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:
130845
Service:
LPD
Call Sign:
KJHP-LP
Channel:
22 (UHF)
File Number:
0000089817
FRN:
0001526086
Eligibility Status:
Eligible
Date Submitted:
03/31/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

SAN BERNARDINO COMMUNITY COLLEGE DISTRICT

Applicant

Doing Business As: SAN BERNARDINO COMMUNITY COLLEGE DISTRICT

Lawrence P Strong (KVCR)

550 E. Hospitality Lane

2nd Floor

San Bernardino, CA 82408

United States

+1 (909) 388-6915 lstrong@sbccd.edu 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

Anthony A Papa

Interim Director of Broadcast Media Systems

EMPIRE | KVCR

Anthony Papa

701 South Mt. Vernon Ave.

San Bernardino, CA 92410

United States

+1 (909) 384-4336 apapa@kvcr.org

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 The plan is for KHJP-LP to replace the existing channel 18 system with a new channel 22 transmitter and antenna. They will remain at the current location and use the current tower location.

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 MX1000
Year 2011
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1 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 UAXTE-2R44
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1 kW
Justification for New Transmitter The existing Larcan transmitter can produce enough power to meet the minimum, like for like. However, this model is no longer supported and obsolete. In addition, the company is out of business.

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) Yes
Switchgear (industrial 800 amp) No
Transformer (480V) No
Rigid Conduit and Wiring Yes
Size 2 inches
Length 30.0 feet
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

Installation

Outside Contractor Support

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 Slotted Coaxial
ERP: 1.0 kW
Manufacturer
Model Ja/LS-4
Year 2006

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: 1.0 kW
Manufacturer
Model DLP-8-M
Year 2019
Justification for New Antenna The existing antenna can't be re-tuned to the new channel 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? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Foam
Diameter 7/8 inches
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)
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Foam
Diameter 7/8 inches
Number of parallel runs 1
Length 150 feet per run
Justification for New Transmission Line The existing transmitter can produce enough power to meet the minimum, like for like. However, this model is no longer supported and the company is out of business.
Interior RF Systems Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators? No

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

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? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? No
Coordinates (NAD83) Latitude (NAD83) 33° 51' 56.0" N-
Longitude (NAD83) 116° 25' 58.0" W-
Overall Structure Height 117.90 feet
Support Structure Height 117.90 feet
Ground Elevation Above Mean Sea Level (AMSL) 1536.00 feet
Structure Type LTOWER - Lattice Tower
Tower Owner Insite Tower
Date Constructed 11/01/1979

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
40518 KLOB FM
93956 KDGL-FM1 FB
10535 KPSP-CD DTV
14059 K232CX FX
14060 K280CV FX

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

Other Expenses

Missing new Ch 5 off air antenna and download cable

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 Supervision of installation, scheduling, and budgetary responsibilities.
Outside RF consulting Engineering Services Perform engineering study for displacement application Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
Prepare Form 601 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 1
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 No
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service No

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Additional Repack Legal Services Not Otherwise Specified in Form 399

based on estimates provided by attorneys.

Consultant

Technical Consultant Engineer

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 No
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
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 $159,093.00 $159,093.00 N/A $0.00 N/A
Total for all systems $320,251.94 $345,913.29 N/A $33,886.00 N/A
Primary Transmitter UAXTE-2R44 $159,093.00 $159,093.00 $0.00
Installation $49,913.00 $49,913.00 N/A $0.00 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $84,000.00 N/A $0.00 N/A
Transmitter Building Site Survey/Installation $10,000.00 $10,000.00 N/A N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $780.00 $780.00 N/A N/A N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $14,400.00 N/A N/A N/A

Components

Actual Information Description File Name
Installation

Component Description:
For invoice 20-28335 ($19,990.00) only $15,300 was paid by PBS. $4690.00 is requested of FCC
Amount:
$4,690.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Taxes reimbursement for Transmitter.
Amount:
$4,955.19
Transmitter Building Site Survey/Installation Information not provided.
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Service entrance 3 phase/800 amp/208 volt 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 $11,927.00 $11,927.00 N/A $0.00 N/A
Total for all systems $320,251.94 $345,913.29 N/A $33,886.00 N/A
Primary Antenna DLP-8-M $11,927.00 $11,927.00 $0.00
UHF-Low Power, Side Mount, Slotted Coaxial, 1.0kW input, Horizontal $6,197.00 $6,197.00 N/A $0.00 N/A
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF-Low Power, Side Mount, Slotted Coaxial, 1.0kW input, Horizontal

Component Description:
Freight and Shipping of Dielectric antenna.
Amount:
$4,805.00
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 $1,650.00 $1,650.00 N/A $0.00 N/A
Total for all systems $320,251.94 $345,913.29 N/A $33,886.00 N/A
Primary Transmission Line $1,650.00 $1,650.00 $0.00
Flexible Foam Transmission Line - dielectric, 7/8" $1,650.00 $1,650.00 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 $66,113.44 $43,725.44 N/A $0.00 N/A
Total for all systems $320,251.94 $345,913.29 N/A $33,886.00 N/A
Primary Tower LTOWER $66,113.44 $43,725.44 $0.00
Tower Rigging Short Tower (less than 500') $56,190.00 $33,802.00 N/A $0.00 N/A
Other Expenses $1,223.44 $1,223.44 New Ch 5 off-air antenna and download cable N/A N/A
Study needed for guyed or free-standing tower $8,700.00 $8,700.00 N/A N/A N/A

