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:
4303
Service:
FM
Call Sign:
WUKY
File Number:
0000086437
FRN:
0001782184
Eligibility Status:
Eligible
Date Submitted:
10/14/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

BOARD OF TRUSTEES, UNIVERSITY OF KENTUCKY

Doing Business As: BOARD OF TRUSTEES, UNIVERSITY OF KENTUCKY

Tom Godell

2640 SPURR ROAD

LEXINGTON, KY 40511

United States

+1 (859) 257-3226 TOM.GODELL@UKY.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

Kathy V. Hight

Accountant Principal

WUKY University of Kentucky

Kathy Hight

2640 Spurr Road

Lexington, KY 40511

United States

+1 (859) 257-7830 kathy.hight@uky.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. Yes
Briefly describe transition plan Please see attached detailed transition plan.

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 Z20 Z16HD
Year 2006
Type Solid State
Solid State Cooling Air Cooled
Model Type Hybrid
Solid State Power Capacity 30 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model TX1000
Transmitter Type Solid State
Solid State Cooling Air Cooled
Model Type Analog
Solid State Power capacity 1 kW
Justification for New Transmitter Transmitter for new auxiliary site.
Does the transmitter require the purchase of a new HD Importer? No
Does the transmitter require the purchase of a new HD Exporter? No

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Other Transmitter Costs Does the transmitter installation require an Additional Exciter? No
Does the transmitter installation require any additional transmitter installation costs? Yes
Does the transmitter installation require a Transmitter Building Site Survey/Installation? Yes
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) Yes
Transformer (480V) No
Rigid Conduit and Wiring No
Other Electrical Service Yes
Description Install electrical service with backup power, at new auxiliary site as required. WUKY is an LP-1 EAS station and required backup power systems.
HVAC Service Does the replacement transmitter require HVAC Service? No
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 480.0 square feet
Other Transmitter-Related Expenses Does the replacement transmitter require a Remote Control? No
Does the replacement transmitter require an RDS Encoder? No
Does the replacement transmitter require Audio Processing? No

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Labor

Labor to install equipment rack and power connections for new transmitter

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 Circular
Type Cross Dipole
ERP: 100.0 kW
Manufacturer
Model MP-8AC-DA-HW
Year 2006

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? Yes
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Circular
Type Cross Dipole
ERP: 12.0 kW
Manufacturer
Model LPX-2C
Year 2018
Justification for New Antenna New Antenna for Aux Site

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex?
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna?
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna?
Sweep Test Do you require the sweep testing of transmission line and antenna?
FM Band Pass Filters Do you require an FM band pass filter?
Notch Filter Do you require a Notch filter?
De-Icers Do you require De-Icers?
Radomes Do you require Radomes?

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 Utilize Existing
Use Primary (Main)
Ownership
Is the existing transmission line shared with another station or stations?
Is Transmission Line in operating condition?
Existing Transmission Line Manufacturer and Type Manufacturer
Type
Diameter
Number of parallel runs
Length

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Antennas Unlimited, Inc.

Antennas Unlimited, Inc. donated the transmission line for new auxiliary transmitter.

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 Construct New
Tower Use Primary (Main)
Ownership
Is this tower consider Complex?
Is this tower currently shared with any other stations?
Is tower documented for structural analysis?
Is tower compliant with Rev G?
Existing Tower Structure Registration Do you have a tower registration number?
Coordinates (NAD83) Latitude (NAD83) - -
Longitude (NAD83) - -
Overall Structure Height
Support Structure Height
Ground Elevation Above Mean Sea Level (AMSL)
Structure Type -
Tower Owner
Date Constructed


Primary Tower

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Tower Construction Costs

Section Question Response
Construct New Tower Use Primary (Main)
Is this a request for upgraded equipment? Yes
Height 191.00 feet
Justification for New Tower New monopole tower for new Auxiliary site.

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower Terrain constrained
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Tower Equipment and Rigging

See detailed descriptions and invoices in attached document named Tower Equipment and Rigging. Total cost $208,930.45.

