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:
17746
Service:
LPD
Call Sign:
KBPX-LD
Channel:
27 (UHF)
File Number:
0000087143
FRN:
0031218621
Eligibility Status:
Eligible
Date Submitted:
07/21/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WORD BROADCASTING NETWORK

Doing Business As: WORD BROADCASTING NETWORK

3701 FERN VALLEY ROAD

LOUISVILLE, KY 40219

United States

+1 (502) 964-2121 TOM@WBNA21.COM Not-for-Profit

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 KBPX-LD transitioned in May 2019 from channel 46 to channel 27 and entered into a channel sharing agreement with KQHO-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 TRN5X-4D-U-C
Year 2018
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 TRN-5X-U-38-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 3.3 kW
Justification for New Transmitter Needed to move transmitter site to achieve comparable coverage from preexisting licensed parameters - new transmitter site required transmitter with more power in order to achieve comparable coverage at new site/elevation

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) Yes
Switchgear (industrial 800 amp) No
Transformer (480V) No
Rigid Conduit and Wiring No
Other Electrical Service No
HVAC Service Does the replacement transmitter require HVAC Service? No
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 15.0 square feet

Primary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

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? Yes
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? Yes
Existing Antenna Manufacturer and Type
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Cross Dipole
ERP: 15.0 kW
Manufacturer
Model PHP-80U22211E
Year 2002

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

Facility ID Call Sign
12895 KETH-TV
24436 KLTJ
53847 KXLN-DT
60537 KFTH-DT

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? Yes
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Circular
Type Broadband Panel
Number of Stations Supported 2
Number of Panels/Bays 9
Lower Limit 548.00 MHz
Upper Limit 554.00 MHz
Design power capacity in use 16.7 %
ERP: 15.0 kW
Manufacturer
Model PSIUP3EC-27-CP
Year 2019
Justification for New Antenna Moved off of ATC tower with Shared antenna and had to purchase new antenna for new transmitter site to use for KBPX-LD and channel sharee KQHO-LD

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? No
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? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes
Power Dividers Does the panel antenna require power dividers? Yes
Number of Power Dividers 8
Cable Harness Does the panel antenna require cable harness? No

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

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 Leased
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
Type Rigid
Diameter 8 3/16 inches
Segment Length 19 3/4 inches
Number of parallel runs 1
Length 1730 feet per run

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

Facility ID Call Sign
60537 KFTH-DT
12895 KETH-TV
24436 KLTJ
53847 KXLN-DT

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 225 feet per run
Justification for New Transmission Line Moved off shared antenna at ATC site, could not bring TX line to new location, needed new TX line.
Interior RF Systems Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators? No

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Construct New
Tower Use Primary (Main)
Ownership Leased
Is this tower consider Complex? Candelabra
Is this tower currently shared with any other stations? Yes
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1064696
Coordinates (NAD83) Latitude (NAD83) 29° 34' 16.0" N-
Longitude (NAD83) 095° 30' 38.0" W-
Overall Structure Height 1973.07 feet
Support Structure Height 1842.17 feet
Ground Elevation Above Mean Sea Level (AMSL) 76.77 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner American Towers LLC
Date Constructed 11/19/2001

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
12895 KETH-TV DTV
60537 KFTH-DT DTV
24436 KLTJ DTV
53847 KXLN-DT DTV

Primary Tower

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Tower Construction Costs

Section Question Response
Construct New Tower Use Primary (Main)
Is this a request for upgraded equipment? No
Height 1066.00 feet
Justification for New Tower Channel Change required moving to new location on an existing building from prior ATC tower in order to replicate approximate existing coverage pattern after move from Channel 46 to Channel 27

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? No
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 No
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 No
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 Yes
Additional Field Engineering Service Yes
Number of Days 4
Justification Supervision of installation of new transmitter and antenna at new rooftop site, field survey measurements for coverage verification

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 No
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 No
New Point to Point Microwave System No

Other Expenses

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Other Expenses Not Listed

Name Description

IP BASED STL

Internet based STL from Studio to transmitter used to deliver broadcast feed

INTERNAL PROJECT MGMT

Internal licensee project management expenses (time based) outside ordinary staff responsibilities.

