preparing FCC documents
Amount:
$2,250.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Additional Field Engineering Service, 2 Days Information not provided.
Preparation of engineering portion of direct measurement of power application for KDAO Information not provided.
KDAO direct measurement of power application legal review and filing 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 $16,995.00 $16,405.00 N/A $512.90 N/A
Total for all systems $182,026.25 $175,701.25 N/A $35,235.63 N/A
Other Expenses $16,995.00 $16,405.00 $512.90
MVPD Notification of Channel Change $1,000.00 $1,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $177.90 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 $335.00 Actual Amount of Filing Fee $335.00 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $1,500.00 $1,500.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $1,500.00 $1,500.00 N/A N/A N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change Information not provided.
DTV Medical Facility Notification

Component Description:
Postage for Certified Letters to Health Care Facilities
Amount:
$80.40

Component Description:
Identification of Medical Facilities for Notification of Frequency Change
Amount:
$97.50
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
FCC Filing Fees - Form 2100 license to cover application

Component Description:
FCC Filing Fee for License to Cover for KDAO-CD
Amount:
$335.00
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Develop and air announcement of upcoming channel change Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $182,026.25 $175,701.25 $35,235.63

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.

Mark K Osmundson

President


03/25/2019

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.

Mark K Osmundson

President


03/25/2019

Attachments

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