Components

Actual Information Description File Name
Tower Rigging Short Tower (less than 500')

Component Description:
Structural Analysis Fee
Amount:
$750.00
Other Expenses Information not provided.
Study needed for guyed or free-standing tower 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 $75,228.50 $123,277.85 N/A $33,886.00 N/A
Total for all systems $320,251.94 $345,913.29 N/A $33,886.00 N/A
Outside Professional Services $75,228.50 $123,277.85 $33,886.00
Consultant $42,780.00 $42,780.00 To facilitate the modification of the KJHP antenna, transmitter, and remote control on Edom Hill, KVCR hired an independent engineer, Sal Castillo, to supervise the on-site activities as well as coordination of vendors at the transmitter site. $30,780.00 N/A
Additional Repack Legal Services Not Otherwise Specified in Form 399 $7,116.00 $7,116.00 Attorney fees $710.00 Legal fees not covered in 399
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $1,000.00 N/A $0.00 N/A
Perform engineering study for displacement application $1,800.00 $1,800.00 based on estimates provided by” engineers a N/A N/A
Project management of the transition $10,550.00 $52,343.35 The additional cost is the result of changes to antenna location because of interference to another station. $0.00 The additional cost is the result of changes to antenna location because of interference to another station.
Prepare request for Special Temporary Authorization $1,280.00 $2,139.50 N/A $0.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $11,490.00 STA Application Attorney Fees $2,396.00 STA Application Attorney Fees
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $159.00 based on estimates provided by attorneys. $0.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $530.00 N/A $0.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $2,210.00 based on estimates provided by attorneys. $0.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A

Components

Actual Information Description File Name
Consultant

Component Description:
Installment 21 for RF Technical Coordinator project (June)
Amount:
$4,780.00

Component Description:
Installment 21 for RF Technical Coordinator project (June)
Amount:
$7,220.00

Component Description:
RF Technical Coordinator project (September) Edom Hill
Amount:
$12,000.00

Component Description:
Installment 22 for RF Technical Coordinator project (July)
Amount:
$12,000.00

Component Description:
RF Technical Coordinator project, Edom Hill,(October)
Amount:
$6,780.00
Additional Repack Legal Services Not Otherwise Specified in Form 399

Component Description:
Legal Fees outside of 399
Amount:
$5,535.00

Component Description:
Legal fees not cover in 399
Amount:
$710.00

Component Description:
Legal fees not cover in 399
Amount:
$765.00

Component Description:
Legal fees not cover in 399
Amount:
$106.00

Component Description:
Legal justification not covered in form 399
Amount:
N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for displacement application Information not provided.
Project management of the transition

Component Description:
Project Manager and Coordination Tasks per Invoice.
Amount:
$2,970.00

Component Description:
Project Manager and Coordination Tasks per Invoice.
Amount:
$2,667.70

Component Description:
Project management task per invoice.
Amount:
$345.00

Component Description:
Project Manager and Coordination Tasks per Invoice.
Amount:
$4,976.25

Component Description:
Project Manager and Coordination Tasks per Invoice.
Amount:
$3,003.15

Component Description:
Project Manager and Coordination Tasks per Invoice.
Amount:
$13,011.25

Component Description:
Project Manager and Coordination Tasks per Invoice.
Amount:
$15,840.00

Component Description:
Project Manager and Coordination Tasks per Invoice.
Amount:
$9,530.00
Prepare request for Special Temporary Authorization

Component Description:
STA preparation.
Amount:
$1,139.50

Component Description:
STA Preparation.
Amount:
$1,000.00
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
STA Application Attorney Fees
Amount:
$4,027.50

Component Description:
STA Application Attorney Fees
Amount:
$4,829.00

Component Description:
STA Application Attorney Fees
Amount:
$237.50

Component Description:
Justification Spreadsheet
Amount:
N/A

Component Description:
STA Application attorney fees
Amount:
$106.00

Component Description:
STA Application Attorney Fees
Amount:
$1,815.00

Component Description:
STA Application Attorney Fees
Amount:
$475.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Justification for License to cover
Amount:
N/A

Component Description:
License to cover
Amount:
$159.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
License to cover application fee
Amount:
$530.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Construction permit
Amount:
$2,210.00

Component Description:
Justification Spread sheet
Amount:
N/A
Prepare/ Review 399 reimbursement form 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 $6,240.00 $6,240.00 N/A $0.00 N/A
Total for all systems $320,251.94 $345,913.29 N/A $33,886.00 N/A
Other Expenses $6,240.00 $6,240.00 $0.00
Equipment Delivery and Handling Charges $2,600.00 $2,600.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $305.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $3,000.00 $3,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $320,251.94 $345,913.29 $33,886.00

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. Yes

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.

Anthony A Papa

Interim Director of Broadcast Media Systems


03/31/2021

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).

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

  2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

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

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

  5. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .

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

  7. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

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

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

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

Anthony A Papa

Interim Director of Broadcast Media Systems


03/31/2021

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.

Anthony A Papa

Interim Director of Broadcast Media Systems


03/31/2021

Attachments

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