KQHO CHANNEL SHAREE EXPENSES

Relocation expenses for KQHO-LD, channel sharee of KBPX-LD

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 $131,700.00 $60,272.20 N/A $57,029.95 N/A
Total for all systems $3,343,860.00 $343,102.20 N/A $97,208.15 N/A
Primary Transmitter TRN-5X-U-38-C $131,700.00 $60,272.20 $57,029.95
Other -- Building Addition Size: 15.0 $1,000.00 $1,000.00 N/A N/A N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $6,000.00 N/A $5,087.75 N/A
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW $106,300.00 $41,272.20 N/A $41,272.20 N/A
Transmitter Building Site Survey/Installation $10,000.00 $12,000.00 Installation located on 87th floor of commercial building required special techiques and conditions to install using specialized crew that had to travel to install. $10,670.00 N/A

Components

Actual Information Description File Name
Other -- Building Addition Size: 15.0 Information not provided.
Service entrance 3 phase/800 amp/208 volt

Component Description:
Furnish and install Electric service circuit and meter for KBPX-LD transmitter
Amount:
$5,087.75
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW

Component Description:
Transmitter for KBPX-LD
Amount:
$41,272.20
Transmitter Building Site Survey/Installation

Component Description:
Invoice for Engineering costs to install KBPX-LD transmitter
Amount:
$10,670.00

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 $46,755.00 $46,755.00 N/A $0.00 N/A
Total for all systems $3,343,860.00 $343,102.20 N/A $97,208.15 N/A
Primary Antenna PSIUP3EC-27-CP $46,755.00 $46,755.00 $0.00
Side Mount antenna brackets $4,625.00 $4,625.00 N/A N/A N/A
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A
Power Dividers (each, for panel antenna system, if not included in antenna cost) $10,400.00 $10,400.00 N/A N/A N/A
UHF-Low Power, Side Mount, Broadband Panel, 9 bay, 15.0kW input, Circular $26,000.00 $26,000.00 N/A N/A N/A

Components

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 $5,400.00 $5,400.00 N/A $0.00 N/A
Total for all systems $3,343,860.00 $343,102.20 N/A $97,208.15 N/A
Primary Transmission Line $5,400.00 $5,400.00 $0.00
Flexible Foam Transmission Line - dielectric, 1 5/8" $5,400.00 $5,400.00 N/A 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 $2,961,330.00 $32,000.00 N/A $25,191.00 N/A
Total for all systems $3,343,860.00 $343,102.20 N/A $97,208.15 N/A
Primary Tower GTOWER $0.00 $0.00 $0.00
Primary Tower $2,961,330.00 $32,000.00 $25,191.00
New tower between 1000' and 1500' without elevator, presumptive soil conditions $2,803,580.00 $0.00 Not a new tower - mounting on roof of existing building. N/A N/A
Tower Rigging Tall Tower (greater than 500') $157,750.00 $32,000.00 N/A $25,191.00 N/A

Components

Actual Information Description File Name
New tower between 1000' and 1500' without elevator, presumptive soil conditions Information not provided.
Tower Rigging Tall Tower (greater than 500')

Component Description:
Invoice for tower rigging engineering services to install new KBPX-LD Antenna
Amount:
$25,191.00

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $89,230.00 $89,230.00 N/A $0.00 N/A
Total for all systems $3,343,860.00 $343,102.20 N/A $97,208.15 N/A
Outside Professional Services $89,230.00 $89,230.00 $0.00
Additional Field Engineering Service, 4 Days $10,000.00 $10,000.00 4 days @$2,500.00 per day N/A N/A
RF Exposure Measurements $12,100.00 $12,100.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A N/A 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
Perform engineering study for displacement application $1,800.00 $1,800.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $52,600.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $3,262.50 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A N/A N/A
Form 399 assistance or other Program Management costs $0.00 $0.00 N/A N/A N/A

Components

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 $109,445.00 $109,445.00 N/A $14,987.20 N/A
Total for all systems $3,343,860.00 $343,102.20 N/A $97,208.15 N/A
Other Expenses $109,445.00 $109,445.00 $14,987.20
KQHO CHANNEL SHAREE EXPENSES $40,000.00 $40,000.00 Expenses of channel sharee KQHO associated with repack/transition, including legal fees, project management, Form 2100 and Form 399 completion, consulting engineer work, etc. N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,110.00 N/A N/A N/A
INTERNAL PROJECT MGMT $20,000.00 $20,000.00 200 hours @$100 p/h for supervision and other services in excess of employee regular responsibilities. N/A N/A
Equipment Storage $5,000.00 $5,000.00 N/A 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) $8,000.00 $8,000.00 removal of TX line and old transmitter from ATC tower site. N/A N/A
IP BASED STL $25,000.00 $25,000.00 N/A $14,987.20 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A

Components

Actual Information Description File Name
KQHO CHANNEL SHAREE EXPENSES Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
INTERNAL PROJECT MGMT 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.
IP BASED STL

Component Description:
IP STL for KBPX-LD
Amount:
$14,987.20
FCC Filing Fees - Form 2100 license to cover application Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $3,343,860.00 $343,102.20 $97,208.15

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.

Tom Fawbush

General Manager


07/21/2020

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.

Tom Fawbush

GM


07/21/2020

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.

Tom Fawbush

GM


07/21/2020

Attachments

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