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:
35994
Service:
DTV
Call Sign:
KXTX-TV
Channel:
36 (UHF)
File Number:
0000028240
FRN:
0019509470
Date Submitted:
10/24/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

NBC TELEMUNDO LICENSE LLC

Margaret L. Tobey

300 NEW JERSEY AVE, N.W.

SUITE 700

WASHINGTON, DC 20001

United States

+1 (202) 524-6401 MARGARET.TOBEY@NBCUNI.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

Margaret L Tobey

NBCUniversal, LLC

300 New Jersey Ave. NW

Suite 700

Washington, DC 20001

United States

+1 (202) 524-6401 Margaret.Tobey@nbcuni.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. Yes
Briefly describe transition plan Switch to backup transmitter and auxiliary antenna to allow main transmitter and combiner filter to be retuned and mask filter replaced for operation on new channel. Remain on auxiliary until operation can start on the new channel.

Question Response
Sharee Station Facility ID 49330
Call Sign KXAS-TV
Type Commercial
Licensee Name STATION VENTURE OPERATIONS, LP
Status LICENSED
DTS No
Community of License FORT WORTH, TX
Pre-auction RF Channel 41
Post-auction RF Channel 24
Neilsen DMA Dallas-Ft. Worth
Network Affiliation

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 Retune Existing
Use Primary (Main)
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 Rohde & Schwarz
Model THU9-72
Year 2017
Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 78 kW

Primary 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 90 kW
Other Power N/A
New Exciter Is a new exciter needed? No

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

Name Description

Combiner Retune

Rechannel Mask Filter/Combiner System (KXTX-TV Portion)

Auxiliary Transmitter

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Add Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Auxiliary (Backup)
Description of Use Used to maintain coverage when work is done on main antenna or auxillary
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-2H
Year 2002
Type Inductive Output Tube
IOT Power Type Two
Power Capacity 43 kW

Auxiliary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Auxiliary (Backup)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model THU9-24
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 37 kW
Justification for New Transmitter New transmitter required because the existing transmitter is End of Life (see attachment). Additionally, we have chosen a Solid State to replace this IOT as it is less expensive then a new IOT transmitter (details attached)

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 Yes
Description Lighting Reconfiguration
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

Name Description

Transmitter Installation

includes electrical, xmtr install with required RF modifications, commissioning and proof, and removal of existing Comark xmtr

Pressure Relief Valves

Pressure Relief Valves

Antennas

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

Auxiliary Antenna

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Add Antenna Information

Section Question Response
Existing Antenna Description Type of change Retune Existing
Antenna Use Auxiliary (Backup)
Description of Use used to maintain coverage when main transmitter or antenna is unavailable
Ownership Owned
Owner N/A
Site N/A
Is this antenna currently shared with any other stations? Yes
Is this antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? Yes
Existing Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 2
Number of Panels 18
Design power capacity in use 50.0 %
Lower Limit 470.00 MHz
Upper Limit 698.00 MHz
Other Antenna Type N/A
ERP: 353.0 kW
Manufacturer Dielectric
Model TUA-C3-6/18U-1-R DC SM
Year 2009

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID Call Sign
49330 KXAS-TV

Auxiliary Antenna

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Adjustment to Existing Antenna

Section Question Response
Sweep Test of Existing Antenna Do you need a sweep test of existing antenna? Yes

Auxiliary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? Yes
Type New
Number of channels supported 2
Frequencies of channels supported Upper and lower frequency
Frequency 470.0 MHz - 698.0 MHz

Auxiliary 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

Auxiliary Transmission Line

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Add Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Auxiliary (Backup)
Description of Use Used to maintain coverage when primary antenna or transmitter is unavailable
Ownership Owned
Owner N/A
Site N/A
Is this transmission currently shared with any other stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Waveguide
Diameter N/A
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 1500 feet per run

Auxiliary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Auxiliary (Backup)
Description of Use Used to maintain coverage when main antenna or transmitter is unavailable
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 Broadband
Other Segment Length N/A
Number of parallel runs 1
Length 1530 feet per run
Justification for New Transmission Line Existing waveguide will not work on new channels for KXAS (ch 24) & KXTX (ch 36). The final cost will be split between both stations

Auxiliary 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 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? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1054150
Coordinates (NAD83) Latitude (NAD83) 32° 35' 07.0" N-
Longitude (NAD83) 096° 58' 07.0" W-
Overall Structure Height 1504.90 feet
Support Structure Height 1400.90 feet
Ground Elevation Above Mean Sea Level (AMSL) 813.97 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner Telemundo of Texas LLC
Date Constructed 02/06/2017

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
49330 KXAS-TV DTV

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 320
Explanation Project oversight of transmitter install, electrical connectivity, tower work, and antenna installation. Additional time will be spent tracking financial and legal process and coordinating with other broadcasters.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development No
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 No
For Auxiliary Facility N/A
For Main Facility N/A
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 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
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 Yes
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 Yes
Number of Days 20
Justification Ground Level RF System Design

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 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? 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 $1,856,759.29 $882,085.87 N/A $667,238.66 N/A
Total for all systems $2,779,414.29 $1,340,111.87 N/A $832,996.43 N/A
Primary Transmitter THU9-72 $221,010.80 $134,464.80 $0.00
UHF and VHF - minor banding issues $105,200.00 $23,554.00 N/A N/A N/A
90 kW mask filter $99,900.00 $95,000.00 N/A N/A N/A
Combiner Retune $15,910.80 $15,910.80 N/A N/A N/A
Auxiliary Transmitter THU9-24 $1,635,748.49 $747,621.07 $667,238.66
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,473,000.00 $584,872.58 N/A $584,872.58 N/A
Other Electrical Service: Lighting Reconfiguration $1,163.69 $1,163.69 Costs split 50/50 between KXAS and KXTX $1,163.68 N/A
Pressure Relief Valves $820.00 $820.00 N/A $820.00 N/A
Transmitter Installation $160,764.80 $160,764.80 See attached quote $80,382.40 N/A

