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:
74113
Service:
LPT
Call Sign:
W23CN-D
Channel:
36 (UHF)
File Number:
0000090108
FRN:
0028930774
Eligibility Status:
Eligible
Date Submitted:
03/05/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

CBS OPERATIONS INVESTMENTS INC.

Doing Business As: CBS OPERATIONS INVESTMENTS INC.

Daniel G. Ryson

2020 M. St., NW - Licensing DEPT

WASHINGTON, DC 20036

United States

+1 (202) 457-4505 DRYSON@CBS.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

Daniel G Ryson

CBS Communications Services Inc.

Daniel G. Ryson

2020 M. St., NW - Licensing DEPT

Washington, DC 20036

United States

+1 (202) 457-4074 dryson@cbs.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 Replace existing antenna, mask filter, exciter, and transmitter. Delays in final antenna delivery will require a temporary interim antenna to prevent extended off-air time.

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 UHF-600
Year 2014
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 600 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-2
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.2 kW
Justification for New Transmitter Change in Frequency results in reduction in coverage due to dipole factor effects. An increase in TPO is required to maintain present coverage.

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 No
HVAC Service Does the replacement transmitter require HVAC Service? No
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Mask Filter

Mask Filter Purchased Separately from Transmitter to be available for temporary use with both existing transmitter on post-transition channel and final transmitter.

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Ownership Owned
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 5.55 kW
Manufacturer
Model BU8A
Year 2002

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Change Type Purchase New
Ownership Owned
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
ERP: 8.0 kW
Manufacturer
Model TLP-8W
Year 2020
Justification for New Antenna Measurement of existing antenna system demonstrates that it is not suitable for repack 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
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

Name Description

Interim Antenna

Interim Antenna - Required due to manufacturing delays of main antenna.

'Pre-Transition Antenna Sweep

Pre-transition antenna sweep. Determined pre-transition antenna was unsuitable for post-transition use.

Various Jumpers Adapters

Various transmission line jumpers and adapters required for both the interim and primary antenna.

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 Owned
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 1030953
Coordinates (NAD83) Latitude (NAD83) 27° 27' 15.0" N-
Longitude (NAD83) 081° 24' 22.0" W-
Overall Structure Height 417.32 feet
Support Structure Height 399.60 feet
Ground Elevation Above Mean Sea Level (AMSL) 109.58 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner CBS Communications Services Inc.
Date Constructed 12/06/1983


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

Structural Engineering

Structural Engineering Study

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 150
Explanation Company lacks internal resources.
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 No
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 No
Prepare and file Form FCC License to Cover Application No
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 No
Form 399 assistance or other program management costs No
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service No

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Pre-Transition Line Sweep

Sweep existing transmission line prior to changes. Verify line is good on post-transition channel.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Permit and Filing Costs FCC Construction Permit Major Change No
FCC Construction Permit Minor Change No
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
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

Medical Notification

Medical Notification

Florida State Sales Tax

Sales Tax on Various Items

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 $86,629.00 $59,892.52 N/A $47,231.53 N/A
Total for all systems $396,386.12 $323,372.14 N/A $167,358.01 N/A
Primary Transmitter UAXTE-2 $86,629.00 $59,892.52 $47,231.53
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $57,263.52 Please see Exhibit 4A for quote. Post-transition channel is less efficient due to dipole factor and antenna with similar pattern has less gain. Cost Includes RF System, Electrical and Installation. $44,602.53 N/A
Mask Filter $2,629.00 $2,629.00 Post-Transition Channel Mask Filter. Purchased separately from transmitter for temporary use with existing transmitter on post-transition channel as well as replacement transmitter. Please see Exhibit 2A for quote. Tax and freight listed separately. $2,629.00 N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Invoice is for transmitter, RF System, Electrical, and Sales Tax. See quote in Exhibit 4A. This cost is all but Sales Tax, listed separately.
Amount:
$44,602.53
Mask Filter

Component Description:
Invoice is for mask filter and expedited shipping. This cost is mask filter alone. As explained in Exhibit 27, we are not seeking reimbursement for shipping.
Amount:
$2,629.00

