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:
167565
Service:
LPD
Call Sign:
WHDS-LD
Channel:
20 (UHF)
File Number:
0000084227
FRN:
0016652232
Eligibility Status:
Eligible
Date Submitted:
08/06/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

COMMUNITY TELEVISION, INC.

Applicant

Doing Business As: COMMUNITY TELEVISION, INC.

1862 ENTERPRISE DR.

NORCROSS, GA 30093

United States

+1 (770) 300-9828 greg@watc.tv 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

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. No
Briefly describe transition plan Displaced in September, 2018, returned to the air in August, 2019 with rental equipment at a different facility under STA due to extreme low power.

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 DT830
Year 2004
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.0 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 TMU9-3
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.2 kW
Justification for New Transmitter Old Axerca transmitter could not be retuned from channel 41 to channel 20. Parts were no longer available. Factory support was really no longer available either.

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) 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? No

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Transmitter decommission

Decommission old transmitter equipment.

Interim Transmitter lease

Lease of interim transmitter until new one can be installed.

Transmitter installation and proof

Transmitter installation and proof of performance.

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? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Cross Dipole
ERP: 1.8 kW
Manufacturer
Model 4DR-8-2HW
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? No
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 DLP-12W
Year 2019
Justification for New Antenna Old antenna was unable to be tuned to the new frequency.

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? 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)
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 330 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 350 feet per run
Justification for New Transmission Line Old line would have been damaged in being moved from one site across town to the replacement site.
Interior RF Systems Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators? Yes

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)
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
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 1030963
Coordinates (NAD83) Latitude (NAD83) 32° 02' 42.9" N-
Longitude (NAD83) 081° 07' 20.5" W-
Overall Structure Height 499.01 feet
Support Structure Height 479.98 feet
Ground Elevation Above Mean Sea Level (AMSL) 16.08 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner Pinnacle Towers LLC
Date Constructed 01/12/2018


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: No 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

Decommission Antenna and Line

Decommission old antenna and line.

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 150
Explanation Site is 5 hours from our primary location requiring multiple days to do the simplest tasks.
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 2
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 Yes
Quantity 2
Negotiation of Lease and other Matter for Shared Locations No
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 3
Justification Field measurements to determine correct coverage area and confirm antenna is in the correct orientation to prevent interference.

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 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 $121,000.00 $112,162.50 N/A $105,476.21 N/A
Total for all systems $327,349.35 $230,001.35 N/A $148,762.90 N/A
Primary Transmitter TMU9-3 $121,000.00 $112,162.50 $105,476.21
Transmitter installation and proof $15,400.00 $15,400.00 N/A $15,400.00 N/A
Interim Transmitter lease $8,600.00 $8,600.00 Transmitter located for $2,500 per month plus installation and de-installation. See attached invoice. Other incidental costs included pertaining to transmitter leases. $8,562.50 N/A
Transmitter decommission $3,000.00 $3,000.00 Estimated cost to decommission old transmitter and site, including removing old antenna and line. Updated 6/15/20 $2,475.00 N/A
Transmitter Building Site Survey/Installation $10,000.00 $1,162.50 Updated 6/15/2020. Most Site Survey items have been completed. $1,162.50 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $84,000.00 N/A $77,876.21 N/A

Components

Actual Information Description File Name
Transmitter installation and proof

Component Description:
Ramer Invoice includes installation, antenna and line sweep.
Amount:
$15,400.00
Interim Transmitter lease

Component Description:
Remove initial leased transmitter from Ventura and box for shipping.
Amount:
$187.50

Component Description:
Leased transmitter, two month rental plus installation and de-installation.
Amount:
$8,000.00

Component Description:
On site to assist in installation of leased transmitter. He split the day into 2 parts due to a prior commitment.
Amount:
$375.00
Transmitter decommission

Component Description:
Decommission pre-displacement antenna & line.
Amount:
$2,400.00

Component Description:
Shut down pre-displacement transmitter.
Amount:
$75.00
Transmitter Building Site Survey/Installation

Component Description:
Site survey with Landlord at post-displacement location.
Amount:
$112.50

Component Description:
Site survey for planning equipment placement, power, HVAC, etc.
Amount:
$150.00

Component Description:
Site prep and start receiving new equipment.
Amount:
$637.50

Component Description:
On site to meet technicians to install data network for post-displacement WHDS location.
Amount:
$262.50
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Ramer & Assoc. transmitter cost
Amount:
$77,876.21

