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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:
60931
Service:
DTV
Call Sign:
WNEH
Channel:
26 (UHF)
File Number:
0000028313
FRN:
0001861160
Date Submitted:
04/21/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

SOUTH CAROLINA EDUCATIONAL TV COMMISSION

Doing Business As: SOUTH CAROLINA EDUCATIONAL TV COMMISSION

Mark Jahnke

1041 GEORGE ROGERS BOULEVARD

COLUMBIA, SC 29201

United States

 +1 (803) 737-3486 mjahnke@scetv.org Government Entity

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

Robert Gehman

ConsultingEngineer

Kessler and Gehman Associates, Inc.

Robert Gehman

507 NW 60 Street

Suite D

Gainesville, FL 32607

United States

 +1 (352) 332-3157 bob@kesslerandgehman.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 transmitter using the existing antenna and line. See attached.

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 ULXTE-10
Year 2015
Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power Capacity 7.2 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 ULXTE-16
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 10.9 kW
Justification for New Transmitter A standby transmitter would be required to keep the station on the air during the modification and a new mask filter would be required for the repack channel. See cover letter.

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

Name Description

Internal RF System

Patch bay, etc to connect xmtr

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use N/A
Change Type Purchase
Manufacturer
Model TBD
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 5 kW
Justification for New Transmitter Needed for continued operation during retuning and for the remainder of the assigned phase. Station will rent if available.

Interim Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) Yes
Transformer (480V) Yes
Power 150 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 100.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 tons
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
Inside RF System Is an additional interior RF system required to support this interim transmitter? Yes

Interim 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 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? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 56
Design power capacity in use 100.0 %
Lower Limit 470.00 MHz
Upper Limit 692.00 MHz
Other Antenna Type N/A
ERP: 106.7 kW
Manufacturer Dielectric
Model TUF-O4-14/56H-1-T
Year 2008

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 Utilize Existing
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 Dielectric
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length Other
Other Segment Length 19.417 feet
Number of parallel runs 1
Length 700 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Sweep Tests

Sweep Tests to determine suitability of transmission line

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? Yes
One or more FM, AM or TV radio broadcaster(s) No
Others Types of Users Yes
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1059185
Coordinates (NAD83) Latitude (NAD83) 34° 22' 19.9" N-
Longitude (NAD83) 082° 10' 03.9" W-
Overall Structure Height 686.02 feet
Support Structure Height 626.96 feet
Ground Elevation Above Mean Sea Level (AMSL) 696.84 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner SOUTH CAROLINA EDUCATIONAL TELEVISION
Date Constructed 02/10/2005


Other Types of Users

Users
WNEH microwave

Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: No study needed
Tower Reinforcements Please select whether tower reinforcements are needed: No reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? 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 102
Explanation It will be necessary to schedule and coordinate multiple vendors and complete progress reports. 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 Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 10
Justification It will be necessary to plan the installation, develop specifications for purchasing, and perform final inspections of this RF project. Station does not have available personnel or personnel trained in such services.

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 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 $987,700.00 $689,750.00 N/A $219,044.90 N/A
Total for all systems $1,418,320.00 $876,880.00 N/A $247,084.12 N/A
Interim Transmitter TBD $473,200.00 $449,750.00 $0.00
UHF inside RF system including switching $147,500.00 $140,000.00 N/A N/A N/A
5 Ton system $20,250.00 $19,250.00 Station previously had a 5 kW air cooled transmitter and now has 7.2 kW liquid. The additional cooling might not be required if the cooling of the prior transmitter is still sufficient. N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $5,200.00 $4,900.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $24,300.00 N/A N/A N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 4 - 6 kW $236,500.00 $225,000.00 N/A $0.00 N/A
Primary Transmitter ULXTE-16 $514,500.00 $240,000.00 $219,044.90
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW $494,500.00 $220,000.00 N/A $219,044.90 N/A
Internal RF System $20,000.00 $20,000.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF inside RF system including switching Information not provided.
5 Ton system Information not provided.
3" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Transformer 3 phase/480v - 150 KVA Information not provided.
Switchgear - industrial 800 amp Information not provided.
UHF - Air Cooled Solid State Transmitter 4 - 6 kW

Component Description:
Transmitter 50% Down Payment
Amount:
$115,886.44
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW

Component Description:
Reimbursable amount of base transmitter. See cover sheet.
Amount:
$219,044.90
Internal RF System Information not provided.