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 $105,514.48 $106,184.48 N/A $85,003.12 N/A
Total for all systems $396,386.12 $323,372.14 N/A $167,358.01 N/A
Primary Antenna TLP-8W $105,514.48 $106,184.48 $85,003.12
Various Jumpers Adapters $3,187.12 $3,187.12 Various transmission line jumpers, adapters, etc. required for the interim antenna. Please see quotes in Exhibits 13 and 15. $3,187.12 N/A
'Pre-Transition Antenna Sweep $2,000.00 $2,000.00 Pre-Transition Transmission Line Sweep - Verify existing line is appropriate for post-transition channel. Please see quote in Exhibit 7. Relocated from Outside Professional Services per Fund Administrator. $2,000.00 N/A
Interim Antenna $13,315.13 $13,315.13 Includes antenna, mounting brackets, transmission line adapters, and sweep. Excludes Mask Filter, freight, dehydrator, and sales tax, all listed separately. Please see quote and change order in Exhibit 2A. $0.00 N/A
UHF-Low Power, Top Mount, Slotted Coaxial, 8.0kW input, Elliptical $1,466.23 $1,466.23 Antenna (Exhibit 1B) minus helicopter lugs (Exhibit 24B) and tax (Exhibit 26A - both listed separately) and non-reimbursable upgrade (Exhibit 24B) is $81,282.23. Of that, $79,816.00 is shown in a now locked cost category. The difference is shown here. N/A N/A
Sweep test of transmission line and antenna $5,730.00 $6,400.00 Please see Exhibit 1A N/A N/A
UHF-Low Power, Top Mount, Slotted Coaxial, 5.55kW input, Horizontal $79,816.00 $79,816.00 ***System Notice: Estimate adjusted and locked because line has been superseded.***See quotation in Exhibit 1A. Includes Cost for elbows, reducer, and cut-line estimates. V-Pol upgrade was not included. Costs for helicopter lug, sweep, freight, and sales tax are listed separately. $79,816.00 N/A

Components

Actual Information Description File Name
Various Jumpers Adapters

Component Description:
Adapter required for antenna. Please see Exhibit 13 for quote.
Amount:
$1,048.00

Component Description:
Transmission Line Jumper, hangers, and adapters required to connect antenna. Please see Exhibit 15.
Amount:
$2,139.12
'Pre-Transition Antenna Sweep

Component Description:
Pre-Transition Transmission Line Sweep - Verify existing line is appropriate for post-transition channel. Please see quote in Exhibit 7. Relocated from Outside Professional Services per Fund Administrator.
Amount:
$2,000.00
Interim Antenna

Component Description:
Invoice is for antenna, dehydrator, reducer, adapter. As explained in Exhibit 28, we are not seeking reimbursement for the dehydrator.
Amount:
$7,188.00
UHF-Low Power, Top Mount, Slotted Coaxial, 8.0kW input, Elliptical Information not provided.
Sweep test of transmission line and antenna Information not provided.
UHF-Low Power, Top Mount, Slotted Coaxial, 5.55kW input, Horizontal

Component Description:
Primary Antenna, Elbows, and Reducer. Please see Exhibit 1A for quotation.
Amount:
$79,816.00

Component Description:
Invoice is for addition of V-Pol and Helicopter Lifting Lugs. Non-reimbursable V-Pol cost is not being requested. Please see statement in Exhibit 24A.
Amount:
$2,500.00

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 $152,099.30 $95,909.30 N/A $14,739.10 N/A
Total for all systems $396,386.12 $323,372.14 N/A $167,358.01 N/A
Primary Tower GTOWER $152,099.30 $95,909.30 $14,739.10
Structural Engineering $12,067.27 $12,067.27 Structural Engineering Study. Based on actual cost to date. $12,067.27 N/A
Tower Rigging Short Tower (less than 500') $56,190.00 $0.00 Catalog Cost for Towers Shorter than 500 feet. Functionally replaced by helicopter lift, listed separately. N/A N/A
Tower Helicopter Lift $83,842.03 $83,842.03 Please see estimates in Exhibit 3A ($75,860.00 rigging & helicopter & $5,310 for sales tax); Exhibit 24B ($2,500 for Lifting Lugs); and Exhibit 26A ($171.83 for Sales Tax on Lifting Lugs). Total corrected 1/15/21 based on projected costs. $2,671.83 N/A

Components

Actual Information Description File Name
Structural Engineering

Component Description:
Tower structural analysis. Please see Exhibit 21.
Amount:
$1,500.00

Component Description:
Interim Antenna Installation. Tax shown separately. Please see Exhibit 18 for quotation.
Amount:
$10,567.27
Tower Rigging Short Tower (less than 500') Information not provided.
Tower Helicopter Lift