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 $11,686.85 $11,656.85 N/A $6,618.72 N/A
Total for all systems $327,349.35 $230,001.35 N/A $148,762.90 N/A
Primary Antenna DLP-12W $11,686.85 $11,656.85 $6,618.72
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal $5,956.85 $5,956.85 ***System Notice: Estimate adjusted and locked because line has been superseded.***Antenna and RF system and accys. $6,618.72 The subtotal apparently was calculated prior to the final invoice being applied. We are still below the FCC approved price for an LPTV Hpol only antenna.
Sweep test of transmission line and antenna $5,730.00 $5,700.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal

Component Description:
ANTENNA ON MAN00991
Amount:
$2,647.49

Component Description:
ANTENNA ON MAN00992
Amount:
$2,978.43

Component Description:
Antenna portion of Dielectric inv448006
Amount:
$661.87

Component Description:
ANTENNA PART OF MAN00990
Amount:
$330.93
Sweep test of transmission line and 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 $18,900.00 $16,800.00 N/A $16,596.72 N/A
Total for all systems $327,349.35 $230,001.35 N/A $148,762.90 N/A
Primary Transmission Line $18,900.00 $16,800.00 $16,596.72
Flexible Foam Transmission Line - dielectric, 1 5/8" $8,400.00 $6,300.00 N/A $6,179.22 N/A
Interior RF Systems: Inside RF system including switching, patch panels and dehydrators $10,500.00 $10,500.00 Approximation, included on Ramer quote 19017R, plus Dielectric RF accys on their orders. $10,417.50 N/A

Components

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

Component Description:
LINE AND ACCYS ON MAN00991
Amount:
$2,016.88

Component Description:
Final payment on transmission line plus change orders.
Amount:
$1,641.23

Component Description:
LINE AND ACCYS ON MAN00992
Amount:
$2,268.99

Component Description:
LINE AND ACCYS ON MAN00990
Amount:
$252.12
Interior RF Systems: Inside RF system including switching, patch panels and dehydrators

Component Description:
FILTER AND RF ACCYS ON MAN00991
Amount:
$1,060.50

Component Description:
RF Accys for transmitter
Amount:
$7,472.50

Component Description:
RF FILTER & ACCYS ON MAN00990
Amount:
$132.56

Component Description:
Final Payment for filter/rf accys.
Amount:
$558.88

Component Description:
RF FILTER AND ACCYS ON MAN00992
Amount:
$1,193.06

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 $64,890.00 $20,700.00 N/A $0.00 N/A
Total for all systems $327,349.35 $230,001.35 N/A $148,762.90 N/A
Primary Tower GTOWER $64,890.00 $20,700.00 $0.00
Tower Rigging Short Tower (less than 500') $56,190.00 $12,000.00 N/A N/A N/A
Study needed for guyed or free-standing tower $8,700.00 $8,700.00 N/A N/A N/A
Decommission Antenna and Line $0.00 $0.00 Estimated cost for crew to remove 330' of line and antenna. $0.00 N/A

Components

Actual Information Description File Name
Tower Rigging Short Tower (less than 500') Information not provided.
Study needed for guyed or free-standing tower Information not provided.
Decommission Antenna and Line

Component Description:
Decommission old ch41 antenna and line and remove from site.
Amount:
N/A

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 $94,622.50 $52,347.00 N/A $11,910.00 N/A
Total for all systems $327,349.35 $230,001.35 N/A $148,762.90 N/A
Outside Professional Services $94,622.50 $52,347.00 $11,910.00
Prepare request for Special Temporary Authorization $2,560.00 $950.00 N/A $950.00 N/A
Additional Field Engineering Service, 3 Days $6,400.00 $6,400.00 Based on high rate engineer. No quote as of this time, if needed. N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $10,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $4,470.00 $4,470.00 N/A $2,752.00 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.00 N/A $297.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,000.00 N/A $432.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,050.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,100.00 N/A N/A N/A
Perform engineering study for displacement application $1,800.00 $4,600.00 Displacement channel search and engineering for multiple channels interference studies. $4,550.00 N/A
Form 399 assistance or other Program Management costs $1,500.00 $1,500.00 Outside consultant. Not sure if needed. N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,700.00 N/A $979.00 N/A
Project management of the transition $15,825.00 $15,000.00 N/A $1,950.00 N/A

Components

Actual Information Description File Name
Prepare request for Special Temporary Authorization

