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:
73363-27
Service:
DRT
Call Sign:
WNYT
Channel:
27 (UHF)
File Number:
0000089351
FRN:
0005828736
Eligibility Status:
Eligible
Date Submitted:
06/17/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WNYT-TV, LLC

Doing Business As: WNYT-TV, LLC

Ryan Vandewiele

3415 University Ave., West

St. Paul, MN 55114

United States

+1 (651) 642-4334 KShuldes@hbi.com 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

Charles R. Naftalin

Legal Counsel

Holland & Knight LLP

800 17th Street, N.W.

Suite #1100

Washington, DC 20006

United States

+1 (202) 457-7040 charles.naftalin@hklaw.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 The DRT will install a new transmitter, transmission line, and antenna to replace its existing facility.

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 MAGNUM DTT2.5KSU
Year 2001
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 2500 W

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-4R
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2400 W
Justification for New Transmitter The existing transmitter is channel specific and cannot be retuned. The model is discontinued and the manufacturer is defunct.

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 Yes
Size 1 inches
Length 150.0 feet
Other Electrical Service Yes
Description Circuit Breaker, Flexible Conduit, Circuit Breaker Panel, Power Distribution Units
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

Surge Suppressor

Electrical Surge Suppressor

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? 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
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model AL8-O
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? No
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 Elliptical
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model ALP-12-L7-ESOC-27
Year 2020
Justification for New Antenna Existing antenna is channel specific. The translator is moving to a new channel.

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? Yes
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 Utilize Existing
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 MYAT
Type Rigid
Diameter 4 1/16 inches
Segment Length 20 inches
Number of parallel runs 1
Length 690 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Jumper, Hangers, and Hardware

Flexible Transmission Line Jumper from Existing Transmission Line to New Antenna

Matching Section Adjustment

RF Analysis to Adjust Matching Section Upon Installation

Matching Section, Fine

Matching Section for Antenna Input

Monitor, Transmission Line Pressure

Monitors pressurization in transmission lines

Reducers

Reducing Adapter

Line Sections - Adapter, Internal

Transmission Line for Inside Transmitter Room and 1-5/8" to 4-1/16" Adapter

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 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? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1004249
Coordinates (NAD83) Latitude (NAD83) 42° 47' 09.0" N-
Longitude (NAD83) 073° 37' 41.0" W-
Overall Structure Height 737.52 feet
Support Structure Height 693.56 feet
Ground Elevation Above Mean Sea Level (AMSL) 950.12 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner WNYT-TV, LLC
Date Constructed 01/01/1978

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
6613 WQBK-FM FM
20922 W254DA FX

Other Types of Users

Users
Public Safety
Land Mobile

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? Yes

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Lighting, Obstruction

FAA "E2" Level Obstruction Lighting System

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? No
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 No
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 No
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 Yes
Additional Field Engineering Service No

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Abatement, Asbestos

Removal of Asbestos Containing Material in Transmitter Room

Evaluation, HVAC

Study of Transmitter Room HVAC Requirements

Floor Resurfacing

Floor Preparation in Transmitter Room

Testing, Asbestos

Evaluation of Transmitter Room Floor Tiles for ACM (Asbestos Containing Material)

Scanning, Blueprints

Scanning of Antenna, Tower, and Building (Construction & Mechanical) Blueprints for Contractors' Use

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

Name Description

Sales Tax

NY State Sales Tax

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 $111,600.00 $105,973.51 N/A $2,994.00 N/A
Total for all systems $638,191.53 $502,720.24 N/A $61,564.43 N/A
Primary Transmitter UAXTE-4R $111,600.00 $105,973.51 $2,994.00
Other Electrical Service: Circuit Breaker, Flexible Conduit, Circuit Breaker Panel, Power Distribution Units $10,400.00 $10,400.00 N/A N/A N/A
Transmitter Building Site Survey/Installation $10,000.00 $10,958.00 Estimates are based on manufacturer's quotes. $2,994.00 N/A
Surge Suppressor $6,000.00 $6,000.00 N/A N/A N/A
1" Rigid Conduit and Wiring $1,200.00 $1,200.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $77,415.51 N/A $0.00 N/A