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 $20,430.00 $19,400.00 N/A $0.00 N/A
Total for all systems $1,418,320.00 $876,880.00 N/A $247,084.12 N/A
Primary Antenna TUF-O4-14/56H-1-T $20,430.00 $19,400.00 $0.00
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed) $13,700.00 $13,000.00 N/A N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A

Components

Information not provided.

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 $6,400.00 $6,400.00 N/A $0.00 N/A
Total for all systems $1,418,320.00 $876,880.00 N/A $247,084.12 N/A
Primary Transmission Line $6,400.00 $6,400.00 $0.00
Sweep Tests $6,400.00 $6,400.00 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 $210,500.00 $20,000.00 N/A $0.00 N/A
Total for all systems $1,418,320.00 $876,880.00 N/A $247,084.12 N/A
Primary Tower TOWER $210,500.00 $20,000.00 $0.00
Tall Tower (greater than 500') $210,500.00 $20,000.00 Rigging for replacement and/or retuning assistance associated with elbow complex 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 $151,026.00 $106,866.00 N/A $23,575.22 N/A
Total for all systems $1,418,320.00 $876,880.00 N/A $247,084.12 N/A
Outside Professional Services $151,026.00 $106,866.00 $23,575.22
Comprehensive coverage verification via field study, if needed $84,200.00 $42,000.00 Quote from Sixarms uploaded. N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A 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 $3,250.00 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $2,500.00 N/A
Project management of the transition $16,116.00 $16,116.00 N/A $15,825.22 N/A
Additional Field Engineering Service, 10 Days $20,000.00 $20,000.00 N/A N/A N/A
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 $1,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Comprehensive coverage verification via field study, if needed Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
WNEH - Prepare CP application
Amount:
$2,000.00
Perform engineering study for new channel assignment and antenna development

Component Description:
WNEH - Engineering study for new channel and antenna development
Amount:
$3,250.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Prepare and or review reimbursement form

Component Description:
Prepare Reimbursement Form 399
Amount:
$2,500.00
Project management of the transition

Component Description:
WNEH Project Management Feb - Jun 2017
Amount:
$1,807.43

Component Description:
Project Management for January - June 2018
Amount:
$2,696.25

Component Description:
Project Management - Jul thru Dec 2019
Amount:
$2,407.50

Component Description:
Project Management - July thru December 2020
Amount:
$1,927.50

Component Description:
Project Management - Jan thru Jun 2019
Amount:
$2,227.50

Component Description:
WNEH Project Management Jul-Dec 2017
Amount:
$1,804.04

Component Description:
Project Management - Jan thru June 2020
Amount:
$2,955.00
Additional Field Engineering Service, 10 Days Information not provided.
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 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 $42,264.00 $34,464.00 N/A $4,464.00 N/A
Total for all systems $1,418,320.00 $876,880.00 N/A $247,084.12 N/A
Other Expenses $42,264.00 $34,464.00 $4,464.00
MVPD Notification of Channel Change $714.00 $714.00 N/A $714.00 N/A
DTV Medical Facility Notification $11,550.00 $3,750.00 N/A $3,750.00 N/A
Develop and air announcement of upcoming channel change $0.00 $0.00 N/A N/A N/A
Equipment Delivery and Handling Charges $20,000.00 $20,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $10,000.00 $10,000.00 N/A N/A N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change

Component Description:
MVPD Notifications
Amount:
$714.00
DTV Medical Facility Notification

Component Description:
Medical Notifications
Amount:
$3,750.00
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.

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $1,418,320.00 $876,880.00 $247,084.12

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.

Leslie Griffin

Repack Project Manager


04/21/2021

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.

Leslie Griffin

Repack Project Manager


04/21/2021

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.

Leslie Griffin

Repack Project Manager


04/21/2021

Attachments

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