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:
25078
Service:
DCA
Call Sign:
WMYO-CD
Channel:
18 (UHF)
File Number:
0000025197
FRN:
0003769833
Date Submitted:
04/06/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

New Albany Broadcasting Co. Inc.

DAVID B. SMITH

PO Box 2623

CLARKSVILLE, IN 47131

United States

+1 (502) 584-2400 DAVID@WKYITV.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

Greg Best

Consulting Engineer

Greg Best Consulting Inc.

Greg Best

16100 Outlook Avenue

Stilwell, KS 66085

United States

+1 (816) 792-2913 gbconsulting54@gmail.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 The site location must change because the new antenna will not fit on the existing tower. New equipment will be purchased & installed at the new site. See attached plan.

Transmitters

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

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 Backup Xmtr
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 SC500UB
Year 2005
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.2 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? No
Manufacturer
Model UAXTE-2
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.2 kW
Justification for New Transmitter This transmitter replaces the existing backup Screen Service transmitter that is no longer supported.

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) Yes
Transformer (480V) Yes
Power 150 kVA
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? 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

Information not provided.

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 NV Series
Year 1999
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.2 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 UAXTE-2
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.2 kW
Justification for New Transmitter The existing transmitter is no longer supported.

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) Yes
Transformer (480V) Yes
Power 150 kVA
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? 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

RF SYSTEM

RF system to switch between main & backup and RF combining system for WMYO-CD & WJYL-CD.

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? No

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 Owned
Owner N/A
Site N/A
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 Andrew
Type Flexible Air
Diameter 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 350 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Transmission line, antenna sweep

Sweep of existing transmission line and antenna for potential use.

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 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? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1028414
Coordinates (NAD83) Latitude (NAD83) 38° 21' 55.2" N-
Longitude (NAD83) 085° 50' 24.2" W-
Overall Structure Height 464.89 feet
Support Structure Height 459.97 feet
Ground Elevation Above Mean Sea Level (AMSL) 962.91 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner SBA GC Towers, LLC
Date Constructed 01/25/1996

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
69113 WUOL-FM FM
38621 WFPK FM
4258 WFPL FM

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

Remove existing antenna and Line

This task removes the existing equipment of antenna, T line, and xmtr at the existing site.

Tower Structure Analysis

Structure Analysis

STL equipment removal and install.

Task to remove existing STL equipment per lease terms and install minimum items at new location.

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 200
Explanation Provide project management & coordination between vendors to ensure project timeline and deliverables are met.
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 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 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 No
RF exposure measurements No
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 No
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? No
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 $438,320.00 $376,920.00 N/A $228,357.28 N/A
Total for all systems $652,220.00 $517,710.00 N/A $295,165.87 N/A
Primary Transmitter UAXTE-2 $247,270.00 $259,920.00 $176,388.14
RF SYSTEM $56,220.00 $56,220.00 See Attached proposal for transmitter. This cost is one half of the combiner cost for WMYO-CD & WJYL-CD. The other half of the cost will be shown on the WJYL-CD 399. $56,220.00 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $133,000.00 WMYO transmitter cost estimate per quote Q-83091. $96,108.14 N/A
Switchgear - industrial 800 amp $38,200.00 $37,150.00 N/A $10,147.00 N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $25,550.00 N/A $6,214.00 N/A
2" Rigid Conduit and Wiring (Cost per foot) $1,300.00 $8,000.00 The revised location has longer runs to the breaker panel and requires more labor than originally planned. $7,699.00 Due to the distance of wiring for the transmitters and the requirement for an independent meter, the labor and parts were more than expected.
Auxiliary Transmitter UAXTE-2 $191,050.00 $117,000.00 $51,969.14
Switchgear - industrial 800 amp $38,200.00 $37,150.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $25,550.00 N/A N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $1,300.00 $1,300.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $53,000.00 N/A $51,969.14 The sales tax was accumulated in this final payment versus distributed among the other 2 payments and so was the freight cost.