Components

Actual Information Description File Name
Other Electrical Service: Circuit Breaker, Flexible Conduit, Circuit Breaker Panel, Power Distribution Units Information not provided.
Transmitter Building Site Survey/Installation

Component Description:
Site Survey
Amount:
$2,994.00
Surge Suppressor Information not provided.
1" Rigid Conduit and Wiring Information not provided.
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Second down payment re primary transmitter.
Amount:
$25,805.17

Component Description:
Final down payment re primary transmitter.
Amount:
$25,805.17

Component Description:
First down payment re primary transmitter.
Amount:
$25,805.17

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 $28,672.50 $27,571.10 N/A $6,400.00 N/A
Total for all systems $638,191.53 $502,720.24 N/A $61,564.43 N/A
Primary Antenna ALP-12-L7-ESOC-27 $28,672.50 $27,571.10 $6,400.00
Sweep test of transmission line and antenna $5,730.00 $6,400.00 Estimated cost is based on attached consultant's quote. $6,400.00 N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical $18,317.50 $18,317.50 Quoted antenna upgrades an existing 8-bay H-Pol antenna to a 12-bay E-Pol one. 12-bay allows a smaller transmitter for equivalent ERP. Reimbursement requested/estimated cost also reflects standard mfr. 15% discount on H-Pol (not E-Pol) antenna. $0.00 N/A
Side Mount antenna brackets $4,625.00 $2,853.60 N/A $0.00 N/A

Components

Actual Information Description File Name
Sweep test of transmission line and antenna

Component Description:
Antenna sweep test
Amount:
$6,400.00
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical

Component Description:
Portion of invoice relating to the antenna. See Quote, Line 11.
Amount:
$9,158.75

Component Description:
Portion of invoice related to antenna. See Quote, Line 11.
Amount:
$9,158.75
Side Mount antenna brackets

Component Description:
Portion of invoice relating to custom brackets (See Quote, Line 2).
Amount:
$1,426.80

Component Description:
Portion of invoice relating to mount brackets (See Quote, Line 2).
Amount:
$1,426.80

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 $15,662.10 $15,662.10 N/A $0.00 N/A
Total for all systems $638,191.53 $502,720.24 N/A $61,564.43 N/A
Primary Transmission Line $15,662.10 $15,662.10 $0.00
Monitor, Transmission Line Pressure $830.36 $830.36 N/A N/A N/A
Matching Section, Fine $2,983.00 $2,983.00 N/A N/A N/A
Line Sections - Adapter, Internal $2,271.41 $2,271.41 N/A $0.00 N/A
Matching Section Adjustment $7,850.00 $7,850.00 N/A N/A N/A
Jumper, Hangers, and Hardware $1,002.28 $1,002.28 N/A $0.00 N/A
Reducers $725.05 $725.05 Adapter from 4-1/16" to 1-5/8" at Antenna End of Transmission Line $0.00 N/A

Components

Actual Information Description File Name
Monitor, Transmission Line Pressure Information not provided.
Matching Section, Fine Information not provided.
Line Sections - Adapter, Internal

Component Description:
Add internal transmission line to the transmitter order.
Amount:
$2,271.41
Matching Section Adjustment Information not provided.
Jumper, Hangers, and Hardware

Component Description:
Portion of invoice relating to jumpers, hangers and hardware. See Quote, Line 3-9.
Amount:
$501.14

Component Description:
Portion of invoice relating to jumpers, hangers and hardware. See Quote, Line 3-9.
Amount:
$501.14
Reducers

Component Description:
Portion of invoice relating to reducers. See Quote, Line 10.
Amount:
$362.52

Component Description:
Portion of invoice relating to reducers. See Quote, Line 10.
Amount:
$362.52

