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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:
16517
Service:
DTV
Call Sign:
WUVC-DT
Channel:
22 (UHF)
File Number:
0000028219
FRN:
0005008305
Date Submitted:
06/10/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WUVC LICENSE PARTNERSHIP, G.P.

Doing Business As: WUVC LICENSE PARTNERSHIP, G.P.

Christopher G. Wood

5999 CENTER DRIVE

LOS ANGELES, CA 90045

United States

 +1 (310) 348-3600 CWOOD@UNIVISION.NET General Partnership

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

Theodore Stoner

VP Distribution Technology Strategy

Univision Management Company

Theodore Stoner

9405 NW 41st Street

Miami, FL 33178

United States

 +1 (513) 608-0308 tstoner@univision.net

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 Install new antenna in top-mounted aperture occupied by dormant analog antenna, replace waveguide with transmission line, replace transmitter and mask filter. See attached Implementation Plan for details.

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 CTT-U-DCX-2
Year 2003
Type Inductive Output Tube
IOT Power Type Two
Power Capacity 50 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 THU9-16evo
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 25.5 kW
Justification for New Transmitter Comark does not support change of channels in DCX transmitters. See attached Transmitter Selection Info document for detailed analysis.

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 Installation of 480:400V step-down transformer and distribution apparatus/wiring to provide primary power to new transmitter
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? 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: 500.0 kW
Manufacturer
Model TFU-24DSC 3C140
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? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Full Power
Mounting Top 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: 480.0 kW
Manufacturer
Model SAA26-WUVC-E300-ET6R-22
Year 2019
Justification for New Antenna Existing antenna is single-channel model not usable 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? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 6 1/8 inches inches
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 Waveguide
Diameter N/A
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 1714 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 7 3/16 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1714 feet per run
Justification for New Transmission Line Replacement of ex-analog rectangular waveguide necessary to avoid prohibited stick length, and reduce tower loading to facilitate bringing tower up to TIA-222-G standard with 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 Rigid
Diameter 7 3/16 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 1820 feet per run
Justification for New Transmission Line Existing line to be used to maintain service on channel 38 until cutover to new channel.

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

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) No
Others Types of Users Yes
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1238110
Coordinates (NAD83) Latitude (NAD83) 35° 30' 43.9" N-
Longitude (NAD83) 078° 58' 39.8" W-
Overall Structure Height 1747.03 feet
Support Structure Height 1747.03 feet
Ground Elevation Above Mean Sea Level (AMSL) 399.93 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner SBA Towers III LLC
Date Constructed 04/09/2003


Other Types of Users

Users
W270AW

Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 915
Explanation Univision stations are only staffed for daily station operations and minor equipment changes, major projects are contracted out externally. The large volume of work associated with repack schedule requires using mult. external project manag't resources
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 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 Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers No
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements 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

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
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? No
Does this relocation require MVPD Notification of a Channel Change? No

Other Expenses

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Other Expenses Not Listed

Name Description

Tower Application Fee

SBA Towers application fee

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 $971,767.00 $401,767.00 N/A $399,208.53 N/A
Total for all systems $2,902,509.00 $1,721,649.64 N/A $1,172,745.09 N/A
Primary Transmitter THU9-16evo $971,767.00 $401,767.00 $399,208.53
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW $947,000.00 $377,000.00 THU9-10 "equivalent ERP" transmitter $320,759, plus 7% sales/use tax, $5,000 shipping, and 10% contingency - see attached Transmitter Selection Info document. $374,441.53 N/A
Other Electrical Service: Installation of 480:400V step-down transformer and distribution apparatus/wiring to provide primary power to new transmitter $24,767.00 $24,767.00 See attached Electrical Cost document, Eagle Engineering Proposal 1066, invoice 1138 $24,767.00 N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW

Component Description:
1st Primary Transmitter
Amount:
$173,846.20

Component Description:
DP 35% Down payment FAT
Amount:
$200,595.33
Other Electrical Service: Installation of 480:400V step-down transformer and distribution apparatus/wiring to provide primary power to new transmitter

Component Description:
1st Primary Transmitter - Other Electrical Service
Amount:
$2,451.00

Component Description:
WUVC 40 Raleigh NC Payment 2 of 2 Customer Bid Ref #1166
Amount:
$12,383.50

Component Description:
WUVC 40 Payment 1 of 2 Customer Bid Ref #1166
Amount:
$12,383.50

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 $308,530.00 $233,100.00 N/A $103,650.00 N/A
Total for all systems $2,902,509.00 $1,721,649.64 N/A $1,172,745.09 N/A
Primary Antenna SAA26-WUVC-E300-ET6R-22 $308,530.00 $233,100.00 $103,650.00
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $289,500.00 $215,000.00 N/A $103,650.00 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,300.00 $11,700.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized

Component Description:
SAA26-ATWS-E300-ET6R-22 / 26 bay, top mounted, elliptically polarized
Amount:
$60,300.00

Component Description:
SAA26-ATWS-E300-ET6R-22 / 26 bay, top mounted, elliptically polarized, Channel 22 RFStar Series antenna with ATW-S azimuth pattern.
Amount:
$43,350.00

Component Description:
SAA26-ATWS-E300-ET6R-22 / 26 bay, top mounted, elliptically polarized, Channel 22 RFStar Series antenna with ATW-S azimuth pattern.
Amount:
$43,350.00
Sweep test of existing antenna Information not provided.
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) 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 $1,024,860.00 $355,100.65 N/A $249,617.32 N/A
Total for all systems $2,902,509.00 $1,721,649.64 N/A $1,172,745.09 N/A
Interim Transmission Line $527,800.00 $0.00 $0.00
Rigid Transmission Line - copper, 7 3/16" $527,800.00 $0.00 Existing line to be used to continue service up to the channel cutover date. N/A N/A
Primary Transmission Line $497,060.00 $355,100.65 $249,617.32
Rigid Transmission Line - copper, 7 3/16" $497,060.00 $355,100.65 Dielectric Quote 800149CMZ-2 and Northeast Towers Quote $249,617.32 N/A

