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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:
168095
Service:
DCA
Call Sign:
WZBJ-CD
Channel:
19 (UHF)
File Number:
0000027230
FRN:
0018223693
Date Submitted:
08/04/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GRAY TELEVISION LICENSEE, LLC

Doing Business As: WDBJ

WDBJ

4370 PEACHTREE ROAD, NE

ATLANTA, GA 30319

United States

 +1 (404) 504-9828 allfcclms@gray.tv Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 

Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Samuel Hariton

Widelity

Samuel Hariton 22030

4031 University Dr

Suite 100

Fairfax, VA 22030

United States

 +1 (339) 222-8107 sam.hariton@widelity.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 We will reuse a channel 24 transmitter that will be re-tuned to channel 19 by the manufacturer and will be moved to the WLHG transmitter location. A new antenna, mask filter, and transmission line will need to be purchased.

Transmitters

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

Primary Transmitter

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Add 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 Nx8000
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 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 THU9-5
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 3.1 kW
Justification for New Transmitter This is a transmitter we currently own for WFFP and will be re-tuning to operate on channel 19. Only costs to be incurred are those for preparing this transmitter for use. This will allow us to stay operational during testing and cut over phase.

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 50.0 feet
Other Electrical Service Yes
Description Electrical CKT Breaker
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

5 kW Mask Filter

Channel 19 Mask Filter

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
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? 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 Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Circular
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: 15.0 kW
Manufacturer
Model PSILP12AOC-43-CP
Year 2010

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? No
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Circular
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: 15.0 kW
Manufacturer
Model TLP12A
Year 2019
Justification for New Antenna Current antenna is for channel 43 not channel 19.

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?
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? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 3 1/8 inches inches
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 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 150 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 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 150 feet per run
Justification for New Transmission Line New transmission line needed to remain operational on both channel 43 and channel 19 during testing and transition period.

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? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users Yes
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1268738
Coordinates (NAD83) Latitude (NAD83) 37° 21' 32.9" N-
Longitude (NAD83) 079° 09' 31.3" W-
Overall Structure Height 95.14 feet
Support Structure Height 95.14 feet
Ground Elevation Above Mean Sea Level (AMSL) 1329.71 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Liberty University, Inc.
Date Constructed 10/01/2009

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
37248 WQLU FM

Other Types of Users

Users
Two-Way Radio

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

Name Description

Tower Rigging

Mounting Antenna and Transmission lines and any needed structural improvements

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 595
Explanation Station has small staff and requires assistance in completing this task.
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 Yes
Environmental Assessment Yes
ASR Modification Yes
FAA Consultation (including preparation of FAA Form 7460) Yes
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

Attorney Fees - Other Matters

Legal Services

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 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? 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

Name Description

Other Entities

Moving Expenses, Meetings, Coordination, etc.

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 $56,581.77 $56,531.77 N/A $50,281.76 N/A
Total for all systems $656,708.27 $362,722.72 N/A $133,875.96 N/A
Primary Transmitter THU9-5 $56,581.77 $56,531.77 $50,281.76
Other Electrical Service: Electrical CKT Breaker $5,000.00 $5,000.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 3.1 kW $49,059.92 $49,059.92 Estimated Cost Justification WZBJ-CD-110-1st Primary Transmitter - UHF Liquid Cooled Solid State, 3.1 kW v0 $49,059.91 N/A
5 kW Mask Filter $1,221.85 $1,221.85 Please see attached DTVPros Quote JEHQ1648-02 $1,221.85 N/A
2" Rigid Conduit and Wiring (Cost per foot) $1,300.00 $1,250.00 N/A N/A N/A

Components

Actual Information Description File Name
Other Electrical Service: Electrical CKT Breaker Information not provided.
UHF - Liquid Cooled Solid State Transmitter 3.1 kW

Component Description:
RF System 5KW
Amount:
$36,024.32

Component Description:
Engineering Services
Amount:
$9,800.00

Component Description:
Coolant Line Package
Amount:
$3,235.59
5 kW Mask Filter

Component Description:
WZBJ-CD-110-1st Primary Transmitter - 5 kW Mask Filter
Amount:
$1,221.85
2" Rigid Conduit and Wiring (Cost per foot) 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 $40,630.00 $46,684.45 N/A $36,561.50 N/A
Total for all systems $656,708.27 $362,722.72 N/A $133,875.96 N/A
Primary Antenna TLP12A $40,630.00 $46,684.45 $36,561.50
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $35,284.45 please see attached DTVPros Quote JEHQ1558. Estimated cost also includes shipping charges listed in DTVPros Invoice 270 $30,161.50 N/A
Elbow complex, single channel, at antenna input, per 3 1/8. feedline (if needed) $7,600.00 $5,000.00 N/A N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $6,400.00 N/A

