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:
167158
Service:
DCA
Call Sign:
WTNG-CD
Channel:
33 (UHF)
File Number:
0000027075
FRN:
0028083111
Date Submitted:
10/11/2019

Applicant Information

Back to Top

Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

Mercy's Bridge Media LLC

Doing Business As: Mercy's Bridge Media LLC

James Croom

PO Box 526

Cordova, NC 28330

United States

+1 (910) 331-2297 croom7@hotmail.com Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

Back to Top

Preparer Contact Name and Information

Applicant Address Phone Email

The Preparer is same as the reimbursement contact.

 

 

 

Broadcaster Information and Transition Plan

Back to Top
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 Install reduced height channel 14 Interim antenna to operate on STA during install phase, install new transmitter and mask filter, modify tower and install new channel 33 antenna

Transmitters

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

Primary Transmitter

Back to Top

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 UTX5K
Year 2008
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 5 kW

Primary Transmitter

Back to Top

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 TMU9c
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 3.0 kW
Justification for New Transmitter Existing Pineapple transmitter manufacturer has gone out of business. Parts to change operating frequency are not available.

Primary Transmitter

Back to Top

Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring Yes
Size 2 inches
Length 50.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size 10 tons
Other Size N/A tons
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 240.0 square feet
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

Back to Top

Other Transmitter Cost Not Listed

Name Description

Consulting and Labor for Transition to new channel and building

planning, obtaining, consulting for equipment. installation and removal as well as 3 phase wiring labor

Antennas

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

Primary Antenna

Back to Top

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? No
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 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: 15.0 kW
Manufacturer
Model ALP8M1-HSO-14
Year 2007

Primary Antenna

Back to Top

New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? No
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 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: 15.0 kW
Manufacturer
Model ALP8M1-HSO-33 ALPLUS
Year 2019
Justification for New Antenna Existing antenna is fixed tuned on pre-auction channel (14)

Primary Antenna

Back to Top

Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna?
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? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? Yes
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

Back to Top

Other Antenna Cost Not Listed

Name Description

Transistion Adapters

RF hardware for adaption between coax and antenna

Transmission Line

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

Interim Transmission Line

Back to Top

New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Flexible Air
Diameter 3 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 400 feet per run
Justification for New Transmission Line Transmission line to support interim antenna

Interim Transmission Line

Back to Top

Other Transmission Line Expenses Not Listed

Name Description

Connectors

RF connectors for Flexline

Dehydrator

Dehydrator for Flexline

RF Parts

Transitions to adapt flexline to existing system and interim antenna

RF Patch Panel and Dummy Load

Patch Panel and Dummy Load They are together here because they were invoiced together

Tower Equipment And Rigging Costs

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

Primary Tower

Back to Top

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? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
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? Yes
ASR Number 1036026
Coordinates (NAD83) Latitude (NAD83) 34° 42' 02.0" N-
Longitude (NAD83) 079° 06' 31.0" W-
Overall Structure Height 499.01 feet
Support Structure Height 496.06 feet
Ground Elevation Above Mean Sea Level (AMSL) 158.13 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Dilicast Broadcast Services, LLC
Date Constructed 10/29/1993

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
91947 WLPS-FM FM

Primary Tower

Back to Top

Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: No study needed
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Primary Tower

Back to Top

Tower Rigging Costs

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

Primary Tower

Back to Top

Other Tower Expenses Not Listed

Name Description

FENCE

NEW FENCING REQUIRED PER NEW ENCLOSURE AND TOWER MODIFICATIONS

Outside Professional Services Costs

Back to Top
Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 55
Explanation consult, plan and obtain equipment necessary for repack. Installation and removal of equipment for broadcasting.
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 No
For Auxiliary Facility N/A
For Main Facility N/A
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 4
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 No
For Auxiliary Facility N/A
For Main Facility N/A
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 4
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification Yes
FAA Consultation (including preparation of FAA Form 7460) Yes
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 No
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 2
Justification RF system checkout and tuning

Outside Professional Services Costs

Back to Top

Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

Back to Top
Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change 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
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

Back to Top

Other Expenses Not Listed

Information not provided.

