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:
76324
Service:
DTV
Call Sign:
WSKY-TV
Channel:
13 (High VHF)
File Number:
0000027685
FRN:
0022836373
Date Submitted:
07/05/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

TIDEWATER TV LLC

Doing Business As: TIDEWATER TV LLC

150 Fayetteville Street

Suite 1700

Raleigh, NC 27601

United States

+1 (919) 839-0300 cramsey@brookspierce.com Limited Liability Company

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

Bob Pectelidis

Director of Engineering

TIDEWATER TV LLC

Bob Pectelidis

3914 Wistar Road

Richmond, VA 23228

United States

+1 (804) 672-6565 bob@lockwoodbroadcast.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 See attached

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 Platinum
Year 2010
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 11.96 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model THV9-12
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 15 kW
Justification for New Transmitter See Transition Plan, attached

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) Yes
Power 150 kVA
Rigid Conduit and Wiring Yes
Size 2 inches
Length 500.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size 15 tons
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 Full Power
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: 70.0 kW
Manufacturer
Model TW-9B9-R
Year 1999

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 Full Power
Mounting Top 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: 70.0 kW
Manufacturer
Model ATW9V3-HSO-13
Year 2020
Justification for New Antenna See Transition Plan , attached

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 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 Flexible Air
Diameter 3 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 1100 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Air
Diameter 3 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 1100 feet per run
Justification for New Transmission Line See Transition Plan, attached

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 Modify Existing
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? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1252202
Coordinates (NAD83) Latitude (NAD83) 36° 31' 15.0" N-
Longitude (NAD83) 076° 18' 15.0" W-
Overall Structure Height 1036.40 feet
Support Structure Height 979.32 feet
Ground Elevation Above Mean Sea Level (AMSL) 12.80 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Tidewater TV LLC
Date Constructed 11/23/2007


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 undocumented/poorly 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 675
Explanation Expenses for experienced RF consultant to layout and assist with project management.
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 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

Additional Repack Legal Services Not Otherwise Specified in Form 399

Non-Catalog Legal Services such as review of quarterly transition status reports and other miscellaneous non-catalog legal fees.

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)? 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

Name Description

Site survey

Initial assessment and cad drawing of existing facilities

Site Preperation

reworking of existing interior rf system

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 $550,505.00 $464,135.00 N/A $442,517.30 N/A
Total for all systems $1,574,775.00 $1,438,027.00 N/A $489,071.21 N/A
Primary Transmitter THV9-12 $550,505.00 $464,135.00 $442,517.30
15 Ton system $88,400.00 $3,780.00 N/A $1,892.67 N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $24,300.00 LMS limits selection for lower power transformer. Station has change order for 208V, 90kVA Transformer. $17,069.63 N/A
2" Rigid Conduit and Wiring (Cost per foot) $13,000.00 $12,500.00 N/A $0.00 N/A
High VHF - Liquid Cooled Solid State Transmitter 15 kW $423,555.00 $423,555.00 Rohde & Schwarz quote SQ169749.1; SJ Ramer Invoices 19006, 19021; Ed Murlatt & Associates, Inc. Quote #R190111WSKY $423,555.00 N/A

Components

Actual Information Description File Name
15 Ton system

Component Description:
Replace A39 belt, install heater for Carrier Air Handler
Amount:
$1,892.67
Transformer 3 phase/480v - 150 KVA

Component Description:
Engineering Costs
Amount:
$2,237.63

Component Description:
Repack related electrical work for WSKY
Amount:
$14,832.00
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
High VHF - Liquid Cooled Solid State Transmitter 15 kW

Component Description:
Installation services - in conjunction with SJ Ramer Associates with installation, commissioning and proof of Rohde-Schwarz THV9evo-12 at WSKY-TV transmitter.
Amount:
$10,000.00

Component Description:
Installation services
Amount:
$9,500.00

Component Description:
Installation services
Amount:
$9,500.00

Component Description:
DP 75% Final Payment, Transmitter Replacement for Repack
Amount:
$288,416.25

Component Description:
DP 25% Down payment; R & S Transmitter Replacement for Repack
Amount:
$96,138.75

Component Description:
Installation Services
Amount:
$10,000.00

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 $356,330.00 $338,800.00 N/A $0.00 N/A
Total for all systems $1,574,775.00 $1,438,027.00 N/A $489,071.21 N/A
Primary Antenna ATW9V3-HSO-13 $356,330.00 $338,800.00 $0.00
High-VHF, One station antenna -- top mount, horizontally polarized $342,000.00 $325,000.00 N/A N/A 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 3 1/8. feedline (if needed) $7,600.00 $7,400.00 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 $64,900.00 $61,600.00 N/A $0.00 N/A
Total for all systems $1,574,775.00 $1,438,027.00 N/A $489,071.21 N/A
Primary Transmission Line $64,900.00 $61,600.00 $0.00
Flexible Air Transmission Line - dielectric, 3" $64,900.00 $61,600.00 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 $394,800.00 $366,987.00 N/A $8,493.50 N/A
Total for all systems $1,574,775.00 $1,438,027.00 N/A $489,071.21 N/A
Primary Tower TOWER $394,800.00 $366,987.00 $8,493.50
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $16,987.00 Includes geotech and mapping, see attached quote. $8,493.50 N/A
Tall Tower (greater than 500') $210,500.00 $200,000.00 N/A N/A N/A
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study

