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:
70482
Service:
DTV
Call Sign:
KSLA
Channel:
23 (UHF)
File Number:
0000024794
FRN:
0018223693
Date Submitted:
10/07/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GRAY TELEVISION LICENSEE, LLC

Doing Business As: KSLA

Robert Folliard

4370 PEACHTREE ROAD, NE

ATLANTA, GA 30319

United States

+1 (318) 677-6708 allfcclms@gray.tv 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

Samuel Hariton

Widelity

4031 University Dr

Suite 100

Fairfax, VA 22030

United States

+1 (339) 222-8107 sam.hariton@widelity.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 Use existing side mount antenna and line as interim Remove and replace existing top mount antenna. Install new main and backup transmitters

Transmitters

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Section Question Response
Transmitter Related Expenses Do you have transmitter related expenses? Yes

Auxiliary Transmitter

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Add Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Retune Existing
Use Auxiliary (Backup)
Ownership Owned
Owner 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 GatesAir
Model UAXT-1000
Year 2010
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.4 kW

Auxiliary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed N/A
New Mask Filter
Power 3 kW
Other Power N/A
New Exciter Is a new exciter needed? No

Auxiliary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
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

Auxiliary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

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 DCX
Year 2003
Type Inductive Output Tube
IOT Power Type Single
Power Capacity 20 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 ULXTE-50
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 31.7 kW
Justification for New Transmitter IOT to Solid State upgrade Existing transmitter can not be retuned. Cost of a new IOT exceeds solid state cost

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) Yes
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 175.0 kW
Manufacturer
Model TFU-16DSB-A(C)
Year 2003

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 181.0 kW
Manufacturer
Model TFU-18GTH/VP-R 04
Year 2019
Justification for New Antenna Existing antenna can not be retuned but can be used as interim E-Pol premium not reimbursable Top mount is less expensive than new side mount and interim antenna.

Primary Antenna

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Other Antenna Costs

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

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1850 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1850 feet per run
Justification for New Transmission Line Existing line section lengths do not work on new channel

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? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 32° 40' 28.3" N-
Longitude (NAD83) 093° 55' 59.1" W-
Overall Structure Height 1790.99 feet
Support Structure Height 1706.67 feet
Ground Elevation Above Mean Sea Level (AMSL) 254.92 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner KSLA LLC
Date Constructed 12/12/1978


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 895
Explanation Pattern analysis Antenna Spec Transmitter Spec Building drawings Installation Supervision Accounting Internal Legal Strategic 399 Support
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 No
Address transition timing and coordination issues w/ other stations and wireless providers No
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements No
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application 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? 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 $1,939,819.19 $1,111,266.54 N/A $222,077.15 N/A
Total for all systems $3,283,579.19 $2,084,034.44 N/A $312,327.86 N/A
Primary Transmitter ULXTE-50 $1,830,464.19 $1,099,055.94 $219,291.75
Transformer 3 phase/480v - 300 KVA $36,800.00 $35,000.00 N/A N/A N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 31.7 kW $808,464.19 $808,464.19 Per GatesAir GA-00021483 includes tax and shipping costs (decreased by $219,291.75 previously forwarded for payment on superseded equipment) Like for Like transmitter ULXTE-40 N/A N/A
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW $947,000.00 $219,291.75 ***System Notice: Estimate adjusted and locked because line has been superseded.***Gates Air Quote attached Headroom analysis attached $219,291.75 N/A
Auxiliary Transmitter UAXT-1000 $109,355.00 $12,210.60 $2,785.40
UHF and VHF - minor banding issues $105,200.00 $12,210.60 Quote attached (GA-00021677) $2,785.40 N/A
3 kW mask filter $4,155.00 $0.00 retune mask filter N/A N/A

Components

Actual Information Description File Name
Transformer 3 phase/480v - 300 KVA Information not provided.
Switchgear - industrial 800 amp Information not provided.
UHF - Liquid Cooled Solid State Transmitter 31.7 kW Information not provided.
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW

Component Description:
ULXTE-40 per Quote Q-69739
Amount:
$87,716.70

Component Description:
ULXTE-40 transmitter per Quote Q-69739
Amount:
$131,575.05
UHF and VHF - minor banding issues

Component Description:
Channel change UAX-1000AT
Amount:
$1,671.24

Component Description:
Channel change UAX-1000AT
Amount:
$1,114.16
3 kW mask filter Information not provided.

