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FCC Form 399: Reimbursement Request

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

(REFERENCE COPY - Not for submission) FCC Form 399: Reimbursement Request

Facility ID:
48237
Service:
DCA
Call Sign:
WQSJ-CD
Channel:
23 (UHF)
File Number:
0000028028
FRN:
0005443965
Date Submitted:
05/01/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WANDA ROLON

LICENSEE

Doing Business As: WANDA ROLON

WANDA ROLON

PO Box 24

TOA ALTA, PR 00954

United States

 +1 (787) 948-2486 pastorawandarolon@yahoo.com Individual

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

Keenan P Adamchak , Esq .

Fletcher, Heald & Hildreth, PLC

1300 N. 17TH STREET, SUITE 1100

ARLINGTON, VA 22209

United States

 +1 (703) 812-0400 adamchak@fhhlaw.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 Station CP will be built and be ready for operation by the time its testing period is due. Once operational, existing channel will be turned OFF and new channel permanently ON at the transition date (transition phase 3).

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model Ranger CZ500
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 0.5 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 THU9
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 0.5 kW
Justification for New Transmitter Effective January 1, 2017, GatesAir will no longer offer channel change services, or support in field channel changes on the following transmitters: Platinum, Platinum CD, Sigma, Sigma CD, Diamond CD and Ranger.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring Yes
Size 2 inches
Length 30.0 feet
Other Electrical Service Yes
Description Additional electrical panel
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size Other
Other Size 2 tons
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

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)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 2.1 kW
Manufacturer
Model PSILP4BG-48
Year 2009

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 1.27 kW
Manufacturer
Model PSILP4BG-23
Year 2017
Justification for New Antenna REQUIRED FOR ASSIGNED NEW CHANNEL, EXISTING ANTENNA CAN NOT BE RETUNE.

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
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Broadband or Single Channel? N/A
Feed Line Size N/A
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
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

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)
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
Type Flexible Foam
Diameter 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 140 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Foam
Diameter 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 140 feet per run
Justification for New Transmission Line EXISTING LINE HAS TO BE USED DURING TRANSITION TO KEEP STATION ON THE AIR.

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 Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 18° 18' 38.8" N-
Longitude (NAD83) 067° 11' 07.7" W-
Overall Structure Height 118.00 feet
Support Structure Height 5.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 1148.28 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner WANDA ROLON
Date Constructed 06/15/2009


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 needed for undocumented/poorly documented 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 100
Explanation It is estimated that 100 hrs of a professional engineer will be required to perform site survey, construction administration, contractor oversight, on-site inspections and invoice certifications.
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 No
Quantity N/A
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 No
Quantity N/A
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 No
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements Yes
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Prepare Quarterly Progress Report

Prepare Quarterly Progress Report

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 No
BLM or NFS Coordination 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? No
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Information not provided.

Cost Information

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Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate 		Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $76,040.24 $76,010.24 N/A $64,885.00 N/A
Total for all systems $555,605.24 $282,425.24 N/A $89,648.90 N/A
Primary Transmitter THU9 $76,040.24 $76,010.24 $64,885.00
UHF - Air Cooled Solid State Transmitter 0.5 kW $71,260.24 $71,260.24 Effective January 1, 2017, GatesAir will no longer offer channel change services, or support in field channel changes on the following transmitters: Platinum, Platinum CD, Sigma, Sigma CD, Diamond CD and Ranger. $64,885.00 N/A
2" Rigid Conduit and Wiring (Cost per foot) $780.00 $750.00 N/A N/A N/A
Other Electrical Service: Additional electrical panel $1,500.00 $1,500.00 N/A N/A N/A
Other -- HVAC Service Type: C Size:2 (Other) $2,500.00 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 0.5 kW

Component Description:
Third Comark invoice for new transmitter
Amount:
$3,244.25

Component Description:
First Comark invoice for new transmitter
Amount:
$32,442.50