Component Description:
Partial Payment for structural analysis and geotechinical survey
Amount:
$8,493.50
Tall Tower (greater than 500') Information not provided.
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 $142,360.00 $148,425.00 N/A $34,579.71 N/A
Total for all systems $1,574,775.00 $1,438,027.00 N/A $489,071.21 N/A
Outside Professional Services $142,360.00 $148,425.00 $34,579.71
Additional Repack Legal Services Not Otherwise Specified in Form 399 $5,000.00 $5,000.00 N/A $897.90 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 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
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $1,888.70 N/A
Project management of the transition $106,650.00 $114,675.00 Per additional quote from Widelity $23,481.05 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $1,161.30 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 $1,750.00 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
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $5,400.76 N/A

Components

Actual Information Description File Name
Additional Repack Legal Services Not Otherwise Specified in Form 399

Component Description:
Repack Legal Services
Amount:
$44.50

Component Description:
Repack Legal Services (76324)
Amount:
$109.30

Component Description:
WSKY-TV Repack Legal Services (76324)
Amount:
$21.60

Component Description:
TV Repack Legal Services (76324)
Amount:
$222.50

Component Description:
Brooks Pierce 3945606
Amount:
$184.40

Component Description:
Brooks Pierce 3944883
Amount:
$59.40

Component Description:
Brooks Pierce 3948020
Amount:
$42.70

Component Description:
Brooks Pierce 3943444
Amount:
$213.50
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.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Brooks Pierce 3941525
Amount:
$1,809.50

Component Description:
Brooks Pierce 3942263
Amount:
$79.20
Project management of the transition

Component Description:
Project Management
Amount:
$5,466.05

Component Description:
Project Management
Amount:
$6,618.80

Component Description:
Hourly Project Management Services
Amount:
$1,462.50

Component Description:
Hourly Project Management Services
Amount:
$1,125.00

Component Description:
Revised Ed Murlatt Invoice WSKY180205 per request for additional information.
Amount:
$225.00

Component Description:
Revised Ed Murlatt Invoice WSKY170701 per request for additional information.
Amount:
$1,500.00

Component Description:
Revised Ed Murlatt Invoice WSKY171204 per request for additional information.
Amount:
$750.00

Component Description:
Project Management
Amount:
$597.45

Component Description:
Project Management
Amount:
$5,736.25
Prepare and or review reimbursement form

Component Description:
Brooks Pierce 3941525
Amount:
$138.60

Component Description:
Brooks Pierce 3942263
Amount:
$158.40

Component Description:
WSKY-Prepare and/or Review Reimbursement Form
Amount:
$371.10

Component Description:
Brooks Pierce 3939261
Amount:
$232.70

Component Description:
WSKY-TV Repack Legal Services
Amount:
$260.50
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:
Revised Smith and Fisher Invoice 6692 per request for additional information.
Amount:
$1,750.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
Travel at half-rate. Travel on June 12, 2017.
Amount:
$4,750.76

Component Description:
Revised Smith and Fisher Invoice 6611 per request for additional information.
Amount:
$650.00

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 $65,880.00 $58,080.00 N/A $3,480.70 N/A
Total for all systems $1,574,775.00 $1,438,027.00 N/A $489,071.21 N/A
Other Expenses $65,880.00 $58,080.00 $3,480.70
DTV Medical Facility Notification $11,550.00 $3,750.00 N/A N/A N/A
Site Preperation $8,000.00 $8,000.00 see transition plan attached $2,097.20 N/A
Equipment Delivery and Handling Charges $15,000.00 $15,000.00 See Transition Plan Attached $1,250.00 N/A
Develop and air announcement of upcoming channel change $5,000.00 $5,000.00 See Transition Plan Attached N/A N/A
MVPD Notification of Channel Change $1,000.00 $1,000.00 See Transition Plan Attached N/A N/A
Site survey $5,330.00 $5,330.00 see transition plan attached N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $20,000.00 $20,000.00 See Transition Plan Attached $133.50 N/A

Components

Actual Information Description File Name
DTV Medical Facility Notification Information not provided.
Site Preperation

Component Description:
Tandem load ABC Rock to be delivered
Amount:
$1,095.68

Component Description:
"Tandem load ABC Rock to be delivered 198 Gallberry Road South Mills, NC (Repairs to road for deliveries)"
Amount:
$1,001.52
Equipment Delivery and Handling Charges

Component Description:
Furnish and install gate in existing fence
Amount:
$1,250.00
Develop and air announcement of upcoming channel change Information not provided.
MVPD Notification of Channel Change Information not provided.
Site survey Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
Disposal Fee 20 Yd - Ro
Amount:
$133.50

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,574,775.00 $1,438,027.00 $489,071.21

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.

Bob Pectelidis

Director of Corporate Engineering


07/05/2019

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.

Bob Pectelidis

Director of Corporate Engineering


07/05/2019

Attachments

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