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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:
10981
Service:
DTV
Call Sign:
WCPX-TV
Channel:
34 (UHF)
File Number:
0000028324
FRN:
0001808468
Date Submitted:
12/17/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

ION MEDIA CHICAGO LICENSE, INC.

Doing Business As: ION MEDIA CHICAGO LICENSE, INC.

Bianca Frye

601 Clearwater Road

West Palm Beach, FL 33401

United States

 +1 (561) 682-4110 BiancaFrye@ionmedia.com Corporation

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

The Preparer is same as the reimbursement contact.

 

 

 

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 The east multiplex main antenna will continue to be utilized by WCPX with a reconfiguration of the combiner required due to the channel change. Replace non re-tuneable transmitter and RF system for post repack channel.

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 DCX
Year 1999
Type Inductive Output Tube
IOT Power Type Two
Power Capacity 40 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 THU9-12 EVO 19kW ATSC
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 19 kW
Justification for New Transmitter See attached Transmitter Exhibits. See attached Transmitter Upgrade Disclaimer.

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 Yes
Description Electrical installation of replacement transmitter
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

Removal of existing equipment

Removal of existing transmitters and equipment / site prep

RF Interconnect

Interconnect between the transmitter and combiner

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 Retune Existing
Antenna Use Primary (Main)
Description of Use N/A
Ownership Leased
Owner 233 Broadcast LLC
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 24
Design power capacity in use 50.0 %
Lower Limit 614.00 MHz
Upper Limit 650.00 MHz
Other Antenna Type N/A
ERP: 200.0 kW
Manufacturer RFS
Model PHP24C
Year 1999

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

Facility ID Call Sign
32334 WJYS

Primary 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

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? Yes
Type Additional Module
Number of channels supported 2
Frequencies of channels supported RF channel
Frequency N/A

Enter a list of RF channel numbers.

RF Channel Number
34
21

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Combiner Module Freight

Australia to US

Combiner Module Staging and Delivery

ISI to Willis Tower

Combiner Tuning and Commissioning

RFS - Todd Loney

Combiner Reconfiguration Labor

Combiner Reconfiguration Labor

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)
Description of Use N/A
Ownership Leased
Owner 233 Broadcasting LLC
Site N/A
Is the existing transmission line shared with another station or stations? Yes
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer RFS
Type Flexible Air
Diameter 4 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 4
Length 500 feet per run

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

Facility ID Call Sign
32334 WJYS

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Transmission Line Installation

Combiner room work per engineering statement.

Tower Equipment And Rigging Costs

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

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? Located on Building
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? Unknown
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1032960
Coordinates (NAD83) Latitude (NAD83) 41° 52' 44.0" N-
Longitude (NAD83) 087° 38' 08.0" W-
Overall Structure Height 1722.09 feet
Support Structure Height 1435.35 feet
Ground Elevation Above Mean Sea Level (AMSL) 595.14 feet
Structure Type BMAST - Building with Mast
Tower Owner 233 Broadcast, LLC
Date Constructed 09/30/2012

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
72115 WGN-TV DTV
51165 WGCI-FM FM
70119 WSNS-TV DTV
9617 WBBM-TV DTV
53971 WEBG FM
74178 WKSC-FM FM
10802 WTTW DTV
66978 WEDE-CD DTV
10801 WFMT FM
73228 WLS-FM FM
48772 WPWR-TV DTV
71425 WWME-CD DTV
32334 WJYS DTV
28621 WJMK FM
70042 WLIT-FM FM
12498 WGBO-DT DTV
60539 WXFT-DT DTV
22211 WFLD DTV
168662 WMEU-CD DTV
9613 WBBM-FM FM
6377 WTMX FM
43176 WMAO-TV DTV
71428 WCIU-TV DTV
73226 WLS-TV DTV

Primary Tower

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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: No reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower Located on Building
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 180
Explanation Required by tower landlord.
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 Yes
Quantity 1
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 Yes
Quantity 1
NEPA Section 106 environmental review Yes
Environmental Assessment Yes
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 Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements Yes
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning Yes
Non-zoning permits Yes
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)? 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

