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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:
29455
Service:
DCA
Call Sign:
KQDK-CD
Channel:
16 (UHF)
File Number:
0000027782
FRN:
0005935499
Date Submitted:
01/20/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

CHRISTIAN TELEVISION CORPORATION, INC.

Doing Business As: Rocky Mountain CTN

Brian Morris

8081 East Orchard Road Suite 225

Greenwood Village, CO 80111

United States

 +1 (727) 580-0712 bmorris@ctntv.net Not-for-Profit

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

Joseph C Chautin , III .

Attorney

Hardy, Carey, Chautin & Balkin, LLP

1080 West Causeway Approach

Mandeville, LA 70471

United States

 +1 (985) 629-0777 jchautin@hardycarey.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 KQDK will be off the air for 1 or 2 days while antenna and mask filter are replaced.

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model A400WST8U
Year 2012
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 0.4 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? Yes
Manufacturer
Model AT71-500-11C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 500 kW
Justification for New Transmitter Current transmitter cannot be re-tuned to the re-pack transition channel

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 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

Primary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

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)
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 Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 1.0 kW
Manufacturer
Model PSILP2401-22
Year 2011

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Ownership Owned
Owner N/A
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 Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 1.0 kW
Manufacturer
Model ALP4L1-HSOC-16
Year 2017
Justification for New Antenna Existing antenna cannot be re-tuned for new channel.

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 N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Broadband or Single Channel? N/A
Feed Line Size N/A
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? Yes
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? No

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 Move Equipment
Tower Use Primary (Main)
Description of Use N/A
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? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1201368
Coordinates (NAD83) Latitude (NAD83) 39° 40' 31.2" N-
Longitude (NAD83) 104° 52' 24.1" W-
Overall Structure Height 263.12 feet
Support Structure Height 263.12 feet
Ground Elevation Above Mean Sea Level (AMSL) 5545.86 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Echo Properties, Inc.
Date Constructed 10/23/2006

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
22218 KJFM FM
35023 KFCO FM

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

Information not provided.

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 1200
Explanation No technically qualified staff available at this location to oversee equipment off-loading, tower crew, and transmitter re-tuning.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations 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

Name Description

Attorney - Other Services

Attorney - Other Matters

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
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
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 $24,282.15 $24,282.15 N/A $12,330.11 N/A
Total for all systems $405,560.15 $266,592.94 N/A $92,223.95 N/A
Primary Transmitter AT71-500-11C $24,282.15 $24,282.15 $12,330.11
UHF - Air Cooled Solid State Transmitter 500 kW $24,282.15 $24,282.15 Please see the attached invoice from Hitachi-Comark #S10354-1; KQDK-110-1st Primary Transmitter Increase Justification v0 $12,330.11 x

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 500 kW

Component Description:
Transmitter work and removal
Amount:
$1,110.00

Component Description:
LCF78-7878-5 7/8" foam coax jumper x 5.0 ft.
Amount:
$1,342.15

Component Description:
AT71-500-11C 208V 500W TRANSMITTER
Amount:
$9,877.96

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 $59,330.00 $16,137.79 N/A $12,937.79 N/A
Total for all systems $405,560.15 $266,592.94 N/A $92,223.95 N/A
Primary Antenna ALP4L1-HSOC-16 $59,330.00 $16,137.79 $12,937.79
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $3,200.00 N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $6,497.17 ***System Notice: Estimate adjusted and locked because line has been superseded.***Antenna Work Quote JEHQ1312 and Estimate 219-336 R3 $6,497.17 N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $3,240.62 ***System Notice: Estimate adjusted and locked because line has been superseded.*** $3,240.62 x

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
Sweep test of existing antenna
Amount:
$3,200.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
Primary Antenna work and removal
Amount:
$450.00

Component Description:
UHF-LOWER POWER SIDE MOUNT
Amount:
$967.17

Component Description:
labor and equipment
Amount:
$5,080.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
UHF Lower Side Power Mount Antenna
Amount:
$3,240.62