Cost Information

Back to Top

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 $291,966.45 $219,405.24 N/A $218,155.24 N/A
Total for all systems $698,679.22 $657,125.05 N/A $463,040.05 N/A
Primary Transmitter TMU9c $291,966.45 $219,405.24 $218,155.24
Consulting and Labor for Transition to new channel and building $20,500.00 $20,500.00 planning, obtaining, consulting for equipment. installation and removal as well as 3 phase wiring labor MOVED TO THIS SECTION PER ADMIN INSTRUCTIONS $20,500.00 N/A
Other -- Building Addition Size: 240.0 $39,666.45 $39,666.45 Existing building will not support additional transmitter. $39,666.45 CellSite Solutions, LLC is no longer a viable option for the building. Tower Direct is source where the building came from. Tower Direct receipt includes shipping, freight and foundation.
10 Ton system $60,500.00 $15,300.00 N/A $15,300.00 N/A
2" Rigid Conduit and Wiring (Cost per foot) $1,300.00 $1,250.00 N/A N/A N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $3,963.79 MATERIAL COST ONLY $3,963.79 N/A
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW $155,600.00 $138,725.00 N/A $138,725.00 N/A

Components

Actual Information Description File Name
Consulting and Labor for Transition to new channel and building

Component Description:
CORRECTION MADE: THIS COMPONENT WAS PREVIOUSLY IN THE WRONG SECTION: planning, obtaining, consulting for equipment. installation and removal as well as 3 phase wiring labor
Amount:
$20,500.00
Other -- Building Addition Size: 240.0

Component Description:
Includes shipping, freight, and foundation
Amount:
$39,666.45

Component Description:
Please Reject
Amount:
N/A
10 Ton system

Component Description:
CORRECTIONS MADE INFO ADDED. LABOR AND MATERIALS INCLUDED.
Amount:
$15,300.00
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Service entrance 3 phase/800 amp/208 volt

Component Description:
Material Cost for 3 phase entry
Amount:
$3,963.79
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW

Component Description:
Price of the Air Cooled Transmitter, Shipping, Installation
Amount:
$138,725.00

Cost Information

Back to Top

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 $39,030.00 $44,932.00 N/A $32,532.00 N/A
Total for all systems $698,679.22 $657,125.05 N/A $463,040.05 N/A
Primary Antenna ALP8M1-HSO-33 ALPLUS $39,030.00 $44,932.00 $32,532.00
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $32,532.00 Existing antenna is fixed tuned on pre-auction channel (14) $32,532.00 Component with cost of 32,532.00 is the correct antenna. Correct documentation is attached.
Transistion Adapters $6,000.00 $6,000.00 RF hardware required for interfacing to antenna and transmitter N/A N/A

Components

Actual Information Description File Name
Sweep test of existing antenna Information not provided.
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
Antenna Costs
Amount:
$32,300.94

Component Description:
Antenna Cost, shipping and freight
Amount:
$32,532.00
Transistion Adapters Information not provided.

Cost Information

Back to Top

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 $40,458.77 $32,318.81 N/A $28,218.81 N/A
Total for all systems $698,679.22 $657,125.05 N/A $463,040.05 N/A
Interim Transmission Line $40,458.77 $32,318.81 $28,218.81
RF Patch Panel and Dummy Load $10,026.77 $10,026.77 Estimate is for Patch Panel and Dummy Load because they were invoiced together, with shipping added. $10,026.77 N/A
RF Parts $2,500.00 $2,500.00 Adapters for interfacing with existing transmitter for interim use. N/A N/A
Dehydrator $2,732.00 $2,732.00 We have Dielectric Flexline not Foam line $2,732.00 N/A
Connectors $1,600.00 $1,600.00 coax connectors for line termination N/A N/A
Flexible Air Transmission Line - dielectric, 3" $23,600.00 $15,460.04 N/A $15,460.04 N/A

Components

Actual Information Description File Name
RF Patch Panel and Dummy Load

Component Description:
Patch Panel and Dummy Load Invoiced together plus shipping
Amount:
$10,026.77
RF Parts Information not provided.
Dehydrator