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $296,230.00 $165,727.90 N/A $16,572.79 N/A
Total for all systems $3,283,579.19 $2,084,034.44 N/A $312,327.86 N/A
Primary Antenna TFU-18GTH/VP-R 04 $296,230.00 $165,727.90 $16,572.79
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $289,500.00 $159,327.90 Quote attached V-Pol premium not included in cost $15,932.79 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $640.00 N/A

Components

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

Component Description:
UHF - high power top mount (200-1,000 KW) antenna
Amount:
$15,932.79
Sweep test of existing antenna

Component Description:
KSLA-210-Primary Antenna - Sweep Test
Amount:
$640.00

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 $373,700.00 $154,665.00 N/A $15,466.50 N/A
Total for all systems $3,283,579.19 $2,084,034.44 N/A $312,327.86 N/A
Primary Transmission Line $373,700.00 $154,665.00 $15,466.50
Rigid Transmission Line - copper, 6 1/8" $373,700.00 $154,665.00 Quote attached $15,466.50 N/A

Components

Actual Information Description File Name
Rigid Transmission Line - copper, 6 1/8"

Component Description:
KSLA-310-Primary Transmission Line - Rigid, Copper, 6 1/8"
Amount:
$15,466.50

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $381,100.00 $370,150.00 N/A $22,200.00 N/A
Total for all systems $3,283,579.19 $2,084,034.44 N/A $312,327.86 N/A
Primary Tower TOWER $381,100.00 $370,150.00 $22,200.00
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A $4,800.00 N/A
Tall Tower (greater than 500') $210,500.00 $200,000.00 N/A N/A N/A
Structural engineering tower load study for well documented tower $12,600.00 $20,150.00 Paul J Ford Invoices $17,400.00 Sub-total equals Estimated Cost.

Components

Actual Information Description File Name
Minor tower reinforcement/modifications

Component Description:
Broadcast Tower Modification Design
Amount:
$4,800.00
Tall Tower (greater than 500') Information not provided.
Structural engineering tower load study for well documented tower

Component Description:
Professional Services - Broadcast Tower Structural Analysis
Amount:
$2,200.00

Component Description:
Professional Services-TIA Inspection
Amount:
$10,800.00

Component Description:
Broadcast tower structural analysis
Amount:
$4,400.00

Component Description:
Structural Analysis
Amount:
$2,750.00

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 $245,330.00 $243,425.00 N/A $36,011.42 N/A
Total for all systems $3,283,579.19 $2,084,034.44 N/A $312,327.86 N/A
Outside Professional Services $245,330.00 $243,425.00 $36,011.42
Project management of the transition $141,410.00 $144,675.00 Widelity Strategic Support Quote $32,732.25 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $779.17 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,500.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A 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
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$38.50

Component Description:
Project Management
Amount:
$2,169.80

Component Description:
Project Management
Amount:
$2,741.30

Component Description:
Project Management
Amount:
$3,313.15

Component Description:
Project Management
Amount:
$2,034.20

Component Description:
Project Management
Amount:
$3,256.95

Component Description:
Project Management
Amount:
$2,873.35

Component Description:
Project Management
Amount:
$231.00

Component Description:
Project Management
Amount:
$2,665.25

Component Description:
Project Management
Amount:
$2,977.55

Component Description:
Project Management
Amount:
$3,176.20

Component Description:
Project Management
Amount:
$2,212.45

Component Description:
Project Management
Amount:
$2,021.60

Component Description:
Project Management
Amount:
$3,020.95
Perform engineering study for new channel assignment and antenna development

Component Description:
KSLA-530-RF Eng - Engineering Study for New Channel Assignment
Amount:
$79.17

Component Description:
Project Management
Amount:
$75.00

Component Description:
Engineering study work for new channel assignment and antenna development;
Amount:
$500.00

Component Description:
Engineering study work for new channel assignment and antenna development
Amount:
$125.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
KSLA FCC Form 2100 Construction permit application
Amount:
$2,500.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.

Cost Information

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Other Expenses

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $47,400.00 $38,800.00 N/A $0.00 N/A
Total for all systems $3,283,579.19 $2,084,034.44 N/A $312,327.86 N/A
Other Expenses $47,400.00 $38,800.00 $0.00
MVPD Notification of Channel Change $0.00 $0.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $2,950.00 Group quote attached N/A N/A
Equipment Delivery and Handling Charges $2,500.00 $2,500.00 On site forklift rental Quote attached N/A N/A
Equipment Storage $30,500.00 $30,500.00 Estimate for Dielectric on site antenna storage Estimate attached N/A N/A
Develop and air announcement of upcoming channel change $2,850.00 $2,850.00 estimate for on air rescan announcement production. Quote attached N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $3,283,579.19 $2,084,034.44 $312,327.86

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.

Robert Folliard , III .

Assistant Secretary


10/07/2019

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.

Robert Folliard , III .

Assistant Secretary


10/07/2019

Attachments

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