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 $348,910.00 $251,214.10 N/A $51,250.00 N/A
Total for all systems $638,191.53 $502,720.24 N/A $61,564.43 N/A
Primary Tower TOWER $348,910.00 $251,214.10 $51,250.00
Lighting, Obstruction $18,662.06 $18,662.06 N/A N/A N/A
Tower Helicopter Lift $163,797.94 $163,797.94 N/A N/A N/A
Study needed for guyed or free-standing tower $8,700.00 $8,000.00 N/A $8,000.00 N/A
Tower Rigging Tall Tower (greater than 500') $157,750.00 $60,754.10 N/A $43,250.00 N/A

Components

Actual Information Description File Name
Lighting, Obstruction Information not provided.
Tower Helicopter Lift Information not provided.
Study needed for guyed or free-standing tower

Component Description:
Broadcast analysis
Amount:
$6,000.00

Component Description:
Broadcast analysis down payment
Amount:
$1,000.00

Component Description:
Broadcast analysis final payment
Amount:
$1,000.00
Tower Rigging Tall Tower (greater than 500')

Component Description:
Installation of new TLP-12 Antenna, including power divider and jumper from antenna to 4" hardline.
Amount:
$43,250.00

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 $122,389.75 $91,647.25 N/A $152.25 N/A
Total for all systems $638,191.53 $502,720.24 N/A $61,564.43 N/A
Outside Professional Services $122,389.75 $91,647.25 $152.25
Scanning, Blueprints $152.25 $152.25 N/A $152.25 N/A
Testing, Asbestos $1,070.00 $1,070.00 N/A $0.00 N/A
Floor Resurfacing $5,000.00 $5,000.00 N/A N/A N/A
Evaluation, HVAC $3,200.00 $3,200.00 N/A N/A N/A
Abatement, Asbestos $32,000.00 $32,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $25,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,575.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,000.00 N/A N/A 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 $1,800.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,700.00 N/A N/A N/A
Form 399 assistance or other Program Management costs $5,000.00 $5,000.00 N/A N/A N/A
RF Exposure Measurements $12,100.00 $9,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Scanning, Blueprints

Component Description:
Harris antenna and tower scans
Amount:
$45.00

Component Description:
Tower drawing scans
Amount:
$33.25

Component Description:
Building blueprint scans
Amount:
$42.00

Component Description:
Building mechanical scans
Amount:
$32.00
Testing, Asbestos

Component Description:
Asbestos inspection
Amount:
$775.00
Floor Resurfacing Information not provided.
Evaluation, HVAC Information not provided.
Abatement, Asbestos Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application 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), 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 Information not provided.
Prepare/ Review 399 reimbursement form Information not provided.
Form 399 assistance or other Program Management costs Information not provided.
RF Exposure Measurements 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 $10,957.18 $10,652.18 N/A $768.18 N/A
Total for all systems $638,191.53 $502,720.24 N/A $61,564.43 N/A
Other Expenses $10,957.18 $10,652.18 $768.18
Disposal Costs (for equipment and other waste, net of any salvage value) $2,000.00 $2,000.00 N/A N/A N/A
Sales Tax $12.18 $12.18 N/A $12.18 N/A
Equipment Delivery and Handling Charges $7,500.00 $7,500.00 N/A $756.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $805.00 N/A N/A N/A

Components

Actual Information Description File Name
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Sales Tax

Component Description:
Sales tax relating to tower drawing scans.
Amount:
$2.66

Component Description:
Sales tax relating to antenna and tower scans.
Amount:
$3.60

Component Description:
Sales tax relating to building mechanical scans.
Amount:
$2.56

Component Description:
Sales tax relating to building blueprint scans.
Amount:
$3.36
Equipment Delivery and Handling Charges

Component Description:
Compact telehandler rental
Amount:
$756.00

Component Description:
Shipping fees relating to asbestos inspection report.
Amount:
$150.00

Component Description:
Freight cost relating to antenna and transmission line.
Amount:
$1,948.01

Component Description:
Telehandler rental
Amount:
$981.01
FCC Filing Fees - Form 2100 license to cover application Information not provided.
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 $638,191.53 $502,720.24 $61,564.43

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.

Ryan Vandewiele

Vice President


06/17/2021

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.

Ryan Vandewiele

Vice President


06/17/2021

Attachments

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