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 0
Explanation Project management was complete as a portion of an overall bid. The total project costs was $498,042. The calculation used was 20% of $498,042 equals 19,608.40.
Outside RF consulting Engineering Services Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility Yes
For Main Facility No
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
For Main Facility No
Prepare request for Special Temporary Authority No
Prepare Form 601 Yes
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility Yes
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
For Main Facility Yes
Prepare request for Special Temporary Authority No
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 Yes
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 1
Justification Detuning tower to to proximity of am station. WLXG

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Outside Other Professional Services

Details of professional services, engineering, detuning, permits, applications for auxiliary facility. Legal and engineering costs for Form 399 preparation. Detailed services and invoices are on attachment titled Other Professional Services Expenses.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? Yes
Is Remediation needed? No
Permit and Filing Costs FCC Construction Permit Major Change No
FCC Construction Permit Minor Change Yes
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
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 Yes
New Point to Point Microwave System No
1 pair IP-only Codecs for fiber, internet or IP microwave systems No

Other Expenses

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Other Expenses Not Listed

Name Description

Construction permit for Auxiliary transmitter site.

Auxiliary site build out: support buildings, site preparation, electrical, EAS required emergency generator, Andrew antennas, wiring, connectors, security fencing. Total cost $367,050.56. See attachment Other Expenses with invoices.

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 $760,561.16 $642,811.20 N/A $642,811.20 N/A
Total for all systems $1,358,064.26 $899,989.30 N/A $893,446.80 N/A
Primary Transmitter TX1000 $760,561.16 $642,811.20 $642,811.20
Transmitter Installation $70,500.00 $6,530.00 N/A $6,530.00 N/A
Labor $41,705.15 $41,705.15 See attachment Other Professional Services for cost details and invoices for engineering, legal and other services. $41,705.15 Please see attachment Other Professional Services for cost details and invoices.
Transmitter Building Site Survey/Installation $10,000.00 $18,595.04 See attached documents: 1-Other Costs - Land and 2-WUKY Building and Land Appraisal report for costs calculations. $18,595.04 Site survey and appraisal. See attachment Other Costs-Land for computation and appraisal documents.
Other -- Building Addition Size: 480.0 $208,930.45 $208,930.45 Other - Tower Equipment and Rigging Costs. See attachment Tower Equipment and Rigging for details and invoices, $08,930.45. Costs include 191 ft monopole, site preparation, grounding, antenna and line installation. $208,930.45 See attached Tower Equipment and Rigging document for detailed expenses and invoices.
Other Electrical Service: Install electrical service with backup power, at new auxiliary site as required. WUKY is an LP-1 EAS station and required backup power systems. $367,050.56 $367,050.56 See attachment Other Expenses for cost detail and invoices for Auxiliary transmitter and STL build out. Expenses include site preparation, buildings installation, antennas, generator installation (required as WUKY is EAS P1 for this region), fencing. $367,050.56 N/A
Switchgear - industrial 800 amp $38,200.00 $0.00 Switchgear Costs were included in Other Expenses. Please see Attachment Other Expenses. $0.00 N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $0.00 Item included in attachment Other Expenses $0.00 This item is included in the costs of attachment Other Expenses.
Air Cooled Solid State FM Transmitter 600 - 1000 Watts Analog $9,775.00 $0.00 The air cooled solid state FM Transmitter 1000 W is included in Attachment Transmitter Costs. $0.00 N/A

Components

Actual Information Description File Name
Transmitter Installation

Component Description:
See attachment Transmitter Costs for details and invoice copy.
Amount:
$6,530.00
Labor

Component Description:
Outside legal, engineering and other services for auxiliary transmission and STL. See attachment Other Professional Services for details and invoices.
Amount:
$41,705.15
Transmitter Building Site Survey/Installation

Component Description:
Calculations for land costs. See attachments Other Costs-Land and WUKY Building and Land Appraisal Report.
Amount:
$18,595.04
Other -- Building Addition Size: 480.0

Component Description:
See attached Tower Equipment and Rigging document for details and invoice copies.
Amount:
$208,930.45
Other Electrical Service: Install electrical service with backup power, at new auxiliary site as required. WUKY is an LP-1 EAS station and required backup power systems.