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 $825,435.75 $587,372.32 N/A $583,509.81 N/A
Total for all systems $1,645,905.27 $943,082.28 N/A $639,168.20 N/A
Primary Transmitter THU9-12 EVO 19kW ATSC $825,435.75 $587,372.32 $583,509.81
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW $684,000.00 $445,936.57 Please see attached Rohde & Schwarz Quote #SQ162279.2. Estimated cost includes tax not included on quote. Rohde Schwarz Quote #248838.0.WCPX $445,699.06 N/A
RF Interconnect $20,735.75 $20,735.75 Please see Rohde Schwarz Quotes #162279.5.WCPX(ION).RFS plus applicable tax $20,735.75 N/A
Removal of existing equipment $25,000.00 $25,000.00 Please see attached Great Lakes Plumbing Heating Quote 98th floor decommissioning project $21,375.00 N/A
Other Electrical Service: Electrical installation of replacement transmitter $95,700.00 $95,700.00 Please see attached quotes from Chicago Electric Company #JC-19-077 & Great Lakes Heating and Plumbing #100th Exchange Project $95,700.00 N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW

Component Description:
3rd milestone payment (35%) for primary transmitter. Supporting documentation is attached.
Amount:
$155,705.42

Component Description:
35% "upon proof of performance" payment for primary transmitter. Supporting documentation is attached.
Amount:
$155,705.42

Component Description:
$1,000 "deposit" on primary transmitter. Supporting documentation is attached. This invoice has been paid.
Amount:
$1,062.50

Component Description:
2nd milestone payment (30%) for primary transmitter. Supporting documentation is attached. This invoice has been paid.
Amount:
$132,461.78

Component Description:
Cost of additional parts for transmitter plumbing system. Supporting documentation is attached. This invoice has been paid.
Amount:
$763.94
RF Interconnect

Component Description:
Engineering cost for RF Filter. Supporting documentation is attached. This invoice has been paid.
Amount:
$20,735.75
Removal of existing equipment

Component Description:
1st progress payment for removal of pre-repack transmitter and related equipment. Supporting documentation is attached. This invoice has been paid.
Amount:
$21,375.00
Other Electrical Service: Electrical installation of replacement transmitter

Component Description:
Cost for installation of electrical equipment related to new transmitter. Supporting documentation is attached. This invoice has been paid.
Amount:
$62,000.00

Component Description:
Cost for installation of heat exchangers and related equipment for new transmitter. Supporting documentation is attached.
Amount:
$33,700.00

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 $108,572.86 $89,944.97 N/A $50,852.90 N/A
Total for all systems $1,645,905.27 $943,082.28 N/A $639,168.20 N/A
Primary Antenna PHP24C $108,572.86 $89,944.97 $50,852.90
Combiner Reconfiguration Labor $7,142.86 $7,142.86 See attached Willis Tower Facility Repack Engineering Statement Exhibit. N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
Combiner Module Freight $3,000.00 $3,000.00 See attached Willis Tower Facility Repack Engineering Statement Exhibit. N/A N/A
Combiner Module Staging and Delivery $3,333.33 $3,333.33 See attached Willis Tower Facility Repack Engineering Statement Exhibit. N/A N/A
Adding a module to existing combiner (without antenna) $84,200.00 $65,902.11 Please see attached quotes from BRE 312 #001-WCPX-TV_IJ and #EQO001837Q_6-6 WCPX $50,852.90 N/A
Combiner Tuning and Commissioning $4,166.67 $4,166.67 See attached Willis Tower Facility Repack Engineering Statement Exhibit. N/A N/A

Components

Actual Information Description File Name
Combiner Reconfiguration Labor Information not provided.
Sweep test of existing antenna Information not provided.
Combiner Module Freight Information not provided.
Combiner Module Staging and Delivery Information not provided.
Adding a module to existing combiner (without antenna)