Component Description:
Engineering for reduced power STA due to leasing a lower power transmitter to go on-air with initially.
Amount:
$950.00
Additional Field Engineering Service, 3 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

Component Description:
WHDS Displacement application
Amount:
$130.00

Component Description:
Review WHDS Displacement notice from T-Mobile.
Amount:
$78.00

Component Description:
Tx leasing and file reduced power STA.
Amount:
$81.00

Component Description:
Filing silent STA after leased transmitter project failed.
Amount:
$297.00

Component Description:
Silent STA extension.
Amount:
$270.00

Component Description:
Review and file WHDS displacement application engineering data.
Amount:
$390.00

Component Description:
Reviewing Silent STA.
Amount:
$81.00

Component Description:
Review displacement and mx issues for WHDS.
Amount:
$159.00

Component Description:
Regarding STA on items 8/9/2019 and 8/29/2019.
Amount:
$351.00

Component Description:
WHDS Displacement consultation.
Amount:
$78.00

Component Description:
Reduced Power STA followup.
Amount:
$81.00

Component Description:
Prepare, file and review Silent STA.
Amount:
$270.00

Component Description:
Modified Reduced Power STA.
Amount:
$81.00

Component Description:
Filing STA
Amount:
$270.00

Component Description:
Legal service regarding displacement of WHDS and consult on Silent STA.
Amount:
$135.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Review and file license to cover application.
Amount:
$297.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
LPTV expense reimbursement for displaced stations. Update: Filed in wrong category.
Amount:
N/A

Component Description:
Review Site Modifications
Amount:
$135.00

Component Description:
Preparing CP information for ch.20 operation.
Amount:
$297.00
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 displacement application

Component Description:
Site modficiations for displaced WHDS-LD.
Amount:
$1,200.00

Component Description:
MX and interference studies for channel 20.
Amount:
$650.00

Component Description:
Displacement channel search.
Amount:
$1,750.00

Component Description:
Antenna change and height adjustment to prevent interference to adjacent channel station.
Amount:
$950.00
Form 399 assistance or other Program Management costs Information not provided.
Prepare/ Review 399 reimbursement form

Component Description:
Form 399 forms and filing.
Amount:
$81.00

Component Description:
LPTV reimbursement questions.
Amount:
$81.00

Component Description:
399 Eligibility Certification.
Amount:
$162.00

Component Description:
Items on 8/15/2019 and 8/21/2019 for displacement eligibility and 1876 review.
Amount:
$304.00

Component Description:
R and O review and advice. Updated amount 6/22/2020.
Amount:
$351.00
Project management of the transition

Component Description:
Partial day on 8/27/19 to meet tower crew at site to start work.
Amount:
$150.00

Component Description:
Project Management - tower crew raising antenna and line.
Amount:
$1,800.00

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 $16,250.00 $16,335.00 N/A $8,161.25 N/A
Total for all systems $327,349.35 $230,001.35 N/A $148,762.90 N/A
Other Expenses $16,250.00 $16,335.00 $8,161.25
Equipment Storage $3,000.00 $3,000.00 Storage of antenna $2,020.00 N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 Estimated freight charges for everything. $5,571.25 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $1,500.00 $1,500.00 Estimate for disposal not covered elsewhere. N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $400.00 Two STA's at $200 each. Receipts filed. $400.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A $170.00 N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,100.00 N/A N/A N/A

Components

Actual Information Description File Name
Equipment Storage

Component Description:
STORAGE CHARGES ON DIELECTRIC ANTENNA AND RF SYSTEM
Amount:
$2,020.00
Equipment Delivery and Handling Charges

Component Description:
Freight Charges on Transmitter.
Amount:
$2,500.00

Component Description:
FREIGHT CHARGES ON ANTENNA & RF SYSTEM
Amount:
$3,071.25
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
FCC Filing Fees - Special Temporary Authorization request

Component Description:
STA Extension request.
Amount:
$200.00

Component Description:
STA Filing fee.
Amount:
$200.00
FCC Filing Fees - Form 2100 license to cover application

Component Description:
License filing fee.
Amount:
$170.00
FCC Filing Fees - Form 2100 minor change CP application Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $327,349.35 $230,001.35 $148,762.90

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.

Scott Wills

Chief Operator, WHDS-LD


08/06/2020

Certification

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Section Question Response
Submission of Final Allocation or Accounting Information Statements

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

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

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

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

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

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

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

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

Scott Wills

Chief Operator, WHDS-LD


08/06/2020

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