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:
54011
Service:
DTV
Call Sign:
KLJB
Channel:
30 (UHF)
File Number:
0000028435
FRN:
0004284899
Date Submitted:
09/10/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

MISSION BROADCASTING, INC.

Doing Business As: MISSION BROADCASTING, INC.

901 INDIANA AVE

SUITE 375

WICHITA FALLS, TX 76301

United States

+1 (940) 228-7861 MISSIONBROADCASTING@GMAIL.COM Corporation

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

Greg Best

Consulting Engineer

Greg Best Consulting Inc.

16100 Outlook Avenue

Stilwell, KS 66085

United States

+1 (816) 792-2913 gbconsulting54@gmail.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. Yes
Briefly describe transition plan Replace transmitter. Install new combiner for new channel and use existing antenna and transmission line. See Transition plan attachment.

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 Millennium DCX
Year 2005
Type Inductive Output Tube
IOT Power Type Two
Power Capacity 50 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 THU9EVO-30
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 46 kW
Justification for New Transmitter The purchase price of a new solid state transmitter is less than a comparable replacement IOT based on a Proposal from Comark for an MSDC IOT. See attached proposal for solid state transmitter.

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) Yes
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 100.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size 20 tons
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

Transmitter installation

Transmitter installation and test services.

Interface line

Cut piece of transmission line to mate xmtr with combiner.

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 Retune Existing
Antenna Use Primary (Main)
Description of Use N/A
Ownership Leased
Owner American Tower
Site N/A
Is the existing antenna shared with another station or stations? Yes
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Top Mount
Antenna position in stack Top
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 2
Number of Panels 56
Design power capacity in use 50.0 %
Lower Limit 470.00 MHz
Upper Limit 605.00 MHz
Other Antenna Type N/A
ERP: 1000.0 kW
Manufacturer DIELECTRIC
Model TUF-O4-14/56H-1-T
Year 2008

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

Facility ID Call Sign
6885 KWQC-TV

Primary Antenna

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Adjustment to Existing Antenna

Section Question Response
Sweep Test of Existing Antenna Do you need a sweep test of existing antenna?

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? Yes
Type New
Number of channels supported 2
Frequencies of channels supported RF channel
Frequency N/A

Enter a list of RF channel numbers.

RF Channel Number
23
30

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 Utilize Existing
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? Yes
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Dielectric
Type Rigid
Diameter 7 3/16 inches
Other Diameter N/A
Segment Length Broadband
Other Segment Length N/A
Number of parallel runs 1
Length 1100 feet per run

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

Facility ID Call Sign
5468 WQPT-TV

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Sweep Tests

Sweep tests to ensure good performance on the assigned channel

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? No

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 300
Explanation Schedule and coordinate multiple vendors, complete progress reports, and update Schedule 399. Station does not have available personnel or personnel trained in project management for such complex projects. Project management services needed.
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 Yes
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 No
RF exposure measurements No
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

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
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 No
FCC License to Cover Application Yes
FCC Special Temporary Authority Application No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
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

Sales Tax

Sales and use tax on goods and services

Generator Move

Generator and fuel move to be compliant with lease terms

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 $1,790,665.00 $1,713,665.00 N/A $1,343,535.62 N/A
Total for all systems $2,163,270.00 $2,101,590.00 N/A $1,510,484.96 N/A
Primary Transmitter THU9EVO-30 $1,790,665.00 $1,713,665.00 $1,343,535.62
Interface line $965.00 $965.00 Special length of line to interface transmitter and combiner. $960.23 N/A
20 Ton system $115,500.00 $115,500.00 N/A $54,372.00 N/A
3" Rigid Conduit and Wiring (Cost per foot) $5,200.00 $4,900.00 N/A N/A N/A
Transformer 3 phase/480v - 300 KVA $36,800.00 $35,000.00 N/A N/A N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,473,000.00 $1,400,000.00 N/A $1,167,671.89 N/A
Transmitter installation $121,000.00 $121,000.00 See transmitter installation quote. $120,531.50 N/A

Components

Actual Information Description File Name
Interface line

Component Description:
Special length of transmission line to mate transmitter with combiner.
Amount:
$960.23
20 Ton system

Component Description:
FINAL INVOICE FOR PROJECT.
Amount:
$27,186.00

Component Description:
First invoice for HVAC work.
Amount:
$27,186.00
3" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Transformer 3 phase/480v - 300 KVA Information not provided.
Switchgear - industrial 800 amp Information not provided.
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW

Component Description:
First invoice for xmtr.
Amount:
$274,812.50

Component Description:
Initial invoice for transmitter installation and test.
Amount:
N/A

Component Description:
Final transmitter invoice.
Amount:
$892,859.39

Component Description:
Please ignore this reimbursement request. These expenses are covered elsewhere in the cost category.
Amount:
N/A
Transmitter installation

Component Description:
Final invoice for Land Comm transmitter and electric installation service.
Amount:
$60,265.75

Component Description:
Initial invoice for Land Comm transmitter install services.
Amount:
$60,265.75

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 $90,930.00 $90,930.00 N/A $74,647.88 N/A
Total for all systems $2,163,270.00 $2,101,590.00 N/A $1,510,484.96 N/A
Primary Antenna TUF-O4-14/56H-1-T $90,930.00 $90,930.00 $74,647.88
New combiner, cost per channel (without antenna) $84,200.00 $84,200.00 N/A $74,647.88 N/A
Sweep test of existing antenna $6,730.00 $6,730.00 N/A N/A N/A

Components

Actual Information Description File Name
New combiner, cost per channel (without antenna)