Component Description:
Cost for adding a module to existing combiner. Supporting documentation is attached.
Amount:
$50,852.90

Component Description:
Additional cost of adding module to existing combiner. Supporting documentation is attached. This invoice has been paid.
Amount:
$13,414.75
Combiner Tuning and Commissioning 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 $20,833.33 $20,833.33 N/A $0.00 N/A
Total for all systems $1,645,905.27 $943,082.28 N/A $639,168.20 N/A
Primary Transmission Line $20,833.33 $20,833.33 $0.00
Transmission Line Installation $20,833.33 $20,833.33 See attached Willis Tower Facility Repack Engineering Statement Exhibit. N/A N/A

Components

Information not provided.

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 $421,000.00 $0.00 N/A $0.00 N/A
Total for all systems $1,645,905.27 $943,082.28 N/A $639,168.20 N/A
Primary Tower BMAST $421,000.00 $0.00 $0.00
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $421,000.00 $0.00 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 $189,650.00 $168,583.33 N/A $4,805.49 N/A
Total for all systems $1,645,905.27 $943,082.28 N/A $639,168.20 N/A
Outside Professional Services $189,650.00 $168,583.33 $4,805.49
RF Exposure Measurements $21,050.00 $20,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A N/A N/A
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
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet $10,520.00 $10,000.00 N/A N/A N/A
NEPA Section 106 environmental review, if needed $6,310.00 $6,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 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 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 - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $4,742.99 Duplicate line item. ION is only requesting reimbursement for Invoice Dated 5/1/2018.
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 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
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $62.50 N/A
Project management of the transition $28,440.00 $15,833.33 See attached Willis Tower Facility Repack Engineering Statement Exhibit. N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed 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.
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet Information not provided.
NEPA Section 106 environmental review, if needed 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.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Invoice for WCPX's portion of general repack legal expenses incurred for 42 of the ION repack stations for period 2/1/2017 - 12/15/2017. Payee has corresponded with FCC staff. Cover letter, hourly supporting documentation and invoice attached.
Amount:
$4,742.99

Component Description:
Invoice for station's portion of general repack legal expenses incurred for 42 of the ION repack stations for period 2/1/2017 - 12/15/2017. Payee has corresponded with FCC staff and has provided corrected supporting documentation.
Amount:
$4,837.97

Component Description:
Invoice for WCPX's portion of general repack legal expenses incurred for 42 of the ION repack stations for period 2/1/2017 - 12/15/2017. Payee has corresponded with FCC staff. Hourly supporting documentation and invoice attached.
Amount:
$4,742.99
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
Cost of engineering consultant work for new channel assignment and antenna development. Hourly supporting documentation attached. This invoice has been paid.
Amount:
$62.50
Project management of the transition Information not provided.
Prepare and or review reimbursement form Information not provided.
Address transition timing and coordination issues w/ other stations and wireless 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 $80,413.33 $76,348.33 N/A $0.00 N/A
Total for all systems $1,645,905.27 $943,082.28 N/A $639,168.20 N/A
Other Expenses $80,413.33 $76,348.33 $0.00
MVPD Notification of Channel Change $3,000.00 $3,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $0.00 $0.00 The amount is yet to be determined (TBD) and ION will submit on-air announcement costs when finalized. N/A N/A
Equipment Storage $333.33 $333.33 See attached Willis Tower Facility Repack Engineering Statement Exhibit. N/A N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $15,000.00 $15,000.00 N/A N/A N/A
Non-zoning permits $15,000.00 $15,000.00 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
DTV Medical Facility Notification $11,550.00 $7,500.00 N/A N/A N/A
Local Zoning $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 $1,645,905.27 $943,082.28 $639,168.20

Reimbursement Status

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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

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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.

Mario Vasquez

Vice President - Finance, Operations


12/17/2019

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.

Mario Vasquez

Vice President - Finance, Operations


12/17/2019

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