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:
66781-18-54679
Service:
DRT
Call Sign:
KIRO-TV
Channel:
18 (UHF)
File Number:
0000089620
FRN:
0014361620
Eligibility Status:
Eligible
Date Submitted:
03/29/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

KIRO-TV, Inc.

Doing Business As: KIRO-TV, Inc.

Chief Engineer

2807 Third Avenue

Seattle, WA 98121

United States

+1 (206) 728-7777 knealey@kiro7.com Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Keith Nealey

Director Of Engineering

KIRO-TV, INC

Director of Engineering

2807 THIRD AVENUE

SEATTLE, WA 98121

United States

+1 (206) 728-7808 knealey@kiro7.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 New 220v power circuits will be installed with existing 110v circuits. We will install new transmitter and antenna alongside existing equipment. Once testing is completed we will move existing feed line onto new transmitter and antenna.

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 MX100U
Year 2005
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 100 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-1P-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 200 W
Justification for New Transmitter Displacement location is within the predicted noise-limited contour and predicted interference greater than 0.5 percent to post spectrum repack for KWDK on channel 34 which is being repacked from channel 42.

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? No
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Rigid Conduit and Wiring No
Other Electrical Service Yes
Description Add 220V breakers and outlets to existing service panel
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

Tax

Tax on Transmitter

Mask Filter System

Mask filter, post-filter coupler and flex line connectors

Sencore Receiver

Translator Receiver with ASI output

Freight

Transmitter shipping costs

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? Yes
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Bottom
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 2
Design power capacity in use 100.0 %
Lower Limit 590.00 MHz
Upper Limit 596.00 MHz
ERP: 0.5 kW
Manufacturer
Model 1X2KBBU
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? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Bottom
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 2
Lower Limit 470.00 MHz
Upper Limit 500.00 MHz
Design power capacity in use 50.0 %
ERP: 5.0 kW
Manufacturer
Model 4DR-4-2HW
Year 2018
Justification for New Antenna Current antenna is not retunable

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? No
Power Dividers Does the panel antenna require power dividers? Yes
Number of Power Dividers 1
Cable Harness Does the panel antenna require cable harness? No

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Freight

Shipping charges for antenna

Scala Connectors

Antenna-specific cables and connectors

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)
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? 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 1202500
Coordinates (NAD83) Latitude (NAD83) 47° 00' 56.2" N-
Longitude (NAD83) 122° 55' 03.5" W-
Overall Structure Height 192.91 feet
Support Structure Height 185.04 feet
Ground Elevation Above Mean Sea Level (AMSL) 418.96 feet
Structure Type MTOWER - Monopole
Tower Owner CCATT LLC
Date Constructed 09/30/2006


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 100
Explanation KIRO-TV does not have sufficient resource capacity and expertise in house to handle all activities necessary for completion of the station's build by the construction deadline. KIRO-TV will hire an outside firm to facilitate a timely transition.
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 Yes
Quantity 1
Negotiation of Lease and other Matter for Shared Locations Yes
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 Yes
RF exposure measurements Yes
Additional Field Engineering Service No

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
Permit and Filing Costs FCC Construction Permit Major Change 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)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? No
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 $34,701.17 $25,641.17 N/A $554.71 N/A
Total for all systems $188,253.99 $63,374.15 N/A $30,440.13 N/A
Primary Transmitter UAXTE-1P-C $34,701.17 $25,641.17 $554.71
UHF - Air Cooled Solid State Transmitter 160 - 300 Watts $24,300.00 $15,240.00 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $0.00 Please see "Q-81230 KIRO-DRT Olympia UAXTE-1P-C 200w with Call.pdf" for quote. Quote does not include tax or freight charges but all components are supported.
Freight $276.12 $276.12 N/A $0.00 N/A
Sencore Receiver $2,708.80 $2,708.80 N/A $0.00 N/A
Mask Filter System $4,560.23 $4,560.23 N/A $0.00 N/A
Tax $2,301.31 $2,301.31 N/A $0.00 N/A
Other Electrical Service: Add 220V breakers and outlets to existing service panel $554.71 $554.71 per schneider electric quote dated 10/1/19 $554.71 N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 160 - 300 Watts

Component Description:
Line 1 - Transmitter cost
Amount:
$15,240.00

Component Description:
Tranmitter, Mask, assembly kit. Freight and tax have been added
Amount:
$25,086.46
Freight

Component Description:
Shipping costs of transmitter, mask filter and transmitter accessories
Amount:
$276.12
Sencore Receiver

Component Description:
Translator receiver costs
Amount:
$2,708.80
Mask Filter System

Component Description:
Includes Line 3 - Mask Filter, Line 4 - RF Accessories, and Line 5 - Flex assembly
Amount:
$4,560.23
Tax

Component Description:
Transmitter Tax Amount
Amount:
$2,301.31
Other Electrical Service: Add 220V breakers and outlets to existing service panel

Component Description:
Install 250v 3W receptacle
Amount:
$554.71

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 $5,347.82 $3,029.82 N/A $3,029.82 N/A
Total for all systems $188,253.99 $63,374.15 N/A $30,440.13 N/A
Primary Antenna 4DR-4-2HW $5,347.82 $3,029.82 $3,029.82
Scala Connectors $374.00 $374.00 N/A $374.00 N/A
Freight $173.82 $173.82 N/A $173.82 N/A
Power Dividers (each, for panel antenna system, if not included in antenna cost) $1,300.00 $594.00 N/A $594.00 N/A
UHF Broadband panel antenna (per panel), horizontally-polarized $3,500.00 $1,888.00 N/A $1,888.00 N/A

