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:
14386
Service:
LPD
Call Sign:
KQRY-LD
Channel:
5 (Low VHF)
File Number:
0000084634
FRN:
0019028406
Eligibility Status:
Eligible
Date Submitted:
04/02/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

PINNACLE MEDIA, LLC

Doing Business As: PINNACLE MEDIA, LLC

Greg Fess

PO Box 23808

LITTLE ROCK, AR 72221

United States

+1 (501) 492-8202 gfess@comcast.net 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

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 See Transition Memo We share a transmitter building and are on the same tower as KWFT-LD

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 1 KW
Year 2015
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1 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 1 KW
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1 kW
Justification for New Transmitter We moved from UHF to VHF. See KXUN-LD Transition Memo.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Other Transmitter Costs
Does the transmitter installation require a Transmitter Building Site Survey/Installation? Yes
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Rigid Conduit and Wiring No
Other Electrical Service Yes
Description Conduit & wiring for the transmitter.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size Other
Other Size 1 tons
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Filter

We require a full service filter

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? 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
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model SWR
Year 2009

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? No
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Other
Other Antenna Type PSIVLY-2-7 5WS Custom
ERP: 3.0 kW
Manufacturer
Model XXXX
Year 2018
Justification for New Antenna We moved from a UHF to a VHF channel

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
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

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Other Antenna Cost Not Listed

Name Description

Brackets and Connectors

Items necessary to hang the antenna

Transmission Line

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

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Ownership Owned
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 225 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 340 feet per run
Justification for New Transmission Line Old line was too short and would cost more to move than it was worth.
Interior RF Systems Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators? Yes

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Hangars

Hangars for the line.

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)
Ownership Leased
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? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1037672
Coordinates (NAD83) Latitude (NAD83) 35° 47' 49.0" N-
Longitude (NAD83) 094° 10' 05.0" W-
Overall Structure Height 349.08 feet
Support Structure Height 339.89 feet
Ground Elevation Above Mean Sea Level (AMSL) 2080.36 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Arklahoma Broadcast & Communiaction Towers, LLC
Date Constructed 04/07/1992

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
58282 KWFT-LD LPD

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

Name Description

Tower Rigging and Disposal

Cost to hang the line and antenna

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 80
Explanation We do not have a professional engineer on staff and must rely on outside contracts for new construction projects.
Outside RF consulting Engineering Services Perform engineering study for displacement application 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
Prepare Form 601 No
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
Negotiation of Lease and other Matter for Shared Locations Yes
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 Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 10
Justification We do not have a professional engineer on staff qualified to perform these services

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
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)? 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
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 Yes
Type Unlicensed

Other Expenses

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Other Expenses Not Listed

Name Description

Local Permits

Possible local zoning permits

Sales Taxes

Possible state sales taxes not paid by vendors.

Travel

Travel expenses incurred while working on this project

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 $34,000.00 $34,000.00 N/A $22,966.50 N/A
Total for all systems $230,789.21 $166,311.71 N/A $60,750.83 N/A
Primary Transmitter 1 KW $34,000.00 $34,000.00 $22,966.50
Filter $0.00 $0.00 Estimate based on Quote from Anywave. The filter was included in the transmitter. N/A N/A
Low VHF - Air Cooled Solid State Transmitter 1000.0 Watts $23,000.00 $23,000.00 See KXUN-LD Transition Memo and KXUN-LD Transmitter and Antenna Memo. $22,966.50 N/A
Other Electrical Service: Conduit & wiring for the transmitter. $500.00 $500.00 Cost to install conduit and wiring for the Transmitter N/A N/A
Other -- HVAC Service Type: H Size:1 (Other) $500.00 $500.00 Cost of installing a small window unit if required. N/A N/A
Transmitter Building Site Survey/Installation $10,000.00 $10,000.00 See KXUN Transition Memo. Based on a quote from Anywave we previously obtained. N/A N/A

Components

Actual Information Description File Name
Filter Information not provided.
Low VHF - Air Cooled Solid State Transmitter 1000.0 Watts