Components

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

Component Description:
UHF - LOW POWER SIDE MOUNT
Amount:
$30,161.50
Elbow complex, single channel, at antenna input, per 3 1/8. feedline (if needed) Information not provided.
Sweep test of existing antenna

Component Description:
UHF - Low Power Side Moun
Amount:
$6,400.00

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 $4,950.00 $4,650.00 N/A $0.00 N/A
Total for all systems $656,708.27 $362,722.72 N/A $133,875.96 N/A
Primary Transmission Line $4,950.00 $4,650.00 $0.00
Flexible Air Transmission Line - dielectric, 1 5/8" $4,950.00 $4,650.00 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 $268,500.00 $52,000.00 N/A $6,630.00 N/A
Total for all systems $656,708.27 $362,722.72 N/A $133,875.96 N/A
Primary Tower TOWER $268,500.00 $52,000.00 $6,630.00
Tower Rigging $0.00 $0.00 Rigging costs to be allocated to the tower category. N/A N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $12,000.00 N/A N/A N/A
Minor tower reinforcement/modifications $158,000.00 $10,000.00 N/A N/A N/A
Short Tower (less than 500') $84,200.00 $30,000.00 N/A $6,630.00 N/A

Components

Actual Information Description File Name
Tower Rigging Information not provided.
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study Information not provided.
Minor tower reinforcement/modifications Information not provided.
Short Tower (less than 500')

Component Description:
Billing for work completed at Liberty University
Amount:
$6,630.00

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 $251,356.50 $175,771.50 N/A $38,402.70 N/A
Total for all systems $656,708.27 $362,722.72 N/A $133,875.96 N/A
Outside Professional Services $251,356.50 $175,771.50 $38,402.70
Attorney Fees - Other Matters $346.50 $346.50 Per WZBJ-CD Justification New Budget Category Attorney Other Matters $346.50 N/A
RF Exposure Measurements $21,050.00 $3,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $30,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 N/A $740.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 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 $592.00 N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A N/A 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
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 $6,000.00 N/A $300.00 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
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase $2,105.00 $2,000.00 N/A N/A N/A
ASR modification (prepare FCC Form 854) $2,105.00 $2,000.00 N/A N/A N/A
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet $10,520.00 $5,000.00 N/A N/A N/A
NEPA Section 106 environmental review, if needed $6,310.00 $6,000.00 N/A N/A N/A
Project management of the transition $94,010.00 $99,675.00 Per Widelity Strategic Quote $36,424.20 N/A

Components

Actual Information Description File Name
Attorney Fees - Other Matters

Component Description:
Professional Services
Amount:
$346.50
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
Prepare Phase Change Request for WZBJ
Amount:
$740.00
Prepare and or review reimbursement form 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:
WZBJ-CD-550-Attorney - Construction Permit Application (Main)
Amount:
$592.00
Prepare request for Special Temporary Authorization 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.
Perform engineering study for new channel assignment and antenna development

Component Description:
Consulting Engineer
Amount:
$300.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase Information not provided.
ASR modification (prepare FCC Form 854) Information not provided.
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet Information not provided.
NEPA Section 106 environmental review, if needed Information not provided.
Project management of the transition

Component Description:
Project Management
Amount:
$2,176.40

Component Description:
Project Management
Amount:
$3,134.65

Component Description:
Project Management
Amount:
$2,627.50

Component Description:
Project Management
Amount:
$2,133.25

Component Description:
Project Management
Amount:
$2,828.40

Component Description:
Project Management
Amount:
$4,889.80

Component Description:
Project Management
Amount:
$3,412.00

Component Description:
Project Management
Amount:
$2,536.80

Component Description:
Project Management
Amount:
$2,352.25

Component Description:
Project Management
Amount:
$2,244.40

Component Description:
Project Management
Amount:
$2,544.95

Component Description:
Project Management
Amount:
$3,343.80

Component Description:
Project Management
Amount:
$2,200.00

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 $34,690.00 $27,085.00 N/A $2,000.00 N/A
Total for all systems $656,708.27 $362,722.72 N/A $133,875.96 N/A
Other Expenses $34,690.00 $27,085.00 $2,000.00
Non-zoning permits $2,500.00 $2,500.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 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
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $4,000.00 N/A N/A N/A
Other Entities $5,000.00 $5,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $5,000.00 $5,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $2,000.00 $2,000.00 N/A N/A N/A
MVPD Notification of Channel Change $2,000.00 $2,000.00 N/A $2,000.00 N/A

Components

Actual Information Description File Name
Non-zoning permits Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
DTV Medical Facility Notification Information not provided.
Other Entities 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.
Develop and air announcement of upcoming channel change Information not provided.
MVPD Notification of Channel Change

Component Description:
Professional services flat fee
Amount:
$2,000.00

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $656,708.27 $362,722.72 $133,875.96

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.

Robert Folliard , III .

Assistant Secretary


08/04/2020

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.

Robert Folliard , III .

Assistant Secretary


08/04/2020

Attachments

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