Components

Actual Information Description File Name
RF SYSTEM

Component Description:
RF Combiner 2nd payment.
Amount:
$18,740.00

Component Description:
RF combiner first payment.
Amount:
$18,740.00

Component Description:
Final Invoice amount related to RF combiner.
Amount:
$18,740.00

Component Description:
WMYO RF combiner second invoice. Amount is 1/3 of combiner amount of $56220.
Amount:
$18,740.00

Component Description:
WMYO RF combiner first invoice. Amount is 1/3 of combiner amount of $56220.
Amount:
$18,740.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
WMYO Main transmitter second invoice for amount exclusive of RF combiner.
Amount:
$25,763.05

Component Description:
Sales tax associated with transmitter purchase.
Amount:
$9,429.44

Component Description:
Final invoice amount for main WMYO transmitter.
Amount:
$25,763.05

Component Description:
Freight costs for shipment of transmitter.
Amount:
$1,110.54

Component Description:
Final invoice for change order to add required parts at installation.
Amount:
$8,279.01

Component Description:
This invoice is no longer applicable. Please reject it.
Amount:
N/A

Component Description:
WMYO Main transmitter amount for first invoice exclusive of RF combiner system.
Amount:
$25,763.05
Switchgear - industrial 800 amp

Component Description:
Electrical panel and switchgear parts and labor for transmitter.
Amount:
$10,147.00
Transformer 3 phase/480v - 150 KVA

Component Description:
Stepdown transformer for transmitter.
Amount:
$6,214.00
2" Rigid Conduit and Wiring (Cost per foot)

Component Description:
Wirinig, conduit, and installation labor for transmitters.
Amount:
$7,699.00
Switchgear - industrial 800 amp Information not provided.
Transformer 3 phase/480v - 150 KVA Information not provided.
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
WMYO backup transmitter first invoice for 1/3 of total amount.
Amount:
$15,998.23

Component Description:
Freight costs for alt xmtr shipment.
Amount:
$1,110.54

Component Description:
Final invoice for alternate xmtr.
Amount:
$15,998.24

Component Description:
Sales tax associated with alt xmtr.
Amount:
$2,863.90

Component Description:
WMYO backup transmitter second invoice for 1/3 invoice total amount.
Amount:
$15,998.23

Component Description:
This invoice does not pertain to the backup transmitter.
Amount:
N/A

Cost Information

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Antennas

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 $5,000.00 $5,000.00 N/A $0.00 N/A
Total for all systems $652,220.00 $517,710.00 N/A $295,165.87 N/A
Primary Transmission Line $5,000.00 $5,000.00 $0.00
Transmission line, antenna sweep $5,000.00 $5,000.00 Sweep of existing transmission line and antenna for future use. $0.00 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 $121,800.00 $37,600.00 N/A $26,927.19 N/A
Total for all systems $652,220.00 $517,710.00 N/A $295,165.87 N/A
Primary Tower GTOWER $121,800.00 $37,600.00 $26,927.19
Remove existing antenna and Line $20,000.00 $20,000.00 Estimate will be followed by quote for removal of all equipment at the present site. $14,010.00 N/A
Tower Structure Analysis $2,600.00 $2,600.00 Please see attached purchase orders and Vertical Structures invoice 20182473 & 20191268. $2,600.00 N/A
Short Tower (less than 500') $84,200.00 $0.00 Applicant is moving to an existing tower and combining into existing antenna so no tower expenses are expected. N/A N/A
STL equipment removal and install. $15,000.00 $15,000.00 N/A $10,317.19 N/A

Components

Actual Information Description File Name
Remove existing antenna and Line

Component Description:
Service to remove pre-repack channel antenna and line per lease agreement.
Amount:
$14,010.00
Tower Structure Analysis

Component Description:
Structural analysis for new Wave Tower.
Amount:
$1,200.00

Component Description:
Old Wave Tower Structure Analysis for WKYI-CD change to channel 18 repack
Amount:
$1,400.00
Short Tower (less than 500') Information not provided.
STL equipment removal and install.