Component Description:
Ch 5 Transmitter
Amount:
$22,966.50
Other Electrical Service: Conduit & wiring for the transmitter. Information not provided.
Other -- HVAC Service Type: H Size:1 (Other) Information not provided.
Transmitter Building Site Survey/Installation 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 $21,429.97 $16,074.97 N/A $11,074.97 N/A
Total for all systems $230,789.21 $166,311.71 N/A $60,750.83 N/A
Primary Antenna XXXX $21,429.97 $16,074.97 $11,074.97
Side Mount antenna brackets $4,625.00 $0.00 N/A N/A N/A
$0.00 $0.00 N/A N/A N/A
Sweep test of transmission line and antenna $5,730.00 $5,000.00 N/A N/A N/A
Low VHF-Low Power, Side Mount, Other, 3.0kW input, Horizontal $10,243.13 $10,243.13 See KXUN-LD Transition Memo. We requested that PSI design an antenna with radomes for ice protection that would achieve our ERP. The cost was 9,550 with an additional 703.13 for shipping. See attached KXUN-LD Transmitter and Antenna Memo $10,243.13 N/A
Pattern scatter analysis for side mount (if not included in antenna base cost) $0.00 $0.00 N/A N/A N/A
Brackets and Connectors $831.84 $831.84 Based on a quote from PSI. $831.84 N/A

Components

Actual Information Description File Name
Side Mount antenna brackets Information not provided.
Information not provided.
Sweep test of transmission line and antenna Information not provided.
Low VHF-Low Power, Side Mount, Other, 3.0kW input, Horizontal

Component Description:
Ch 5 Antenna
Amount:
$10,243.13
Pattern scatter analysis for side mount (if not included in antenna base cost) Information not provided.
Brackets and Connectors

Component Description:
Ch 5 Antenna Connectors
Amount:
$831.84

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 $10,160.00 $6,200.00 N/A $5,682.76 N/A
Total for all systems $230,789.21 $166,311.71 N/A $60,750.83 N/A
Primary Transmission Line $10,160.00 $6,200.00 $5,682.76
Interior RF Systems: Inside RF system including switching, patch panels and dehydrators $2,000.00 $2,000.00 STL to the tower - Wireless unlicensed link or dedicated fiber internet. This is a new site and does not have a bi-directional connection to the studio required to originate programming. $1,482.76 N/A
Flexible Foam Transmission Line - dielectric, 1 5/8" $8,160.00 $4,200.00 This is a lower cost than normal. We purchased used 1 5/8' line. 350' at $12/foot $4,200.00 N/A
Hangars $0.00 $0.00 Hangars for the line if required N/A N/A

Components

Actual Information Description File Name
Interior RF Systems: Inside RF system including switching, patch panels and dehydrators

Component Description:
RF CONNECTORS FOR THE TRANSMISSION SYSTEM
Amount:
$1,346.47

Component Description:
RF CONNECTORS
Amount:
$136.29
Flexible Foam Transmission Line - dielectric, 1 5/8"

Component Description:
350' OF 1 5/8" LINE
Amount:
$4,200.00
Hangars 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 $57,190.00 $31,000.00 N/A $0.00 N/A
Total for all systems $230,789.21 $166,311.71 N/A $60,750.83 N/A
Primary Tower TOWER $57,190.00 $31,000.00 $0.00
Tower Rigging and Disposal $1,000.00 $1,000.00 Estimated cost to dispose of old equipment (net of any salvage value) N/A N/A
Tower Rigging Short Tower (less than 500') $56,190.00 $30,000.00 Verbal quote from Contractor. Cost not to exceed $30,000. 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 $90,385.00 $59,717.50 N/A $19,210.00 N/A
Total for all systems $230,789.21 $166,311.71 N/A $60,750.83 N/A
Outside Professional Services $90,385.00 $59,717.50 $19,210.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A $1,577.50 This was paid prior to the reduction in the authorized amount for legal fees for filing the license. We are only requesting reimbursement for the lesser amount that was approved.
Comprehensive coverage verification via field study, if needed $52,600.00 $20,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $4,470.00 Because of T Mobile requiring us off early, we had to file 2 STA forms. See Transition Information. $4,470.00 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $3,000.00 N/A N/A N/A
Additional Field Engineering Service, 10 Days $9,300.00 $9,300.00 62 hours at $150/hr. We do not have a staff for this type of work and rely on outside vendors. $5,375.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A $1,052.50 N/A
Project management of the transition $8,440.00 $8,400.00 We rely on outside contractors for this activity. 56 hours @ $150/hour. N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A $1,710.00 N/A
Form 399 assistance or other Program Management costs $2,000.00 $2,000.00 40 hours at $50 per hour. We do not have staff set up for this so we rely on outside contractors. $2,000.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A $3,025.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,280.00 $1,280.00 N/A N/A N/A
Perform engineering study for displacement application $1,800.00 $1,800.00 N/A N/A N/A

