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:
70101
Service:
LPD
Call Sign:
K45IM-D
Channel:
29 (UHF)
File Number:
0000089205
FRN:
0021332531
Eligibility Status:
Eligible
Date Submitted:
04/08/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

DEVELOPERS & MANAGERS GROUP, LLC

Applicant

Doing Business As: DEVELOPERS & MANAGERS GROUP, LLC

Ernest Johnson, DD

3313 GOVERNMENT ST

SUITE G

BATON ROUGE, LA 70806

United States

+1 (225) 413-3219 ERNESTJOHNSON@LACAPFUND.COM Other

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

Tony Zummallen

Anywave Communications Technologies

Tony Zummallen

300 Knightsbridge Parkway

Suite 150

Lincolnshire, IL 60069

United States

+1 (816) 882-5600 tony.zummallen@anywavecom.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. No
Briefly describe transition plan Replace the transmitter, antenna and transmission line using reasonable and customary engineering and business practices.

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? No
Existing Transmitter Manufacturer and Type Manufacturer
Model Unknown
Year 2010
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 4 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-U-2000-FA
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 4 kW
Justification for New Transmitter Replace the transmitter per the channel relocation project using reasonable and customary engineering and business practices.

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) Yes
Power 150 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 65.0 feet
Other Electrical Service Yes
Description Breaker cut off required.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size 10 tons
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 200.0 square feet

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Misc. Parts

Parts and pieces required to connect new equipment

Shipping

Estimated shipping costs

Encoder

Encoder and encoder installation costs

Decommission

Estimated costs to decommission old transmitter

Taxes

Estimated sales tax

Site Prep

Estimated costs to prepare site

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? Yes
Is antenna in operating condition? No
Is antenna located on or in close proximity to an antenna farm? Yes
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model Unknown
Year 2010

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? 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 Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model Eclipse
Year 2019
Justification for New Antenna Replace antenna per the channel relocation project using reasonable and customary engineering and business practices.

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? No
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

Taxes

Estimated sales tax

Shipping

Estimated freight costs

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? No
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 50 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 50 feet per run
Justification for New Transmission Line Replace the transmission line per the channel relocation project using reasonable and customary engineering and business practices.
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

Name Description

Sales Tax

Sales taxes

Shipping

Shipping fees

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)
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1034014
Coordinates (NAD83) Latitude (NAD83) 32° 39' 36.0" N-
Longitude (NAD83) 092° 05' 15.0" W-
Overall Structure Height 1074.79 feet
Support Structure Height 1074.79 feet
Ground Elevation Above Mean Sea Level (AMSL) 74.15 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner NEW SOUTH COMMUNICATIONS INC
Date Constructed 01/01/1987


Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study need for guyed or free-standing tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 350
Explanation Required to assist in the turnkey management of the channel relocation project in order that the existing internal personnel can maintain and operate the stations daily operational requirements and plans.
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 Yes
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 5
Justification Estimated field engineering services during transition activities. Actual costs to be determined.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Engineering - General services

General engineering for repacked station design

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 Yes
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 No
New Point to Point Microwave System No

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 $405,980.00 $425,980.00 N/A $114,800.00 N/A
Total for all systems $780,010.00 $815,110.00 N/A $156,609.40 N/A
Primary Transmitter TRN-U-2000-FA $405,980.00 $425,980.00 $114,800.00
Decommission $7,000.00 $7,000.00 Estimated costs to deinstall, disconnect and decommission old transmitter. $6,000.00 N/A
Transmitter Building Site Survey/Installation $10,000.00 $30,000.00 Estimated costs for site survey and transmitter installation. Revised upon Site Survey. $20,000.00 N/A
Shipping $2,000.00 $2,000.00 Estimated costs to ship transmitter. Actual costs to be determined. $2,000.00 N/A
Taxes $20,000.00 $20,000.00 Estimated sales tax. Actual costs to be determined. N/A N/A
Encoder $39,800.00 $39,800.00 Per attached quote. N/A N/A
Misc. Parts $9,000.00 $9,000.00 Estimated costs of miscellaneous parts and pieces required to connect new equipment. Actual costs to be determined. N/A N/A
Other -- Building Addition Size: 200.0 $10,000.00 $10,000.00 Estimated costs to modify building. Actual costs to be determined. N/A N/A
10 Ton system $60,500.00 $60,500.00 N/A N/A N/A
Other Electrical Service: Breaker cut off required. $10,000.00 $10,000.00 Estimated costs to modify breaker. Actual costs to be determined. N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $3,380.00 $3,380.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $25,550.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 4 - 6 kW $200,750.00 $200,750.00 N/A $79,800.00 N/A
Site Prep $8,000.00 $8,000.00 Estimated costs to prepare site. Includes receiving and inventory of transmitter and associated components; pre-assembly of cabinets and subassemblies; and ensuring site has all materials ready for installation crew. $7,000.00 N/A

Components

Actual Information Description File Name
Decommission

Component Description:
Old transmitter decommissioning - Anywave - INV FA2103-0796
Amount:
$6,000.00
Transmitter Building Site Survey/Installation

Component Description:
Transmitter install - Anywave - FA2103-0796
Amount:
$20,000.00
Shipping

Component Description:
Transmitter shipping - Anywave - FA2103-0799
Amount:
$2,000.00
Taxes Information not provided.
Encoder Information not provided.
Misc. Parts Information not provided.
Other -- Building Addition Size: 200.0 Information not provided.
10 Ton system Information not provided.
Other Electrical Service: Breaker cut off required. Information not provided.
3" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Transformer 3 phase/480v - 150 KVA Information not provided.
UHF - Air Cooled Solid State Transmitter 4 - 6 kW