Component Description:
Second Comark invoice for new transmitter
Amount:
$29,198.25
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Other Electrical Service: Additional electrical panel Information not provided.
Other -- HVAC Service Type: C Size:2 (Other) 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 $33,030.00 $31,400.00 N/A $13,860.00 N/A
Total for all systems $555,605.24 $282,425.24 N/A $89,648.90 N/A
Primary Antenna PSILP4BG-23 $33,030.00 $31,400.00 $13,860.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $25,000.00 N/A $13,860.00 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
Antenna Equipment
Amount:
$13,860.00
Sweep test of existing antenna 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 $3,360.00 $3,220.00 N/A $2,315.90 N/A
Total for all systems $555,605.24 $282,425.24 N/A $89,648.90 N/A
Primary Transmission Line $3,360.00 $3,220.00 $2,315.90
Flexible Foam Transmission Line - dielectric, 1 5/8" $3,360.00 $3,220.00 N/A $2,315.90 N/A

Components

Actual Information Description File Name
Flexible Foam Transmission Line - dielectric, 1 5/8"

Component Description:
Transmission line equipment
Amount:
$2,315.90

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 $268,500.00 $80,000.00 N/A $0.00 N/A
Total for all systems $555,605.24 $282,425.24 N/A $89,648.90 N/A
Primary Tower TOWER $268,500.00 $80,000.00 $0.00
Short Tower (less than 500') $84,200.00 $25,000.00 N/A N/A N/A
Minor tower reinforcement/modifications $158,000.00 $50,000.00 N/A N/A N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $5,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate 		Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $156,030.00 $78,750.00 N/A $8,425.50 N/A
Total for all systems $555,605.24 $282,425.24 N/A $89,648.90 N/A
Outside Professional Services $156,030.00 $78,750.00 $8,425.50
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $0.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 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
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $1,918.25 N/A
Project management of the transition $15,800.00 $15,000.00 N/A $3,793.75 N/A
Prepare Quarterly Progress Report $10,000.00 $10,000.00 N/A $1,137.50 N/A
RF Exposure Measurements $21,050.00 $10,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $20,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A $562.50 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $1,013.50 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for new channel assignment and antenna development Information not provided.
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Prepare and or review reimbursement form

Component Description:
Drafting and filing of construction permit
Amount:
$1,918.25
Project management of the transition

Component Description:
Legal fees for project management of transition
Amount:
$3,793.75
Prepare Quarterly Progress Report

Component Description:
Preparation and filing of Quarterly Progress Reports
Amount:
$1,137.50
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Drafting and filing license to cover application
Amount:
$562.50
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Drafting and filing Construction Permit Application
Amount:
$1,013.50
Prepare engineering section of FCC Form 2100 (main), License to Cover 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 $18,645.00 $13,045.00 N/A $162.50 N/A
Total for all systems $555,605.24 $282,425.24 N/A $89,648.90 N/A
Other Expenses $18,645.00 $13,045.00 $162.50
MVPD Notification of Channel Change $1,500.00 $1,500.00 Estimate based on quatity of MVPD's in market $162.50 N/A
Develop and air announcement of upcoming channel change $1,500.00 $1,500.00 Estimate based on known costs N/A N/A
Equipment Delivery and Handling Charges $650.00 $650.00 Estimate based on known costs N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $2,000.00 $2,000.00 Applicant will be required to dispose of pre-repack antenna and transmitter. Estimate based on known costs. N/A N/A
DTV Medical Facility Notification $11,550.00 $6,000.00 Estimate based on known quotes $0.00 N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change

Component Description:
MVPD Notification of Channel Change
Amount:
$162.50
Develop and air announcement of upcoming channel change 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.
DTV Medical Facility Notification

Component Description:
Invoice for medical notifications
Amount:
$2,600.00
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
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 $555,605.24 $282,425.24 $89,648.90

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.

Wanda Rolon

Licensee


05/01/2020

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.

Wanda Rolon

Licensee


05/01/2020

Attachments

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