Component Description:
Combiner second invoice.
Amount:
$49,765.26

Component Description:
Combiner first invoice.
Amount:
$24,882.62

Component Description:
Please reject this invoice as this item is covered in the transmitter cost category.
Amount:
N/A
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 $6,400.00 $6,400.00 N/A $0.00 N/A
Total for all systems $2,163,270.00 $2,101,590.00 N/A $1,510,484.96 N/A
Primary Transmission Line $6,400.00 $6,400.00 $0.00
Sweep Tests $6,400.00 $6,400.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

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 $76,590.00 $92,460.00 N/A $57,620.46 N/A
Total for all systems $2,163,270.00 $2,101,590.00 N/A $1,510,484.96 N/A
Outside Professional Services $76,590.00 $92,460.00 $57,620.46
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,210.00 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 N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $3,000.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $5,750.00 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $4,500.00 Due to MBG business structure changes filing for the repack, and coordination with other facilities, KLJB costs were higher. $2,518.75 Attorney was providing transition reporting and also required coordination with new project manager/engineer.
Prepare and or review reimbursement form $2,630.00 $10,000.00 Internal resources were insufficient so outside resources were used to prepare the 399 forms. $8,431.25 N/A
Project management of the transition $47,400.00 $55,000.00 Engineering to close out project and review all reimbursable expense required more project management costs. $37,120.46 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $800.00 N/A

Components

Actual Information Description File Name
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.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
See cover letter item 4 - Prepare engineering section of FCC form 2100, Construction Permit Application services provided by consultant Kessler and Gehman Associates.
Amount:
$3,000.00
Perform engineering study for new channel assignment and antenna development

Component Description:
See cover letter item 3 - Perform engineering study for new channel assignment and antenna development services provided by consultant Kessler and Gehman Associates.
Amount:
$5,750.00
Address transition timing and coordination issues w/ other stations and wireless

Component Description:
Transition report and coordination of transition plan creation.
Amount:
$243.75

Component Description:
Preparation of transition report and coordination with other counsel.
Amount:
$406.25

Component Description:
Coordination of various repack procedures with client.
Amount:
$1,056.25

Component Description:
Transition procedures for repack.
Amount:
$81.25

Component Description:
Address transition plan issues and planning for reimbursement.
Amount:
$568.75

Component Description:
Transition report review.
Amount:
$81.25

Component Description:
Transition plan coordination. Other items on this invoice are not reimbursable so please just reimburse the indicated amount.
Amount:
$162.50

Component Description:
New Cores account and reimbursement setup.
Amount:
$1,056.25
Prepare and or review reimbursement form

Component Description:
Preparation of 399 form information.
Amount:
$243.75

Component Description:
Change in licensee required research for new 1876 identity.
Amount:
$731.25

Component Description:
Identification of 399 items for reimbursement and reimbursement rules for processing.
Amount:
$1,137.50

Component Description:
Change in licensee structure required research for new 1876 form and to start new 1876 credentials all over.
Amount:
$4,550.00

Component Description:
See cover letter item 2 - Prepare and or review reimbursement form services provided by consultant Kessler and Gehman Associates.
Amount:
$2,500.00
Project management of the transition

Component Description:
Project management activities including progress reports.
Amount:
$5,700.00

Component Description:
Project management activities for August.
Amount:
$1,837.50

Component Description:
Project management services for schedule 387 progress report preparation by consultants Kessler and Gehman Associates for 2018 Q2 and 2018 Q4.
Amount:
$300.00

Component Description:
Project management and engineering to choose equipment and services, and for site visit for combiner planning.
Amount:
$11,269.46

Component Description:
Project management for structural analysis and tower modification services 5.26.18 through 6.29.18 and consulting services by Kessler and Gehman Associates May 2018.
Amount:
$460.00

Component Description:
Project management services provided by consultants Kessler and Gehman Associates.
Amount:
$550.00

Component Description:
See cover letter item 1, 5-8 - project management services
Amount:
$5,784.00

Component Description:
Project management tasks including equipment review and selection.
Amount:
$1,050.00

Component Description:
Project management activities for test and transition reporting.
Amount:
$4,000.00

Component Description:
Project Management and site trip to do station equipment planning. Direct expenses itemized.
Amount:
$7,544.50

Component Description:
Project management including scheduling of resources for testing.
Amount:
$2,625.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Preparation and submittal of license to cover application.
Amount:
$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 $198,685.00 $198,135.00 N/A $34,681.00 N/A
Total for all systems $2,163,270.00 $2,101,590.00 N/A $1,510,484.96 N/A
Other Expenses $198,685.00 $198,135.00 $34,681.00
Generator Move $10,800.00 $10,800.00 N/A $10,200.00 N/A
Sales Tax $119,000.00 $119,000.00 N/A $0.00 N/A
MVPD Notification of Channel Change $3,500.00 $3,500.00 N/A $2,865.00 N/A
Develop and air announcement of upcoming channel change $3,500.00 $3,500.00 N/A N/A N/A
Equipment Storage $10,000.00 $10,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $20,000.00 $20,000.00 N/A $16,630.00 N/A
Non-zoning permits $10,000.00 $10,000.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A $0.00 N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $4,986.00 N/A

Components

Actual Information Description File Name
Generator Move

Component Description:
Relocation of generator per lease terms.
Amount:
$10,200.00
Sales Tax Information not provided.
MVPD Notification of Channel Change

Component Description:
Notifications to MVPD operations.
Amount:
$2,865.00
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
Removal and disposal of all transmitter room equipment to be compliant with lease terms.
Amount:
$16,630.00
Non-zoning permits Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
DTV Medical Facility Notification

Component Description:
Notifications provided to Medical facilities.
Amount:
$4,986.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $2,163,270.00 $2,101,590.00 $1,510,484.96

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 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.

Sharon Moser

Controller


09/10/2020

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.

Sharon Moser

Controller


09/10/2020

Attachments

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