Component Description:
Removal of STL equipment and install of minimum to maintain control of transmitter,
Amount:
$10,317.19

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 $66,520.00 $84,970.00 N/A $33,481.40 N/A
Total for all systems $652,220.00 $517,710.00 N/A $295,165.87 N/A
Outside Professional Services $66,520.00 $84,970.00 $33,481.40
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,680.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,210.00 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 $1,272.00 N/A
Prepare request for Special Temporary Authorization $2,050.00 $2,050.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,580.00 N/A $1,575.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $612.50 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $12,000.00 Relocation for transmission system has required additional FCC filings and redesign of the transmission system parameters and equipment. $11,550.00 Change in system design due to WAVE site location has required redesign of transmission system including RF combiner.
Project management of the transition $31,600.00 $46,200.00 Project management costs are higher because of the shift to the new location. $18,471.90 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
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:
Advise client on post-auction filing requirements and filings.
Amount:
$1,272.00
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Prepare and file LTC for WMYO and associated progress reports.
Amount:
$1,575.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Greg Best engineering services repack WKYI-CD
Amount:
$612.50
Perform engineering study for new channel assignment and antenna development

Component Description:
Review system design, transmitter and antenna quotes for WKYI-CD. Services performed by Greg Best. Service through 8-1-18.
Amount:
$1,050.00

Component Description:
Engineering Repack Services
Amount:
$525.00

Component Description:
Antenna study to prepare for CP.
Amount:
$700.00

Component Description:
Engineering analysis for WMYO for TPO, obtaining quotes, conveying technical info to Widelity, investigation of changes to transmission system for WAVE tower location.
Amount:
$4,637.50

Component Description:
Engineering services for WMYO-CD to revise location and transmission system.
Amount:
$1,925.00

Component Description:
Execute study for WKYI-CD omnioid collocated with WJYL-CD due to possible current tower limitations. Minor mod application.
Amount:
$875.00

Component Description:
GBC engineering services for electrical system design and CP mod for new site.
Amount:
$2,712.50
Project management of the transition

Component Description:
Project management services provided by David Smith.
Amount:
$18,360.00

Component Description:
Internal management and project manager for repack for WKYI-CD
Amount:
$4,505.00

Component Description:
Project Management
Amount:
$1,907.60

Component Description:
Project Management
Amount:
$3,444.15

Component Description:
Project Management activities for WMYO-CD.
Amount:
$1,237.50

Component Description:
WKYI-CD internal invoice for services performed by GM/REPACK MANAGER. Revised with hourly rate and hour descriptions.
Amount:
$4,505.00

Component Description:
Project Management
Amount:
$2,360.30

Component Description:
Project Management
Amount:
$2,217.35

Component Description:
Project management activities for obtaining quotes and invoices for services provided to WMYO-CD.
Amount:
$2,800.00
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 $20,580.00 $13,220.00 N/A $6,400.00 N/A
Total for all systems $652,220.00 $517,710.00 N/A $295,165.87 N/A
Other Expenses $20,580.00 $13,220.00 $6,400.00
FCC Filing Fees - Special Temporary Authorization request $195.00 $195.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $4,200.00 N/A $4,126.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
Non-zoning permits $500.00 $500.00 Electrical Work permit. N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $500.00 $500.00 N/A N/A N/A
Equipment Delivery and Handling Charges $2,000.00 $2,000.00 N/A N/A N/A
Equipment Storage $2,500.00 $2,500.00 N/A N/A N/A
MVPD Notification of Channel Change $3,000.00 $3,000.00 N/A $2,274.00 N/A

Components

Actual Information Description File Name
FCC Filing Fees - Special Temporary Authorization request Information not provided.
DTV Medical Facility Notification

Component Description:
Notifications to medical facilities for post-repack channel operation.
Amount:
$4,126.00
FCC Filing Fees - Form 2100 license to cover application Information not provided.
Non-zoning permits Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Equipment Storage Information not provided.
MVPD Notification of Channel Change

Component Description:
Notification of channel change to MVPD providers.
Amount:
$2,274.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $652,220.00 $517,710.00 $295,165.87

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. Yes
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator. No

Certification

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Section Question Response
Submission of Estimated Expenses Statements

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.

  1. The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  3. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  4. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).

  5. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  6. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.

  7. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  8. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

David Brian Smith , Sr .

General Manager


04/06/2020

Certification

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Section Question Response
Submission of Final Allocation or Accounting Information Statements

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.

  1. The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  2. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  3. The above-named entity certifies that all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates.

  4. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  5. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  6. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

David Brian Smith , Sr .

General Manager


04/06/2020

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