Components

Actual Information Description File Name
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Legal fees for filing the license exceeded the amount authorized. We are only requesting the amount authorized.
Amount:
$1,577.50
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
Legal fees for the 2 STAs that were required. See Transition Information Memo.
Amount:
$4,470.00
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Additional Field Engineering Service, 10 Days

Component Description:
Field engineering services to test signal and reset the link to the site for VHF reception vs existing UHF link.
Amount:
$1,250.00

Component Description:
Site engineering services for the Building, Electrical and HVAC
Amount:
$4,125.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
The engineering fees for the preparation of the license exceeded the amount authorized. We are requesting the amount authorized.
Amount:
$1,052.50
Project management of the transition Information not provided.
Prepare/ Review 399 reimbursement form

Component Description:
Fees for preparing and reviewing the form 399.
Amount:
$1,710.00
Form 399 assistance or other Program Management costs

Component Description:
Fees for additional Form 399 assistance
Amount:
$2,000.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
The bill was $100 more than the approved budget. We are only asking for reimbursement for the approved amount.
Amount:
$3,025.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Perform engineering study for displacement application 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 $17,624.24 $19,319.24 N/A $1,816.60 N/A
Total for all systems $230,789.21 $166,311.71 N/A $60,750.83 N/A
Other Expenses $17,624.24 $19,319.24 $1,816.60
Sales Taxes $7,424.24 $7,424.24 Estimate for any sales taxes are not collected by the vendors N/A N/A
Local Permits $100.00 $100.00 Estimate of the local permit cost based on previous experience. N/A N/A
New Point to Point Microwave System: Unlicensed $2,250.00 $3,750.00 RF equipment for the STL $1,090.00 N/A
Point to Point Microwave (STL/ICR): Frequency Coordination for Bi-Direction System $1,100.00 $1,000.00 N/A N/A N/A
Equipment Storage $500.00 $500.00 If Required N/A N/A
Equipment Delivery and Handling Charges $1,500.00 $1,500.00 Shipping expenses not included in the base pricing of the equipment N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $1,000.00 $1,000.00 Estimate of disposal costs resulting from leaving the previous site. N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,100.00 Cost if required N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $610.00 STA Filing fees for 2 STA filings $360.00 Because we T Mobile required us to move early, we had to file for a STA renewal to stay on the air until we could finish our buildout on the permanent channel.
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A $170.00 N/A
Travel $2,000.00 $2,000.00 Estimated Travel expenses for the installation $196.60 N/A

Components

Actual Information Description File Name
Sales Taxes Information not provided.
Local Permits Information not provided.
New Point to Point Microwave System: Unlicensed

Component Description:
Receive antenna for the Ch 5 VHF signal.
Amount:
$1,090.00
Point to Point Microwave (STL/ICR): Frequency Coordination for Bi-Direction System Information not provided.
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
FCC Filing Fees - Special Temporary Authorization request

Component Description:
Because of the long duration of the repack, we had to file for a STA renewal to stay on the air.
Amount:
$360.00
FCC Filing Fees - Form 2100 license to cover application

Component Description:
FCC License fee
Amount:
$170.00
Travel

Component Description:
Travel expenses for the engineering work performed.
Amount:
$196.60

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $230,789.21 $166,311.71 $60,750.83

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.

LARRY MORTON

MANAGER


04/02/2020

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.

LARRY MORTON

MANAGER


04/02/2020

Attachments

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