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FCC Form 399: Reimbursement Request

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

(REFERENCE COPY - Not for submission) FCC Form 399: Reimbursement Request

Facility ID:
60653
Service:
DTV
Call Sign:
WETM-TV
Channel:
23 (UHF)
File Number:
0000028766
FRN:
0009961889
Date Submitted:
12/08/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

Nexstar Inc.

Elizabeth Ryder

545 E. John W. Carpenter Freeway

SUITE 700

Irving, TX 75062

United States

 +1 (972) 373-8800 eryder@nexstar.tv 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

Elizabeth Ryder

General Counsel

Nexstar Inc.

Elizabeth Ryder

545 E. John Carpenter Freeway

Suite 700

Irving, TX 75062

United States

 +1 (972) 373-8800 eryder@nexstar.tv

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 See Attached Transition Plan.

Transmitters

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

Auxiliary Transmitter

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Add Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Auxiliary (Backup)
Description of Use Backup
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 1232A
Year 1992
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.3 kW

Auxiliary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Auxiliary (Backup)
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model TMU9evo-4
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.2 kW
Justification for New Transmitter Existing transmitter cannot be converted to repacked channel and manufacturer is no longer in business.

Auxiliary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Auxiliary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

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 NV8303
Year 2010
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.5 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-5
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 8.2 kW
Justification for New Transmitter See attached Transmitter Justification Technical Statement.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring Yes
Size 2 inches
Length 100.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Additional Transmitter Costs

Additional Transmitter Costs

Concrete Pad and Ice Shield

Concrete Pad and Ice Shield

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 Owned
Owner N/A
Site N/A
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 Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 40
Design power capacity in use 10.0 %
Lower Limit 470.00 MHz
Upper Limit 700.00 MHz
Other Antenna Type N/A
ERP: 100.0 kW
Manufacturer HARRIS
Model TAD-20UDA 4/40
Year 1997

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? Yes

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? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? Yes

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 880 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 880 feet per run
Justification for New Transmission Line Existing line has been swept and shows VSWR stackup from incorrect line sections.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Interim Line

450 ft of 3" flex line to run to temporary antenna while other line is replaced.

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
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? Yes
ASR Number 1010439
Coordinates (NAD83) Latitude (NAD83) 42° 06' 22.0" N-
Longitude (NAD83) 076° 52' 16.0" W-
Overall Structure Height 842.84 feet
Support Structure Height 798.87 feet
Ground Elevation Above Mean Sea Level (AMSL) 1706.02 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Nexstar Broadcasting, Inc.
Date Constructed 09/01/1963


Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Interim antenna rigging

Install interim antenna and transmission 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 173
Explanation It will be necessary to 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.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
NEPA Section 106 environmental review 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 No
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers No
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 Yes
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change Yes
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? 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

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 $708,100.00 $405,965.00 N/A $403,225.00 N/A
Total for all systems $1,467,793.00 $1,129,984.00 N/A $443,600.00 N/A
Primary Transmitter THU9evo-5 $582,100.00 $328,930.00 $326,190.00
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW $494,500.00 $241,330.00 See attached Transmitter Justification Technical Statement and quote $241,330.00 N/A
2" Rigid Conduit and Wiring (Cost per foot) $2,600.00 $2,600.00 N/A N/A N/A
Concrete Pad and Ice Shield $58,500.00 $58,500.00 See Precision Communications quote 20371-5 $58,500.00 N/A
Additional Transmitter Costs $26,500.00 $26,500.00 See Rohde & Schwarz quotes 325006.0 and 370904.0 $26,360.00 N/A
Auxiliary Transmitter TMU9evo-4 $126,000.00 $77,035.00 $77,035.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $77,035.00 See Land Communications Estimate 1073; cost includes electrical, installation and proof $77,035.00 N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW

Component Description:
Transmitter, installment #1
Amount:
$60,332.50

Component Description:
Transmitter, installment #2
Amount:
$180,997.50
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Concrete Pad and Ice Shield

Component Description:
Concrete pad and ice shield
Amount:
$58,500.00
Additional Transmitter Costs

Component Description:
Additional transmitter component
Amount:
$950.00

Component Description:
Additional transmitter parts
Amount:
$25,410.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Auxiliary transmitter, installment #1
Amount:
$38,517.50

Component Description:
Auxiliary transmitter, installment #2
Amount:
$38,517.50

Component Description:
Interim transmitter, installment #1
Amount:
$38,517.50

Component Description:
Interim transmitter, installment #2
Amount:
$38,517.50

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 $6,730.00 $6,400.00 N/A $195.00 N/A
Total for all systems $1,467,793.00 $1,129,984.00 N/A $443,600.00 N/A
Primary Antenna TAD-20UDA 4/40 $6,730.00 $6,400.00 $195.00
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $195.00 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
Sweep test
Amount:
$195.00

