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:
74373
Service:
LPD
Call Sign:
WOIW-LD
Channel:
17 (UHF)
File Number:
0000086297
FRN:
0004378071
Eligibility Status:
Not Determined
Date Submitted:
10/11/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

American Christian Television Services, Inc.

1844 Baty Road

Lima, OH 45807

United States

+1 (419) 339-4444 kbowers@wtlw.com Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

The Preparer is same as the reimbursement contact.

 

 

 

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 WOIW-LD has transitioned from channel 23 to channel 17 and is operating with a license to operate.

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)
Ownership Owned
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model AT7120
Year 2012
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 120 W

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 UAXTE-4R37
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2173 W
Justification for New Transmitter The existing transmitter is not capable of being tuned to channel 17 and cannot meet the requirements of the displacement construction permit. The existing output mask filter is channel-specific and must be replaced to accommodate the new channel.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Other Transmitter Costs
Does the transmitter installation require a Transmitter Building Site Survey/Installation? No
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Rigid Conduit and Wiring No
Other Electrical Service No
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 10 tons
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Intall Material

Install Material

Barrier Gas 1 5-8

Transmitter part Barrier Gas

Kit - UAXT RF Access

RF Access

Couplings

Two couplings

Kit Rf XSMN Line 1 5-8

RF Kit

Mask Filter 2.5 kw

Mask Filter Tuned

Parallel Surge Suppressor

Surge Suppressor

Elbow 90 degree 1 5-8

Elbow

Transmitter Installation

Install

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)
Ownership Owned
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
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Other
Other Antenna Type Cone
ERP: 3.0 kW
Manufacturer
Model Ultra Blaster
Year 1992

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Change Type Purchase New
Ownership Owned
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
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model TLP-16A/VP
Year 2019
Justification for New Antenna The replaced antenna was designed for channel 23 and would not work for channel 17.

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
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

Name Description

VPOL Components

Feed line components.

Reducer

Reducer to feed line

Antenna Mounting Brackets

mounting brackets for tower legs

Parts Shipping

Additional shipping for component parts.

Antenna Shipping

Shipment from Dielectric.

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)
Ownership Owned
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 623 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Air
Diameter 3 inches
Number of parallel runs 1
Length 125 feet per run
Justification for New Transmission Line 125 ft purchased to extend existing and reusable 2.25" line on tower.
Interior RF Systems Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators? No

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Move Equipment
Tower Use Primary (Main)
Ownership Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users 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 1012894
Coordinates (NAD83) Latitude (NAD83) 40° 45' 47.0" N-
Longitude (NAD83) 084° 11' 01.0" W-
Overall Structure Height 720.14 feet
Support Structure Height 660.10 feet
Ground Elevation Above Mean Sea Level (AMSL) 826.76 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner American Christian Television Services Inc.
Date Constructed 02/27/2019

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID Call Sign Service
74294 WWSR FM
1222 WTLW DTV

Other Types of Users

Users
Internet Provid
Radio Communica

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Structural Analysis

Tower Study

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? No
Outside RF consulting Engineering Services Perform engineering study for displacement application No
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
Prepare Form 601 No
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
Negotiation of Lease and other Matter for Shared Locations No
Prepare or Review FCC Form 399 for Reimbursement Yes
Form 399 assistance or other program management costs No
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service No

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
Permit and Filing Costs FCC Construction Permit Major Change No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
FCC Special Temporary Authority Application No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? No
Does this relocation require Equipment Storage? No
Point to Point Microwave (STL/ICR) Frequency Coordination for Unidirection System No
Frequency Coordination for Bi-Direction System No
New Point to Point Microwave System No

Other Expenses

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Other Expenses Not Listed

Name Description

Removal of Previous Antenna

Removal of old antenna and transmission line.

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 $144,236.46 $90,805.59 N/A $90,805.59 N/A
Total for all systems $388,058.29 $219,157.56 N/A $208,883.61 N/A
Primary Transmitter UAXTE-4R37 $144,236.46 $90,805.59 $90,805.59
10 Ton system $38,900.00 $11,282.53 N/A $11,282.53 N/A
Transmitter Installation $12,628.35 $12,628.35 N/A $12,628.35 N/A
Elbow 90 degree 1 5-8 $383.88 $383.88 N/A $383.88 N/A
Parallel Surge Suppressor $1,510.82 $1,510.82 N/A $1,510.82 N/A
Mask Filter 2.5 kw $3,272.72 $3,272.72 N/A $3,272.72 N/A
Couplings $368.90 $368.90 N/A $368.90 N/A
Kit - UAXT RF Access $542.06 $542.06 N/A $542.06 N/A
Barrier Gas 1 5-8 $241.55 $241.55 N/A $241.55 N/A
Intall Material $680.00 $680.00 N/A $680.00 N/A
Kit Rf XSMN Line 1 5-8 $1,708.18 $1,708.18 N/A $1,708.18 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $58,186.60 N/A $58,186.60 N/A

Components

Actual Information Description File Name
10 Ton system

Component Description:
HVAC also service other transmitter channel 4. Second invoice reflects additional ducting.
Amount:
$2,209.03

Component Description:
HVAC also services our other transmitter channel 4.
Amount:
$9,073.50
Transmitter Installation