Component Description:
Transmitter - Anywave - INV FA2103-0799
Amount:
$79,800.00
Site Prep

Component Description:
Site prep - Anywave - Inv FA2103-0796
Amount:
$7,000.00

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 $49,455.00 $49,455.00 N/A $37,100.00 N/A
Total for all systems $780,010.00 $815,110.00 N/A $156,609.40 N/A
Primary Antenna Eclipse $49,455.00 $49,455.00 $37,100.00
Shipping $2,000.00 $2,000.00 Estimated freight costs to ship antenna. Actual costs to be determined. $2,000.00 Per actual costs on invoice
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal $35,100.00 $35,100.00 Per actual quote from Anywave $35,100.00 N/A
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
Taxes $2,000.00 $2,000.00 Estimated sales tax. Actual costs to be determined. N/A N/A

Components

Actual Information Description File Name
Shipping

Component Description:
shipping antenna - Anywave - INV FA2103-0797
Amount:
$2,000.00
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal

Component Description:
Antenna - Anywave - INV FA2103-0797
Amount:
$35,100.00
Side Mount antenna brackets Information not provided.
Sweep test of transmission line and antenna Information not provided.
Taxes 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 $3,200.00 $6,000.00 N/A $0.00 N/A
Total for all systems $780,010.00 $815,110.00 N/A $156,609.40 N/A
Primary Transmission Line $3,200.00 $6,000.00 $0.00
Shipping $1,500.00 $1,500.00 Estimated shipping costs for transmission line. Actual costs to be determined. N/A N/A
Flexible Foam Transmission Line - dielectric, 1 5/8" $1,200.00 $4,000.00 Estimated costs for new line. Actual costs to be determined. N/A N/A
Sales Tax $500.00 $500.00 Estimated sales tax for transmission line. Actual costs to be determined. 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 $176,450.00 $170,985.00 N/A $0.00 N/A
Total for all systems $780,010.00 $815,110.00 N/A $156,609.40 N/A
Primary Tower TOWER $176,450.00 $170,985.00 $0.00
Study needed for guyed or free-standing tower $8,700.00 $3,235.00 Anywave Quote PR2103-1263 Rev. N/A N/A
Tower Rigging Tall Tower (greater than 500') $157,750.00 $157,750.00 N/A N/A N/A
Minor tower reinforcement/modifications $10,000.00 $10,000.00 Estimated costs to modify tower if required by engineering study 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 $131,715.00 $149,480.00 N/A $4,709.40 N/A
Total for all systems $780,010.00 $815,110.00 N/A $156,609.40 N/A
Outside Professional Services $131,715.00 $149,480.00 $4,709.40
Engineering - General services $5,000.00 $5,000.00 Estimated costs for general engineering related to station design for repack. Actual costs to be determined. N/A N/A
Additional Field Engineering Service, 5 Days $12,500.00 $12,500.00 Estimated field engineering services during transition activities. Actual costs to be determined. 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 - Prepare and File request for Special Temporary Authorization $2,235.00 $2,235.00 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
Prepare Form 601 $755.00 $755.00 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
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
Form 399 assistance or other Program Management costs $5,890.00 $5,890.00 Per attached Anywave quote. $2,209.40 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $2,500.00 Per attached Anywave quote. $2,500.00 N/A
Project management of the transition $36,925.00 $53,900.00 Estimated 350 hours at $154/hour N/A N/A

Components

Actual Information Description File Name
Engineering - General services Information not provided.
Additional Field Engineering Service, 5 Days Information not provided.
Comprehensive coverage verification via field study, 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.
Prepare Form 601 Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application 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.
Prepare request for Special Temporary Authorization Information not provided.
Perform engineering study for displacement application Information not provided.
Form 399 assistance or other Program Management costs

Component Description:
March, April 2020 PM Hours - Anywave - INV FA2005-0497
Amount:
$893.20

Component Description:
Jan 2020 PM Hours - Anywave - INV FA2002-0537
Amount:
$107.80

Component Description:
May 2020 PM Hours - Anywave - INV FA2008-0508
Amount:
$354.20

Component Description:
June 2020 PM Hours - Anywave - INV FA2008-0509
Amount:
$354.20

Component Description:
Prepare and process 399 - Anywave INV 7457-01 - PR1910-0488
Amount:
$500.00
Prepare/ Review 399 reimbursement form

Component Description:
399 form submittal to meet 11/14/19; Anywave INV 7457-01 - PR1910-0488
Amount:
$2,500.00
Project management of the transition 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 $13,210.00 $13,210.00 N/A $0.00 N/A
Total for all systems $780,010.00 $815,110.00 N/A $156,609.40 N/A
Other Expenses $13,210.00 $13,210.00 $0.00
Equipment Storage $2,500.00 $2,500.00 Expecting multiple staggered equipment deliveries from different vendors and need to store and stage new equipment prior to installation date. Anticipate from 6-24 months of storage time. N/A N/A
Equipment Delivery and Handling Charges $2,000.00 $2,000.00 Transport, forklift rental and handling fees from staging area to transmitter site. N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $2,000.00 $2,000.00 4-6 yard disposal bin on site to capture all waste from on site system integration and tower vendors. 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
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A
FCC Filing Fees - Form 2100 Major change CP application $4,960.00 $4,960.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $305.00 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 $780,010.00 $815,110.00 $156,609.40

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
Construction of final facilities or all necessary modifications are complete. No
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator. No

Certification

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Section Question Response
Submission of Estimated Expenses Statements

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

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

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

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

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

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

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

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

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

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

Ernest Johnson

Licensee


04/08/2021

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.

Ernest Johnson

Licensee


04/08/2021

Attachments

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