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate 		Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $202,960.00 $194,160.00 N/A $0.00 N/A
Total for all systems $1,467,793.00 $1,129,984.00 N/A $443,600.00 N/A
Primary Transmission Line $202,960.00 $194,160.00 $0.00
Rigid Transmission Line - copper, 6 1/8" $177,760.00 $168,960.00 N/A N/A N/A
Interim Line $25,200.00 $25,200.00 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 $461,100.00 $442,000.00 N/A $0.00 N/A
Total for all systems $1,467,793.00 $1,129,984.00 N/A $443,600.00 N/A
Primary Tower TOWER $461,100.00 $442,000.00 $0.00
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A N/A N/A
Structural engineering tower load study for well documented tower $12,600.00 $12,000.00 N/A N/A N/A
Tall Tower (greater than 500') $210,500.00 $200,000.00 N/A N/A N/A
Interim antenna rigging $80,000.00 $80,000.00 N/A N/A N/A

Components

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 $55,414.00 $53,575.00 N/A $23,045.00 N/A
Total for all systems $1,467,793.00 $1,129,984.00 N/A $443,600.00 N/A
Outside Professional Services $55,414.00 $53,575.00 $23,045.00
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $2,050.00 $2,025.00 N/A $2,025.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $625.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,900.00 See KGA CP applications $3,900.00 a
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $1,400.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
Project management of the transition $27,334.00 $25,900.00 N/A $15,095.00 N/A

Components

Actual Information Description File Name
Attorney Fees - Prepare and File request for Special Temporary Authorization 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 request for Special Temporary Authorization

Component Description:
STA Extension
Amount:
$525.00

Component Description:
Prepared engineering portion of STA
Amount:
$1,500.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Prepare License to Cover Application
Amount:
$625.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Minor modification of CP due to ERP reduction
Amount:
$1,400.00

Component Description:
See invoice summary line 5
Amount:
$2,500.00
Perform engineering study for new channel assignment and antenna development

Component Description:
Engineering study for new channel assignment
Amount:
$525.00

Component Description:
Engineering study for new channel assignment
Amount:
$350.00

Component Description:
Engineering study for new channel assignment
Amount:
$525.00

Component Description:
Engineering study for new channel assignment
Amount:
$875.00
Prepare and or review reimbursement form Information not provided.
Project management of the transition

Component Description:
Project Management for Structural Analysis and Tower Modifications including consultants Kessler and Gehman Associates. Services from January 27, 2018 through February 23, 2018.
Amount:
$300.00

Component Description:
Project Management for Structural Analysis and Tower Modifications. Services from June 30, 2018 through July 27, 2018.
Amount:
$375.00

Component Description:
Project management services
Amount:
$387.00

Component Description:
Project management services 3.2.19 through 3.29.19
Amount:
$375.00

Component Description:
Project management services
Amount:
$150.00

Component Description:
Project management services
Amount:
$3,025.00

Component Description:
Project management services 10.27.18 through 11.30.18
Amount:
$650.00

Component Description:
Project management services
Amount:
$237.00

Component Description:
Project management services
Amount:
$1,159.00

Component Description:
Project management services
Amount:
$250.00

Component Description:
Project management services
Amount:
$300.00

Component Description:
Project management services
Amount:
$250.00

Component Description:
Project management services 5.26.18 through 6.29.18
Amount:
$870.00

Component Description:
Project management services
Amount:
$150.00

Component Description:
Project management services
Amount:
$310.00

Component Description:
Project Management of Structural Analysis and Tower Modification period 10/27/17 to 12/31/17
Amount:
$900.00

Component Description:
Project management services 6.1.19 through 6.28.19
Amount:
$75.00

Component Description:
Project management and reporting services. See invoice summary lines: 1, 2, 3,4 for services September 30, 2017 through October 27, 2017 and February 24, 2018 through May 25, 2018 to include services provided by consultants Kessler and Gehman Associates.
Amount:
$2,870.00

Component Description:
Project management services 12.1.18 through 1.31.19
Amount:
$600.00

Component Description:
Project management services 7.28.18 through 9.28.18
Amount:
$450.00

Component Description:
Project Management of Structural Analysis and Tower Modification period 1/1/18 to 1/26/18
Amount:
$600.00

Component Description:
Project management services Apr 2019
Amount:
$84.50

Component Description:
Project management services 9.29.18 through 10.26.18
Amount:
$300.00

Component Description:
Project management services
Amount:
$427.50

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 $33,489.00 $27,884.00 N/A $17,135.00 N/A
Total for all systems $1,467,793.00 $1,129,984.00 N/A $443,600.00 N/A
Other Expenses $33,489.00 $27,884.00 $17,135.00
MVPD Notification of Channel Change $1,500.00 $1,500.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $1,500.00 $1,500.00 Develop and produce spots and crawls for viewer notification. N/A N/A
Equipment Storage $1,299.00 $1,299.00 See related invoices $1,299.00 N/A
Equipment Delivery and Handling Charges $15,000.00 $15,000.00 See related invoices $13,992.00 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $500.00 $500.00 N/A N/A N/A
Local Zoning $500.00 $500.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $6,000.00 N/A $1,844.00 N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage

Component Description:
Transmitter additional storage
Amount:
$1,299.00
Equipment Delivery and Handling Charges

Component Description:
Transmitter consolidation services
Amount:
$13,992.00
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Local Zoning Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
DTV Medical Facility Notification

Component Description:
Notification of medical facilities
Amount:
$1,844.00

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $1,467,793.00 $1,129,984.00 $443,600.00

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. 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.

Elizabeth Ryder

General Counsel


12/08/2020

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

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

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

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

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

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

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

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

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

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

  9. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Elizabeth Ryder

General Counsel


12/08/2020

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