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:
25722
Service:
DCA
Call Sign:
WHPS-CD
Channel:
15 (UHF)
File Number:
0000028679
FRN:
0023521115
Date Submitted:
09/15/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

HME Equity Fund II, LLC

Doing Business As: HME Equity Fund II, LLC

Seth Ellis

121 S. Orange Avenue

Suite 1500

Orlando, FL 32801

United States

+1 (407) 377-6851 sellis@assurancemezz.com Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Davina Sashkin

Counsel

Fletcher, Heald & Hildreth, PLC

Davina Sashkin

Fletcher, Heald & Hildreth, PLC

1300 N. 17th Street, Suite 1100

Arlington, VA 22209

United States

+1 (703) 812-0400 sashkin@fhhlaw.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 Revised plan includes proposed move to new tower location upon discovery of concerns with current tower site, antenna and transmitter. See attached Memo dated Jan. 18, 2018 for details.

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model UAX500AT
Year 2015
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 0.5 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 UNKNOWN
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 4 kW
Justification for New Transmitter Manufacturer warranty has been voided on current transmitter and it is therefore not retunable. A new transmitter is required. See attached Jan. 18, 2018 Memo for explanation.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service 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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Add 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 this antenna currently shared with any other stations? No
Is this 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 Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
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: 4.0 kW
Manufacturer
Model ATC-BPH8C2
Year 2015

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 Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Other
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 Class A Single Station Antenna - Basic
ERP: 15.0 kW
Manufacturer
Model ALP16L2-HSW
Year 2019
Justification for New Antenna Manufacturer warranty has been voided on current antenna and it is therefore not retunable. A new antenna is required. See attached Jan. 18, 2018 Memo for explanation.

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 Foam
Diameter 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 3
Length 650 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? Yes
Type Flexible Foam
Diameter 7/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 250 feet per run
Justification for New Transmission Line issues with current transmitter and antenna, as documented in attached Jan. 18, 2018 Memo, support conclusion that current transmission line may not be re-used for new facilities.

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)
Description of Use N/A
Ownership Leased
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? Yes
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 42° 24' 29.0" N-
Longitude (NAD83) 083° 05' 30.0" W-
Overall Structure Height 199.80 feet
Support Structure Height 199.80 feet
Ground Elevation Above Mean Sea Level (AMSL) 831.00 feet
Structure Type MTOWER - Monopole
Tower Owner Woodward Broadcasting LLC
Date Constructed 01/15/2015


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 600
Explanation Applicant has no internal resources capable of overseeing, identifying, purchasing, installing and commissioning this repack project. It will rely solely on outside services to manage all work required.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Other Transition- Related Professional Service Costs

Prepare and/or review reimbursement form

Quarterly Transition Reports

Quarterly Transition Reports

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 Yes
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

Name Description

Other Miscellaneous Expenses

Other Miscellaneous Expenses.

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 $236,500.00 $225,000.00 N/A $0.00 N/A
Total for all systems $522,790.00 $488,250.00 N/A $97,606.08 N/A
Primary Transmitter UNKNOWN $236,500.00 $225,000.00 $0.00
UHF - Air Cooled Solid State Transmitter 4 - 6 kW $236,500.00 $225,000.00 N/A $0.00 N/A

Components

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 $26,300.00 $25,000.00 N/A $18,930.64 N/A
Total for all systems $522,790.00 $488,250.00 N/A $97,606.08 N/A
Primary Antenna ALP16L2-HSW $26,300.00 $25,000.00 $18,930.64
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $25,000.00 N/A $18,930.64 N/A

Components

Actual Information Description File Name
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
After the invoice you will see an breakout/allocation of the Antenna and Transmission line costs with the shipping and the tax (7.25%) for each. I have attached the proposal that that is the detail of Antenna and Transmission line.
Amount:
$18,930.64

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 $2,750.00 $18,000.00 N/A $17,931.17 N/A
Total for all systems $522,790.00 $488,250.00 N/A $97,606.08 N/A
Primary Transmission Line $2,750.00 $18,000.00 $17,931.17
Flexible Foam Transmission Line - dielectric, 7/8" $2,750.00 $18,000.00 WHPS was moved to a taller tower and therefore there were more turns the transmission line had to go thru. So a more sturdier line had to be purchased and more line had to be purchased as it was a taller tower. $17,931.17 N/A

Components

Actual Information Description File Name
Flexible Foam Transmission Line - dielectric, 7/8"