Components

Actual Information Description File Name
Rigid Transmission Line - copper, 7 3/16" Information not provided.
Rigid Transmission Line - copper, 7 3/16"

Component Description:
Please deny this invoice
Amount:
N/A

Component Description:
Primary Transmission Line - 7 3/16" Rigid Copper
Amount:
$120,496.16

Component Description:
Primary Transmission Line - 7 3/16" Rigid Copper
Amount:
$120,496.16

Component Description:
Materials 1/3 deposit due with signed quote and purchase order
Amount:
$8,625.00

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 $381,100.00 $527,134.99 N/A $367,634.99 N/A
Total for all systems $2,902,509.00 $1,721,649.64 N/A $1,172,745.09 N/A
Primary Tower TOWER $381,100.00 $527,134.99 $367,634.99
Tall Tower (greater than 500') $210,500.00 $365,134.99 Northeast Towers, Inc. Quote #SSJR-18-0713-1A; Justifying Quote - Larry Barber Enterprises Sanford 5 AOL Beacon $365,134.99 N/A
Structural engineering tower load study for well documented tower $12,600.00 $12,000.00 N/A $2,500.00 N/A
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A N/A N/A

Components

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

Component Description:
Materials / Balance of materials
Amount:
$17,250.00

Component Description:
Antenna & Transmission Line Replacement
Amount:
$105,483.33

Component Description:
Tower Work ref quote SSJR-18-0713-1A
Amount:
$105,483.33

Component Description:
AOL beacon, strobe cable, and necessary hardware for Sanford 5NC14298-A
Amount:
$1,395.00

Component Description:
Change order due to elevator not working loosing days & hours of work
Amount:
$30,040.00

Component Description:
Antenna & Transmission Line Replacement
Amount:
$105,483.33
Structural engineering tower load study for well documented tower

Component Description:
LINE 1 SITE ID # NC14298-A
Amount:
$2,500.00
Minor tower reinforcement/modifications 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 $171,130.00 $168,485.00 N/A $50,384.25 N/A
Total for all systems $2,902,509.00 $1,721,649.64 N/A $1,172,745.09 N/A
Outside Professional Services $171,130.00 $168,485.00 $50,384.25
Project management of the transition $144,570.00 $147,675.00 Univision stations are only staffed for daily station operations and minor equipment changes; major projects are contracted out using external project management resources. Widelity (which includes 1 possible site visit) & Rosequist quotes are in LMS. $47,571.75 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $2,000.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $812.50 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,000.00 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 $2,500.00 N/A N/A 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
Prepare and or review reimbursement form $2,630.00 $2,560.00 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$4,498.10

Component Description:
Project Management
Amount:
$1,483.60

Component Description:
Engineering/Project Management
Amount:
$10,120.00

Component Description:
Project management Services
Amount:
$148.85

Component Description:
Project management Services
Amount:
$402.35

Component Description:
Project management Services
Amount:
$302.25

Component Description:
Project Management
Amount:
$4,156.55

Component Description:
Project Management
Amount:
$5,902.10

Component Description:
Project Management
Amount:
$1,863.15

Component Description:
Project management services
Amount:
$372.00

Component Description:
Project management services
Amount:
$375.00

Component Description:
Project management services
Amount:
$112.50

Component Description:
Project management services
Amount:
$175.50

Component Description:
Project management services
Amount:
$721.50

Component Description:
Project Management
Amount:
$3,600.05

Component Description:
Project Management
Amount:
$1,237.30

Component Description:
Project management services
Amount:
$385.50

Component Description:
Project Management
Amount:
$1,308.00

Component Description:
Project Management
Amount:
$2,368.20

Component Description:
Project management services
Amount:
$703.50

Component Description:
Project Management
Amount:
$5,118.75

Component Description:
Project Management
Amount:
$2,217.00
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
"Engineering study work for new channel assignment and antenna development (Off-the-shelf Antenna), Preparation of the engineering section of FCC Form 2100."
Amount:
$750.00

Component Description:
K. Lahm - TPO calculation update
Amount:
$62.50
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
WUVC-DT-530-RF Eng - Construction Permit Application (Main)
Amount:
$2,000.00
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 Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare and or review reimbursement form 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 $45,122.00 $36,062.00 N/A $2,250.00 N/A
Total for all systems $2,902,509.00 $1,721,649.64 N/A $1,172,745.09 N/A
Other Expenses $45,122.00 $36,062.00 $2,250.00
DTV Medical Facility Notification $11,550.00 $2,500.00 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
Tower Application Fee $2,250.00 $2,250.00 Please see the attached invoice from SBA TOWERS # IN42090779 $2,250.00 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $30,987.00 $30,987.00 Obsolete Comark transmitter removal/disposal costs - see Eagle Engineering quote attached. N/A N/A

Components

Actual Information Description File Name
DTV Medical Facility Notification Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
Tower Application Fee

Component Description:
Sanford 5, NC: Application Fee: Acct 4035
Amount:
$2,250.00
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $2,902,509.00 $1,721,649.64 $1,172,745.09

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.

Marcello Enriquez

Senior Finance Analyst


06/10/2019

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.

Marcello Enriquez

Senior Finance Analyst


06/10/2019

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