Components

Actual Information Description File Name
UHF and VHF - minor banding issues Information not provided.
90 kW mask filter Information not provided.
Combiner Retune Information not provided.
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW

Component Description:
Transmitter, reject loads & interconnect
Amount:
$584,872.58
Other Electrical Service: Lighting Reconfiguration

Component Description:
Costs split 50/50 between KXAS and KXTX
Amount:
$1,163.68
Pressure Relief Valves

Component Description:
Pressure relief valves
Amount:
$820.00
Transmitter Installation

Component Description:
Aux transmitter install
Amount:
$80,382.40

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 $109,890.00 $86,750.00 N/A $875.00 N/A
Total for all systems $2,779,414.29 $1,340,111.87 N/A $832,996.43 N/A
Auxiliary Antenna TUA-C3-6/18U-1-R DC SM $109,890.00 $86,750.00 $875.00
Sweep test of existing antenna $6,730.00 $1,750.00 See Marsand quote $875.00 N/A
New combiner, cost per channel (without antenna) $84,200.00 $80,000.00 N/A N/A N/A
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed) $13,700.00 $0.00 No longer required N/A N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,260.00 $5,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
See "antenna & transmission line sweep) on invoice
Amount:
$875.00
New combiner, cost per channel (without antenna) Information not provided.
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed) Information not provided.
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) Information not provided.

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 $354,960.00 $108,661.00 N/A $97,794.90 N/A
Total for all systems $2,779,414.29 $1,340,111.87 N/A $832,996.43 N/A
Auxiliary Transmission Line $354,960.00 $108,661.00 $97,794.90
Rigid Transmission Line - copper, 6 1/8" broadband $354,960.00 $108,661.00 50% of $217,322 total cost $97,794.90 N/A

Components

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

Component Description:
Half of lines 2-19
Amount:
$48,897.45

Component Description:
Half of lines 2-19
Amount:
$48,897.45

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 $210,500.00 $85,100.00 N/A $42,550.00 N/A
Total for all systems $2,779,414.29 $1,340,111.87 N/A $832,996.43 N/A
Primary Tower GTOWER $210,500.00 $85,100.00 $42,550.00
Tall Tower (greater than 500') $210,500.00 $85,100.00 See attached quote, first 2 lines plus "misc items" $42,550.00 N/A

Components

Actual Information Description File Name
Tall Tower (greater than 500')

Component Description:
See all lines on invoice except sweep.
Amount:
$42,550.00

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 $169,225.00 $106,750.00 N/A $24,537.87 N/A
Total for all systems $2,779,414.29 $1,340,111.87 N/A $832,996.43 N/A
Outside Professional Services $169,225.00 $106,750.00 $24,537.87
Project management of the transition $50,560.00 $48,000.00 N/A $23,325.75 N/A
Additional Field Engineering Service, 20 Days $20,000.00 $20,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $25,000.00 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
Attorney Fees - Aux Antenna, prepare and File Form 2100 Construction Permit or License Application $4,210.00 $4,000.00 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 $453.60 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $758.52 N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management work for the month of July
Amount:
$2,664.30

Component Description:
Project management
Amount:
$1,650.00

Component Description:
Project Management Services
Amount:
$2,550.00

Component Description:
Project Management Services
Amount:
$348.95

Component Description:
Project Management Services
Amount:
$1,365.00

Component Description:
Project Management Services
Amount:
$2,145.00

Component Description:
April Project Management
Amount:
$3,150.00

Component Description:
Point B Project Management January 2019
Amount:
$290.00

Component Description:
Project Management Services
Amount:
$975.00

Component Description:
Project Management Services
Amount:
$1,072.50

Component Description:
Point B project management services for the month of February 2019. See line item.
Amount:
$1,305.00

Component Description:
Project Management Invoice
Amount:
$1,160.00

Component Description:
Project management
Amount:
$4,650.00
Additional Field Engineering Service, 20 Days Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Aux Antenna, prepare and File Form 2100 Construction Permit or License Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Preparation of minor change application
Amount:
$226.80

Component Description:
See lines 1 & 2 of invoice, less 10% vendor discount.
Amount:
$226.80
Prepare and or review reimbursement form

Component Description:
See lines 3-5 of invoice, less 10% vendor discount.
Amount:
$424.26

Component Description:
Amendments of Form 399
Amount:
$159.66

Component Description:
See line 2 of invoice, less 10% vendor discount
Amount:
$130.95

Component Description:
Review of Form 399
Amount:
$43.65

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 $78,080.00 $70,765.00 N/A $0.00 N/A
Total for all systems $2,779,414.29 $1,340,111.87 N/A $832,996.43 N/A
Other Expenses $78,080.00 $70,765.00 $0.00
MVPD Notification of Channel Change $12,000.00 $12,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $4,250.00 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 - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 N/A N/A N/A
Equipment Storage $24,000.00 $24,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $25,000.00 $25,000.00 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 $2,779,414.29 $1,340,111.87 $832,996.43

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.

Margaret L Tobey

Assistant Secretary


10/24/2019

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.

Margaret L Tobey

Assistant Secretary


10/24/2019

Attachments

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