Component Description:
Price of Dehydrator and Shipping
Amount:
$2,732.00
Connectors Information not provided.
Flexible Air Transmission Line - dielectric, 3"

Component Description:
Price is for 3" line and freight.
Amount:
$15,460.04

Cost Information

Back to Top

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 $246,900.00 $279,700.00 N/A $176,700.00 N/A
Total for all systems $698,679.22 $657,125.05 N/A $463,040.05 N/A
Primary Tower TOWER $246,900.00 $279,700.00 $176,700.00
Minor tower reinforcement/modifications $158,000.00 $195,000.00 CORRECTIONS MADE: COVER LETTER ATTACHED INCLUDED IS RIGGING AND INSTALLATION OF NEW ANTENNA, REMOVAL OF OLD ANTENNA AND LINE AS WELL AS PAINT, PER FAA GUIDELINES $172,000.00 N/A
FENCE $4,700.00 $4,700.00 N/A $4,700.00 N/A
Short Tower (less than 500') $84,200.00 $80,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Minor tower reinforcement/modifications

Component Description:
CORRECTIONS MADE: COVER LETTER ATTACHED includes tower reinforcements, rigging, antenna installation and paint per FAA guidelines. MINUS COST OF NON-REIMBURSABLE ITEMS
Amount:
$172,000.00
FENCE

Component Description:
Price to replace existing fencing due to tower mods and enclosure addition.
Amount:
$4,700.00
Short Tower (less than 500') Information not provided.

Cost Information

Back to Top

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 $61,965.00 $69,750.00 N/A $0.00 N/A
Total for all systems $698,679.22 $657,125.05 N/A $463,040.05 N/A
Outside Professional Services $61,965.00 $69,750.00 $0.00
Project management of the transition $8,690.00 $20,500.00 INCLUDED IN THIS INVOICE IS LABOR FOR THREE PHASE WIRING. $0.00 N/A
Additional Field Engineering Service, 2 Days $8,000.00 $8,000.00 System alignment and proof of performance N/A N/A
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase $2,105.00 $2,000.00 N/A N/A N/A
ASR modification (prepare FCC Form 854) $2,105.00 $2,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $14,720.00 $14,000.00 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 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
Prepare request for Special Temporary Authorization $8,200.00 $6,000.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A N/A 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

Components

Actual Information Description File Name
Project management of the transition

Component Description:
THIS COMPONENT WAS PLACED IN THE WRONG SECTION AND IS BEING MOVED TO THE TRANSMITTER SECTION
Amount:
N/A
Additional Field Engineering Service, 2 Days Information not provided.
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase Information not provided.
ASR modification (prepare FCC Form 854) Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Prepare and or review reimbursement form Information not provided.
Perform engineering study for new channel assignment and antenna development Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.

Cost Information

Back to Top

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 $18,359.00 $11,019.00 N/A $7,434.00 N/A
Total for all systems $698,679.22 $657,125.05 N/A $463,040.05 N/A
Other Expenses $18,359.00 $11,019.00 $7,434.00
MVPD Notification of Channel Change $3,169.00 $3,169.00 Cost estimate to conduct MVPD Notification $3,169.00 N/A
Develop and air announcement of upcoming channel change $1,500.00 $1,500.00 cost estimate to develop and air announcement of upcoming channel change N/A N/A
Non-zoning permits $500.00 $500.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $4,265.00 N/A $4,265.00 N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change

Component Description:
MVPD notification fees CORRECTIONS MADE
Amount:
$3,169.00
Develop and air announcement of upcoming channel change Information not provided.
Non-zoning permits Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
DTV Medical Facility Notification

Component Description:
Notification for Medical Facilities CORRECTIONS MADE
Amount:
$4,265.00

Cost Information

Back to Top

Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $698,679.22 $657,125.05 $463,040.05

Reimbursement Status

Back to Top
Question Response
The facility has ceased operating on its pre-auction channel. Yes
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

Back to Top
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.

James D Croom

Member


10/11/2019

Certification

Back to Top
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.

James D Croom

Member


10/11/2019

Attachments

Back to Top