Component Description:
Installation
Amount:
$12,628.35
Elbow 90 degree 1 5-8

Component Description:
Elbow Two
Amount:
$383.88
Parallel Surge Suppressor

Component Description:
Surge Suppressor
Amount:
$1,510.82
Mask Filter 2.5 kw

Component Description:
Mask Filter Tuned 2.5kw
Amount:
$3,272.72
Couplings

Component Description:
Couplings Two
Amount:
$368.90
Kit - UAXT RF Access

Component Description:
RF Access Kit
Amount:
$542.06
Barrier Gas 1 5-8

Component Description:
Barrier Gas 1 5-8
Amount:
$241.55
Intall Material

Component Description:
Install Material Maxiva Kit
Amount:
$680.00
Kit Rf XSMN Line 1 5-8

Component Description:
Kit XMSN Line
Amount:
$1,708.18
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
UAXTE-4R37 Transmitter
Amount:
$58,186.60

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 $52,704.33 $52,704.33 N/A $46,974.33 N/A
Total for all systems $388,058.29 $219,157.56 N/A $208,883.61 N/A
Primary Antenna TLP-16A/VP $52,704.33 $52,704.33 $46,974.33
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A $0.00 N/A
Parts Shipping $281.33 $281.33 N/A $281.33 N/A
Antenna Mounting Brackets $3,583.00 $3,583.00 N/A $3,583.00 N/A
Reducer $426.00 $426.00 N/A $426.00 N/A
Antenna Shipping $3,510.00 $3,510.00 N/A $3,510.00 N/A
VPOL Components $5,966.00 $5,966.00 N/A $5,966.00 N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical $33,208.00 $33,208.00 N/A $33,208.00 N/A

Components

Actual Information Description File Name
Sweep test of transmission line and antenna Information not provided.
Parts Shipping

Component Description:
Shipping for component parts.
Amount:
$281.33
Antenna Mounting Brackets

Component Description:
Antenna Mounting Brackets
Amount:
$3,583.00
Reducer

Component Description:
Reducer
Amount:
$426.00
Antenna Shipping

Component Description:
Shipping and Freight
Amount:
$3,510.00
VPOL Components

Component Description:
VPOL Components
Amount:
$5,966.00
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical

Component Description:
Channel 17 antenna
Amount:
$33,208.00

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 $7,375.00 $6,515.14 N/A $6,515.14 N/A
Total for all systems $388,058.29 $219,157.56 N/A $208,883.61 N/A
Primary Transmission Line $7,375.00 $6,515.14 $6,515.14
Flexible Air Transmission Line - dielectric, 3" $7,375.00 $6,515.14 N/A $6,515.14 N/A

Components

Actual Information Description File Name
Flexible Air Transmission Line - dielectric, 3"

Component Description:
125 ft of heliax to extend repurposed existing line.
Amount:
$6,515.14

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 $166,250.00 $50,200.00 N/A $50,200.00 N/A
Total for all systems $388,058.29 $219,157.56 N/A $208,883.61 N/A
Primary Tower GTOWER $166,250.00 $50,200.00 $50,200.00
Structural Analysis $8,500.00 $8,500.00 N/A $8,500.00 N/A
Tower Rigging Tall Tower (greater than 500') $157,750.00 $41,700.00 N/A $41,700.00 N/A

Components

Actual Information Description File Name
Structural Analysis

Component Description:
Tower inspection and analysis
Amount:
$8,500.00
Tower Rigging Tall Tower (greater than 500')

Component Description:
Antenna and transmission line installation.
Amount:
$41,700.00

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 $12,982.50 $14,422.50 N/A $9,878.55 N/A
Total for all systems $388,058.29 $219,157.56 N/A $208,883.61 N/A
Outside Professional Services $12,982.50 $14,422.50 $9,878.55
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A $1,414.80 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $3,675.00 N/A $3,675.00 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A $1,557.50 N/A
Prepare request for Special Temporary Authorization $1,280.00 $1,280.00 N/A $250.00 Engineering portion of STA Application
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A $1,050.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A $125.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A $1,806.25 N/A

Components

Actual Information Description File Name
Prepare/ Review 399 reimbursement form

Component Description:
Form 300 Review
Amount:
$1,201.05

Component Description:
Form 399 Review
Amount:
$213.75
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
STA legal review
Amount:
$111.25

Component Description:
Eve Reed .35 hours at $795 per hour
Amount:
$198.75

Component Description:
STA Legal Assistance: Eve Reed .5 hours, Brian Clayton .75 hrs
Amount:
$708.75

Component Description:
STA Application
Amount:
$2,656.25
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
License to Operate Application
Amount:
$1,557.50
Prepare request for Special Temporary Authorization

Component Description:
Engineering STA Application
Amount:
$250.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Engineering for construction permit application.
Amount:
$1,050.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Engineering services for License to Cover application.
Amount:
$125.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Eve Reed, Attorney .25 hours
Amount:
$198.75

Component Description:
Eve Reed, Attorney, 1 hour
Amount:
$795.00

Component Description:
Displacement CP Application
Amount:
$198.75

Component Description:
Displacement CP Application
Amount:
$613.75

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 $4,510.00 $4,510.00 N/A $4,510.00 N/A
Total for all systems $388,058.29 $219,157.56 N/A $208,883.61 N/A
Other Expenses $4,510.00 $4,510.00 $4,510.00
Removal of Previous Antenna $4,510.00 $4,510.00 N/A $4,510.00 N/A

Components

Actual Information Description File Name
Removal of Previous Antenna

Component Description:
Removal of previous transmission line and antenna.
Amount:
$4,510.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $388,058.29 $219,157.56 $208,883.61

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. Yes

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.

Kevin Bowers

President


10/11/2019

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.

Kevin Bowers

President


10/11/2019

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.

Kevin Bowers

President


10/11/2019

Attachments

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