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:
71023
Service:
DTV
Call Sign:
KTNW
Channel:
22 (UHF)
File Number:
0000028348
FRN:
0001563949
Date Submitted:
07/12/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WASHINGTON STATE UNIVERSITY

Doing Business As: WASHINGTON STATE UNIVERSITY

Murrow Public Media.

Jackson Hall rm 382, P.O. BOX 642530

PULLMAN, WA 99164

United States

+1 (509) 335-6585 doug.krehbiel@wsu.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

Martin L. Gibbs

FCC Planning Engineer

Washington State University Murrow Public Media

2710 Crimson Way

Richland, WA 99354

United States

+1 (509) 948-1496 m.gibbs@wsu.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 Replace analog antenna at top of tower with new antenna; install new transmitter. This will allow parallel operation during the testing phase without additional expenses for temporary facilities. Ref: Attachment 1

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 Magnum
Year 2003
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 2 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-EVO
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 8.2 kW
Justification for New Transmitter Larcan Magnum transmitter is no longer supported and has many obsolete parts. Current manufacturer does not have documentation for re-tune. In addition, a higher TPO (4.9kW) is necessary to support the proposed antenna, 7.6kW is an upgrade

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 Yes
Size 2 inches
Length 25.0 feet
Other Electrical Service Yes
Description Branch panel with disconnect
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? Yes
Existing Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 47.6 kW
Manufacturer
Model TLP-8L
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? No
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types 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: 29.5 kW
Manufacturer
Model SFN-3030-2
Year 2018
Justification for New Antenna Old antenna cannot be retuned from channel 38 to channel 22. Ref: Attachment 1

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? No

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 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 120 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 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 140 feet per run
Justification for New Transmission Line Enable parallel operation during testing period. Ref: Attachment 1

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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Add 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? Yes
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) 46° 06' 12.8" N-
Longitude (NAD83) 119° 07' 44.6" W-
Overall Structure Height 62.00 feet
Support Structure Height 62.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 2182.00 feet
Structure Type UTOWER - Unguyed - Free Standing Tower
Tower Owner Washington State University
Date Constructed 06/02/2003


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 400
Explanation Planning and coordination of project to assure adherence to Phase 1 schedule. See Attachment 1
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 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 Yes
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 Yes
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? Yes
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 $508,225.00 $278,886.00 N/A $271,810.60 N/A
Total for all systems $976,425.00 $727,976.00 N/A $363,793.25 N/A
Primary Transmitter THU9-EVO $508,225.00 $278,886.00 $271,810.60
2" Rigid Conduit and Wiring (Cost per foot) $650.00 $625.00 N/A N/A N/A
Other Electrical Service: Branch panel with disconnect $13,075.00 $13,075.00 N/A $6,624.60 N/A
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW $494,500.00 $265,186.00 N/A $265,186.00 Estimate revised to include parts required for transmitter that were not included on original estimate.

Components

Actual Information Description File Name
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Other Electrical Service: Branch panel with disconnect

Component Description:
material and labor to upgrade electrical system for new KTNW transmitter
Amount:
$6,624.60
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW

Component Description:
Additional parts needed for installation as per revised estimate.
Amount:
$5,192.17

Component Description:
Various parts and assembly hardware
Amount:
$5,192.17

Component Description:
KTNW Transmitter - portion of invoice based on bid for smaller unit.
Amount:
$259,993.83

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 $50,000.00 $50,000.00 N/A $19,045.65 N/A
Total for all systems $976,425.00 $727,976.00 N/A $363,793.25 N/A
Primary Antenna SFN-3030-2 $50,000.00 $50,000.00 $19,045.65
UHF - High Power, Side Mount, basic slot antenna, 30 kW input, directional,, horizontally polarized $50,000.00 $50,000.00 N/A $19,045.65 N/A

Components

Actual Information Description File Name
UHF - High Power, Side Mount, basic slot antenna, 30 kW input, directional,, horizontally polarized

Component Description:
rods, washers and bolts for antenna installation
Amount:
$190.54