Cost Information

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Transmission Line

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 $84,200.00 $80,000.00 N/A $0.00 N/A
Total for all systems $405,560.15 $266,592.94 N/A $92,223.95 N/A
Primary Tower TOWER $84,200.00 $80,000.00 $0.00
Short Tower (less than 500') $84,200.00 $80,000.00 N/A $0.00 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 $212,798.00 $121,773.00 N/A $62,706.05 N/A
Total for all systems $405,560.15 $266,592.94 N/A $92,223.95 N/A
Outside Professional Services $212,798.00 $121,773.00 $62,706.05
Project management of the transition $189,600.00 $99,675.00 Per Widelity Strategic Support Quote Revised 10-7-2019 $58,312.05 N/A
Attorney - Other Services $848.00 $848.00 see Estimated Cost Justification KQDK-590-Attorney - Other matters v1 $848.00 x
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A $0.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $546.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $0.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,000.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $1,000.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $0.00 N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project management
Amount:
$195.00

Component Description:
Project Management
Amount:
$1,808.45

Component Description:
Project Management
Amount:
$2,030.50

Component Description:
Project Management
Amount:
$31.25

Component Description:
Project Management
Amount:
$1,023.10

Component Description:
Project Management
Amount:
$218.75

Component Description:
Project Management
Amount:
$1,744.55

Component Description:
Project Management
Amount:
$1,986.40

Component Description:
Project Management
Amount:
$2,890.40

Component Description:
Project Management
Amount:
$1,508.10

Component Description:
Project Management
Amount:
$250.00

Component Description:
Project Management
Amount:
$1,647.05

Component Description:
Project Management
Amount:
$2,172.15

Component Description:
Project Management
Amount:
$1,449.10

Component Description:
Project Management
Amount:
$1,644.90

Component Description:
Project Management
Amount:
$2,774.45

Component Description:
Project Management
Amount:
$3,141.45

Component Description:
Project Management
Amount:
$2,121.75

Component Description:
Project Management
Amount:
$1,505.60

Component Description:
Project Management
Amount:
$6,748.95

Component Description:
Please deny this invoice
Amount:
N/A

Component Description:
Project Management
Amount:
$91.50

Component Description:
Project Management
Amount:
$2,266.40

Component Description:
Project Management
Amount:
$2,611.55

Component Description:
Project Management
Amount:
$1,589.45

Component Description:
Project Management
Amount:
$2,325.50

Component Description:
Project Management
Amount:
$3,233.60

Component Description:
Project Management
Amount:
$1,699.60

Component Description:
Project Management
Amount:
$1,575.90

Component Description:
Project Management
Amount:
$2,760.05

Component Description:
Project Management
Amount:
$3,266.60
Attorney - Other Services

Component Description:
Review email from FCC with phase 2 transition deadlines
Amount:
$216.00

Component Description:
Review FCC email authorizing bank account association for KQDK
Amount:
$78.00

Component Description:
KQDK-590-Attorney - Other matters
Amount:
$260.00

Component Description:
Review grant of KQDK channel 16 permit
Amount:
$78.00

Component Description:
Review KQDK post-auction construction permit
Amount:
$216.00
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

Component Description:
Review memo from FCC staff on LMS association
Amount:
$546.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
KQDK-530-RF Eng - Construction Permit Application (Main)
Amount:
$2,000.00
Perform engineering study for new channel assignment and antenna development

Component Description:
1. Engineering study work for new channel assignment including antenna development. 2. Preparation of the engineering section of FCC Form 2100.
Amount:
$1,000.00
Prepare and or review 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 $24,950.00 $24,400.00 N/A $4,250.00 N/A
Total for all systems $405,560.15 $266,592.94 N/A $92,223.95 N/A
Other Expenses $24,950.00 $24,400.00 $4,250.00
Develop and air announcement of upcoming channel change $400.00 $400.00 N/A $0.00 N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 N/A $0.00 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $1,500.00 $1,500.00 N/A $0.00 N/A
MVPD Notification of Channel Change $1,500.00 $1,500.00 N/A $1,500.00 N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $2,750.00 N/A

Components

Actual Information Description File Name
Develop and air announcement of upcoming channel change Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
MVPD Notification of Channel Change

Component Description:
Project management
Amount:
$1,500.00
DTV Medical Facility Notification

Component Description:
Project management
Amount:
$2,750.00

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $405,560.15 $266,592.94 $92,223.95

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. Yes
Construction of final facilities or all necessary modifications are complete. Yes
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator. No

Certification

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Section Question Response
Submission of Estimated Expenses Statements

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

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

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

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

  4. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).

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

  6. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.

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

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

CHRIS L MAVROS

D.E., Christian Television Network


01/20/2021

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.

CHRIS L MAVROS

D.E., Christian Television Network


01/20/2021

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.

CHRIS L MAVROS

D.E., Christian Television Network


01/20/2021

Attachments

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