Components

Actual Information Description File Name
Scala Connectors

Component Description:
Antenna-specific cable and connectors
Amount:
$374.00
Freight

Component Description:
Antenna freight costs
Amount:
$173.82
Power Dividers (each, for panel antenna system, if not included in antenna cost)

Component Description:
Power Divider portion of invoice
Amount:
$594.00
UHF Broadband panel antenna (per panel), horizontally-polarized

Component Description:
Line 1 of BGS invoice for Antenna cost only
Amount:
$1,888.00

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 $56,190.00 $5,100.00 N/A $5,082.45 N/A
Total for all systems $188,253.99 $63,374.15 N/A $30,440.13 N/A
Primary Tower MTOWER $56,190.00 $5,100.00 $5,082.45
Tower Rigging Short Tower (less than 500') $56,190.00 $5,100.00 N/A $5,082.45 N/A

Components

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

Component Description:
Replacing panel antennas on monopole
Amount:
$5,082.45

Component Description:
Antenna rigging and replacement
Amount:
$5,082.45

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 $92,015.00 $29,603.16 N/A $21,773.15 N/A
Total for all systems $188,253.99 $63,374.15 N/A $30,440.13 N/A
Outside Professional Services $92,015.00 $29,603.16 $21,773.15
Project management of the transition $10,550.00 $10,205.25 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $10,205.25 N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $5,712.15 N/A $0.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $327.60 Please see KIRO-TV2 Attorney - STA Budget Revision Justification Letter $327.60 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $47.10 Please see KIRO-TV2 Attorney – Lease Negotiation and Other Matters Budget Revision Justification Letter $47.10 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $500.00 N/A $0.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $1,998.54 N/A $1,998.54 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $300.00 N/A $0.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $1,317.86 N/A $0.00 N/A
Perform engineering study for displacement application $1,800.00 $8,835.16 Please see Est Cost Justification KIRO-TV2-530-RF Eng - Engineering Study for Displacement Application V0 $8,835.16 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $284.50 Please see KIRO-TV2 Prepare/Review 399 Reimbursement Form Budget Revision Justification Letter. The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time $284.50 N/A
RF Exposure Measurements $12,100.00 $75.00 N/A $75.00 N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$1,325.25

Component Description:
Project Management
Amount:
$1,488.00

Component Description:
Project Management
Amount:
$3,852.50

Component Description:
Project Management
Amount:
$3,539.50
Comprehensive coverage verification via field study, if needed

Component Description:
RF study portion of Olympia translator - See Merrill Weiss 399 costs worksheet - Olympia.pdf
Amount:
$5,712.15

Component Description:
RF study portion of Olympia translator - See Merrill Weiss 399 costs worksheet - Olympia.pdf
Amount:
$5,712.15
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
STA
Amount:
$29.30

Component Description:
STA
Amount:
$62.80

Component Description:
STA
Amount:
$235.50
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
Lease
Amount:
$47.10
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Legal LTC application portion of Olympia translator - See Cooley 399 costs worksheet - Olympia.pdf
Amount:
N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
C.P.A
Amount:
$78.50

Component Description:
C.P.A
Amount:
$298.30

Component Description:
C.P.A
Amount:
$117.20

Component Description:
Invoices to be resubmitted per NMI message.
Amount:
N/A

Component Description:
C.P.A
Amount:
$251.20

Component Description:
C.P.A
Amount:
$242.36

Component Description:
C.P.A
Amount:
$194.26

Component Description:
C.P.A
Amount:
$5.86

Component Description:
C.P.A
Amount:
$810.86
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
RF LTC application portion of Olympia translator - See Merrill Weiss 399 costs worksheet - Olympia.pdf
Amount:
$300.00

Component Description:
RF LTC application portion of Olympia translator - See Merrill Weiss 399 costs worksheet - Olympia.pdf
Amount:
$300.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
RF CP application portion of Olympia translator - See Merrill Weiss 399 costs worksheet - Olympia.pdf
Amount:
$1,317.86

Component Description:
RF CP application portion of Olympia translator - See Merrill Weiss 399 costs worksheet - Olympia.pdf
Amount:
$1,317.86
Perform engineering study for displacement application

Component Description:
Engineering Study
Amount:
$8,835.16

Component Description:
Invoice to be resubmitted.
Amount:
N/A

Component Description:
Invoice to be resubmitted
Amount:
N/A
Prepare/ Review 399 reimbursement form

Component Description:
Professional Services
Amount:
$255.20

Component Description:
Cooley
Amount:
$29.30
RF Exposure Measurements

Component Description:
Duplicate component created due to being locked out of original. Can be deleted
Amount:
N/A

Component Description:
Exposure Measurements
Amount:
$75.00

Component Description:
Invoice to be resubmitted
Amount:
N/A

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 $0.00 $0.00 N/A $0.00 N/A
Total for all systems $188,253.99 $63,374.15 N/A $30,440.13 N/A
Other Expenses $0.00 $0.00 $0.00

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $188,253.99 $63,374.15 $30,440.13

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.

Keith Nealey

Director of Engineering


03/29/2021

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.

Keith Nealey

Director of Engineering


03/29/2021

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.

Keith Nealey

Director of Engineering


03/29/2021

Attachments

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