Component Description:
DTV Channel 22 UHF Slotted antenna with 10 full wave spaced bays.
Amount:
$18,136.20

Component Description:
Sales Tax paid by WSU directly to state. Not included in Invoice 9874-Magnum Towers.
Amount:
$711.68

Component Description:
Hex cap screws for antenna installation
Amount:
$7.23

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 $4,620.00 $4,340.00 N/A $9,853.96 N/A
Total for all systems $976,425.00 $727,976.00 N/A $363,793.25 N/A
Primary Transmission Line $4,620.00 $4,340.00 $9,853.96
Flexible Air Transmission Line - dielectric, 1 5/8" $4,620.00 $4,340.00 N/A $9,853.96 Additional line and fittings required to attach antenna to transmitter than originally estimated.

Components

Actual Information Description File Name
Flexible Air Transmission Line - dielectric, 1 5/8"

Component Description:
Transmission Line plus assembly parts.
Amount:
$9,853.96

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 $254,800.00 $242,000.00 N/A $20,376.30 N/A
Total for all systems $976,425.00 $727,976.00 N/A $363,793.25 N/A
Primary Tower UTOWER $254,800.00 $242,000.00 $20,376.30
Short Tower (less than 500') $84,200.00 $80,000.00 N/A $10,230.30 N/A
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A $8,896.00 N/A
Structural engineering tower load study for well documented tower $12,600.00 $12,000.00 N/A $1,250.00 N/A

Components

Actual Information Description File Name
Short Tower (less than 500')

Component Description:
Review of project site, determine materials and process
Amount:
$402.30

Component Description:
Labor and crane to install pole mount for new antenna at KTNW.
Amount:
$9,828.00
Minor tower reinforcement/modifications

Component Description:
Pole Mount for antenna
Amount:
$8,896.00
Structural engineering tower load study for well documented tower

Component Description:
Tower Structural analysis
Amount:
$1,250.00

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $109,230.00 $103,750.00 N/A $32,098.44 N/A
Total for all systems $976,425.00 $727,976.00 N/A $363,793.25 N/A
Outside Professional Services $109,230.00 $103,750.00 $32,098.44
RF Exposure Measurements $21,050.00 $20,000.00 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 $2,250.00 N/A
Project management of the transition $63,200.00 $60,000.00 N/A $19,725.03 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $599.84 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
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $2,125.20 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $482.34 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $4,784.50 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,131.53 N/A

Components

Actual Information Description File Name
RF Exposure Measurements Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Attorney service related to licensing and form 399
Amount:
$990.50

Component Description:
Attorney Fees - Construction portion of invoice
Amount:
$42.50

Component Description:
Attorney services related to licensing and form 399
Amount:
$339.00

Component Description:
Attorney service related to application, licensing and form 399
Amount:
$349.00

Component Description:
Attorney service related to licensing and form 399
Amount:
$317.00

Component Description:
Attorney service for licensing and form 399
Amount:
$212.00
Project management of the transition

Component Description:
Project Management -March 2019
Amount:
$142.50

Component Description:
Form 399 revision assistance; channel transition
Amount:
$380.00

Component Description:
wages attributed to transition management
Amount:
$92.00

Component Description:
Progress reports and FCC filings
Amount:
$737.50

Component Description:
project management of February
Amount:
$130.00

Component Description:
project management - wages allocated during 3rd quarter 2017
Amount:
$1,334.00

Component Description:
Transmitter line resubmit form 399
Amount:
$142.50

Component Description:
Portion of 2nd quarter wages allocated to general project management
Amount:
$2,205.70

Component Description:
Project management - wages for 1st quarter.
Amount:
$782.00

Component Description:
Progress reports
Amount:
$265.00

Component Description:
Portion of wages allocated to Project Management during 4th quarter 2017
Amount:
$1,061.68

Component Description:
Portion of M. Gibbs time on Project Management of Repack for 2nd quarter of year.
Amount:
$2,656.04

Component Description:
portion of wages attributed to project management
Amount:
$76.03

Component Description:
Attorney service related to management of overall project.
Amount:
$1,156.00