Component Description:
Helicopter Lifting Lugs. Please see Exhibit 25B.
Amount:
$2,500.00

Component Description:
Sales tax for helicopter lifting lugs. Sales tax on V-Pol Upgrade deducted. Please see Exhibit 26A.
Amount:
$171.83

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 $19,727.50 $28,970.00 N/A $8,795.61 N/A
Total for all systems $396,386.12 $323,372.14 N/A $167,358.01 N/A
Outside Professional Services $19,727.50 $28,970.00 $8,795.61
Pre-Transition Line Sweep $0.00 $0.00 Pre-Transition Transmission Line Sweep - Verify existing line is appropriate for post-transition channel. Please see quote in Exhibit 7. Cost relocated to antenna cost category per Fund Administrator. $0.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $3,070.00 Cost Catalog estimate. $1,300.00 N/A
Perform engineering study for displacement application $1,800.00 $2,800.00 Cost Catalog estimate. $1,187.50 N/A
Project management of the transition $15,825.00 $23,100.00 150 hours at $154/hour - Cost Catalog estimate. Estimate based on projected costs. This will be adjusted when final invoice is submitted. $6,308.11 N/A

Components

Actual Information Description File Name
Pre-Transition Line Sweep

Component Description:
Pretransition transmission line sweep. Please see quote in Exhibit 7. Cost moved to Antenna Cost Category per Fund Administrator.
Amount:
N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Prepare Engineering Section of Construction Permit Application.
Amount:
$1,300.00
Perform engineering study for displacement application

Component Description:
Engineering Study for Displacement Application.
Amount:
$1,187.50
Project management of the transition

Component Description:
Project Management
Amount:
$1,601.65

Component Description:
Project Management
Amount:
$225.00

Component Description:
Project Management
Amount:
$1,518.96

Component Description:
Project Management
Amount:
$2,550.00

Component Description:
Project Management
Amount:
$262.50

Component Description:
Project Management
Amount:
$150.00

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 $32,415.84 $32,415.84 N/A $11,588.65 N/A
Total for all systems $396,386.12 $323,372.14 N/A $167,358.01 N/A
Other Expenses $32,415.84 $32,415.84 $11,588.65
Medical Notification $5,000.00 $5,000.00 Approximate - within range of Widelity Cost Catalog estimates. N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $305.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $5,000.00 $5,000.00 Approximation N/A N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 Approximation $2,256.11 N/A
Equipment Storage $5,000.00 $5,000.00 Approximation $0.00 N/A
Florida State Sales Tax $11,775.84 $11,775.84 Estimated and actual Florida State Sales Tax. Please see Exhibits 3A ($5,310.20), 17A ($160.43), 19 ($740.00), 25 ($4,913.96), 30 ($184.03), 31 ($467.22), and 33 ($2,866.90). $9,332.54 The Predetermined Cost equals the Actual Cost.

Components

Actual Information Description File Name
Medical Notification 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.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Equipment Delivery and Handling Charges

Component Description:
Transmitter shipping.
Amount:
$2,256.11
Equipment Storage Information not provided.
Florida State Sales Tax

Component Description:
Invoice is for transmitter, RF System, Electrical, and Sales Tax. See quote in Exhibit 4A. This cost is Sales Tax. Other items listed listed separately
Amount:
$2,866.90

Component Description:
FL Sales Tax on Dielectric Invoice 687027
Amount:
$184.03

Component Description:
Sales Tax for interim antenna installation. Please see Exhibit 18 for quotation.
Amount:
$740.00

Component Description:
Sales tax on primary antenna. Please see Exhibit 25.
Amount:
$4,913.96

Component Description:
Partial reimbursement for Sales Tax on Dielectric Invoice 688001. Please see Exhibit 31A for details.
Amount:
$467.22

Component Description:
Invoice is for sales tax on non-reimbursable V-Pol and Helicopter lifting lug. Seeking reimbursement only for lifting lug tax. Please see Exhibit 26.
Amount:
$171.83

Component Description:
Florida State Sales Tax on Interim TX Line Jumper. Please see Exhibits 16 and 17A.
Amount:
$160.43

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $396,386.12 $323,372.14 $167,358.01

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.

Andrew J Siegel

Assistant Secretary


03/05/2021

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.

Andrew J Siegel

Assistant Secretary


03/05/2021

Attachments

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