Component Description:
After the invoice you will see an breakout/allocation of the Antenna and Transmission line costs with the shipping and the tax (7.25%) for each. I have attached the proposal that that is the detail of Antenna and Transmission line.
Amount:
$17,931.17

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 $84,200.00 $60,000.00 N/A $0.00 N/A
Total for all systems $522,790.00 $488,250.00 N/A $97,606.08 N/A
Primary Tower MTOWER $84,200.00 $60,000.00 $0.00
Short Tower (less than 500') $84,200.00 $60,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $132,490.00 $126,250.00 N/A $60,744.27 N/A
Total for all systems $522,790.00 $488,250.00 N/A $97,606.08 N/A
Outside Professional Services $132,490.00 $126,250.00 $60,744.27
Quarterly Transition Reports $6,000.00 $6,000.00 N/A $1,510.00 N/A
Other Transition- Related Professional Service Costs $2,500.00 $2,500.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 N/A $3,667.00 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $1,803.75 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $0.00 Cost of preparing the section was more than expected
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $2,492.75 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A $1,500.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $5,250.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,000.00 N/A
Project management of the transition $94,800.00 $90,000.00 Project management expenses. $42,520.77 N/A

Components

Actual Information Description File Name
Quarterly Transition Reports

Component Description:
Initial first quarterly transition reports for W33BY-D the Detroit Station. The fees are all the ones denoted with the letter F next to them.
Amount:
$475.00

Component Description:
Work on preparing quarterly transition reports.
Amount:
$1,035.00
Other Transition- Related Professional Service Costs Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
Various attorney fees for repack items for W33BY-D for Detroit station. The fees are all the ones denoted with the letter A next to them.
Amount:
$3,667.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
These are the attorney fees for the construction permit application on form 2100. The fees are all the ones denoted with the letter C next to them. Also some of the line items have CP as an abbreviation for Construction permit application.
Amount:
$1,803.75
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Preparation of engineering section of FCC form 2100
Amount:
$2,000.00
Prepare and or review reimbursement form

Component Description:
These are the attorney fees for preparing and reviewing the reimbursement form 399. The fees are all the ones denoted with the letter D next to them.
Amount:
$2,492.75
Address transition timing and coordination issues w/ other stations and wireless

Component Description:
Address issues, research and coordinate between parties.
Amount:
$1,500.00
Perform engineering study for new channel assignment and antenna development

Component Description:
Getting Clarification from vendor on invoice
Amount:
N/A

Component Description:
Getting Clarification from vendor on invoice
Amount:
N/A

Component Description:
Perform and engineering structural analysis. PO request with detail and cancelled check attached.
Amount:
$3,250.00

Component Description:
Engineering work for new channel assignment and antenna development
Amount:
$2,000.00

Component Description:
Getting Clarification from vendor on invoice
Amount:
N/A

Component Description:
Engineering study work for new channel assignment and antenna development
Amount:
$2,000.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Work on Construction Permit Application for form 2100
Amount:
$2,000.00
Project management of the transition

Component Description:
Project Management services for the Detroit stations WHPS
Amount:
$14,180.00

Component Description:
Project Management services for the Detroit stations WHPS
Amount:
$5,643.75

Component Description:
Project management services. A narrative letter is attached explaining the breakout of the invoice. Expense receipts are attached to the invoice. Also this company does not use specific invoice numbers so I just did a description
Amount:
$8,503.27

Component Description:
Project Management services for the Detroit stations WHPS
Amount:
$8,881.25

Component Description:
Project management fees for Detroit.
Amount:
$7,253.27

Component Description:
Project Management services for the Detroit stations WHPS
Amount:
$6,562.50

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 $40,550.00 $34,000.00 N/A $0.00 N/A
Total for all systems $522,790.00 $488,250.00 N/A $97,606.08 N/A
Other Expenses $40,550.00 $34,000.00 $0.00
Other Miscellaneous Expenses $5,000.00 $5,000.00 N/A N/A N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $2,500.00 $2,500.00 N/A N/A N/A
Equipment Storage $2,500.00 $2,500.00 N/A N/A N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 N/A N/A N/A
Non-zoning permits $2,000.00 $2,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $5,000.00 N/A N/A N/A
Local Zoning $2,000.00 $2,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $5,000.00 $5,000.00 N/A 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 $522,790.00 $488,250.00 $97,606.08

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.

Ann Olsen

Consultant


09/15/2019

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.

Ann Olsen

Consultant


09/15/2019

Attachments

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