Component Description:
Portion of First Quarter 2018 wages applicable to Project Management
Amount:
$4,010.28

Component Description:
Progress reports and updates
Amount:
$530.00

Component Description:
portion of invoice related to general transition management
Amount:
$1,307.50

Component Description:
July - September portion of wages related Repack
Amount:
$2,716.30
Prepare and or review reimbursement form

Component Description:
portion of wages attributed to reimbursement form review
Amount:
$599.84
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
Engineering Study portion of 2nd quarter wages.
Amount:
$1,840.00

Component Description:
portion of wages attributed to engineering study and antenna development
Amount:
$285.20
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
portion of invoice related to license to cover
Amount:
$216.00

Component Description:
portion of wages attributed to FCC form 2100
Amount:
$266.34
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Attorney fees for July 2018
Amount:
$427.50

Component Description:
Attorney fees - Construction permit application - Dec 17
Amount:
$47.50

Component Description:
portion of invoice related to construction permit application
Amount:
$37.00

Component Description:
FCC licensing and filing
Amount:
$227.00

Component Description:
Attorney service related to construction permit preparation and submission
Amount:
$301.00

Component Description:
Attorney Fees - Construction permit application June
Amount:
$185.00

Component Description:
Attorney Fees - Construction permit application - March
Amount:
$242.50

Component Description:
Attorney Fees - Construction Permit application - April
Amount:
$712.50

Component Description:
Attorney service related to construction permit preparation and submission
Amount:
$375.00

Component Description:
Attorney fees August 2018
Amount:
$522.50

Component Description:
Attorney Fees - Construction permit application -February
Amount:
$159.00

Component Description:
Attorney service related to construction permit preparation and submission
Amount:
$1,548.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Attorney fees related to Repack prep/construction license.
Amount:
$1,211.53

Component Description:
prepare engineering section of Form 2100, construction permit application. wages during 2nd qtr 2017
Amount:
$690.00

Component Description:
prepare engineering section of Form 2100, construction permit application. Portion of wages allocated during 3rd quarter 2017
Amount:
$230.00

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 $49,550.00 $49,000.00 N/A $10,608.30 N/A
Total for all systems $976,425.00 $727,976.00 N/A $363,793.25 N/A
Other Expenses $49,550.00 $49,000.00 $10,608.30
MVPD Notification of Channel Change $2,000.00 $2,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $4,130.00 N/A
Non-zoning permits $2,000.00 $2,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $2,000.00 $2,000.00 N/A $488.70 N/A
Equipment Delivery and Handling Charges $25,000.00 $25,000.00 N/A $5,089.60 N/A
Equipment Storage $4,000.00 $4,000.00 N/A $900.00 N/A
Develop and air announcement of upcoming channel change $3,000.00 $3,000.00 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:
Notification of Cable and Satellite MVPD Providors of new RF Chanel & Transport Stream parameters
Amount:
$1,755.00

Component Description:
Notification of Medical Facilities
Amount:
$2,375.00
Non-zoning permits Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
Rental of dumpster and disposal of waste
Amount:
$314.16

Component Description:
Rental of large metal dumpster
Amount:
$174.54
Equipment Delivery and Handling Charges

Component Description:
Transmitter handling and delivery
Amount:
$2,718.00

Component Description:
Pole mount handling and delivery
Amount:
$1,900.50

Component Description:
rental of front loader
Amount:
$380.10

Component Description:
Rental of portable toilet
Amount:
$91.00
Equipment Storage

Component Description:
Storage of transmitter
Amount:
$900.00
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 $976,425.00 $727,976.00 $363,793.25

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. Yes
Construction of final facilities or all necessary modifications are complete. Yes
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.

Denise Crossler

Grant & Contract Specialist


07/12/2019

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.

Denise Crossler

Grant & Contract Specialist


07/12/2019

Certification

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Section Question Response
Submission of Final Allocation or Accounting Information 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 representations.

  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 all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates.

  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 acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  6. 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.

Denise Crossler

Grant & Contract Specialist


07/12/2019

Attachments

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