Component Description:
See attachment Other Expenses for Auxiliary transmission site and STL build out.
Amount:
$367,050.56
Switchgear - industrial 800 amp

Component Description:
Switchgear costs included in attachment Other Expenses.
Amount:
N/A
Service entrance 3 phase/800 amp/208 volt

Component Description:
Item is included in attachment Other Expenses.
Amount:
N/A
Air Cooled Solid State FM Transmitter 600 - 1000 Watts Analog 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 $7,900.00 $0.00 N/A $0.00 N/A
Total for all systems $1,358,064.26 $899,989.30 N/A $893,446.80 N/A
Primary Antenna LPX-2C $7,900.00 $0.00 $0.00
High Power 11 kW - 25 kW Circularly-polarized $7,900.00 $0.00 N/A $0.00 N/A

Components

Actual Information Description File Name
High Power 11 kW - 25 kW Circularly-polarized

Component Description:
Antenna cost included in attachment titled Tower Equipment and Rigging.
Amount:
N/A

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 $0.00 $0.00 N/A $0.00 N/A
Total for all systems $1,358,064.26 $899,989.30 N/A $893,446.80 N/A
Primary Transmission Line $0.00 $0.00 $0.00
Antennas Unlimited, Inc. $0.00 $0.00 Antennas Unlimited donated the transmission line. See Attachment Transmission Line Donation. $0.00 N/A

Components

Actual Information Description File Name
Antennas Unlimited, Inc.

Component Description:
Transmission line was donated by Antennas Unlimited. Please see Attachment Transmission Line Donation.
Amount:
N/A

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 $533,630.45 $208,930.45 N/A $208,930.45 N/A
Total for all systems $1,358,064.26 $899,989.30 N/A $893,446.80 N/A
Primary Tower $533,630.45 $208,930.45 $208,930.45
Tower Equipment and Rigging $208,930.45 $208,930.45 See Attachment Tower Equipment and Rigging for detail of costs and invoices. $208,930.45 N/A
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas) $0.00 $0.00 N/A $0.00 N/A
New tower shorter than 500' $324,700.00 $0.00 Costs are in Attachment Tower Equipment and Rigging. $0.00 N/A
Primary Tower $0.00 $0.00 $0.00

Components

Actual Information Description File Name
Tower Equipment and Rigging

Component Description:
See Attachment Tower Equiupment and Rigging.
Amount:
$208,930.45
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas) Information not provided.
New tower shorter than 500' 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 $48,772.65 $46,307.65 N/A $41,705.15 N/A
Total for all systems $1,358,064.26 $899,989.30 N/A $893,446.80 N/A
Outside Professional Services $48,772.65 $46,307.65 $41,705.15
Additional Field Engineering Service, 1 Days $0.00 $0.00 N/A N/A N/A
Prepare Form 601 $755.00 $0.00 Cost included in attachment Other Professional Services. $0.00 N/A
Outside Other Professional Services $41,705.15 $41,705.15 See Attachment Other Professional Services for detail and invoices. $41,705.15 See Attachment Other Professional Services for detail and invoices.
Prepare/ Review 399 reimbursement form $1,710.00 $0.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A N/A N/A
Form 399 assistance or other Program Management costs $0.00 $0.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A N/A N/A
Project management of the transition $0.00 $0.00 N/A N/A N/A

Components

Actual Information Description File Name
Additional Field Engineering Service, 1 Days Information not provided.
Prepare Form 601 Information not provided.
Outside Other Professional Services

Component Description:
See attachment Other Professional Services for detail and invoices.
Amount:
$41,705.15
Prepare/ Review 399 reimbursement form Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Form 399 assistance or other Program Management costs Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Project management of the transition 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 $7,200.00 $1,940.00 N/A $0.00 N/A
Total for all systems $1,358,064.26 $899,989.30 N/A $893,446.80 N/A
Other Expenses $7,200.00 $1,940.00 $0.00
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $200.00 $200.00 N/A N/A N/A
Construction permit for Auxiliary transmitter site. $0.00 $0.00 N/A N/A N/A
Point to Point Microwave (STL/ICR): Frequency Coordination for Bi-Direction System $1,100.00 $1,100.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $305.00 N/A N/A N/A
AM Pattern Disturbance -- Impact study $5,260.00 $0.00 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 $1,358,064.26 $899,989.30 $893,446.80

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. 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.

Kathy V. Hight

Accountant Principal


10/14/2019

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.

Kathy V. Hight

Accountant Principal


10/14/2019

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.

Kathy V. Hight

Accountant Principal


10/14/2019

Attachments

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