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:
182815
Service:
LPT
Call Sign:
W40CV-D
Channel:
29 (UHF)
File Number:
0000089785
FRN:
0009134289
Eligibility Status:
Eligible
Date Submitted:
04/19/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WAND(TV) PARTNERSHIP

Applicant

Doing Business As: WAND(TV) PARTNERSHIP

Greg Yadon

904 SOUTH SIDE DRIVE

DECATUR, IL 62521

United States

+1 (217) 424-2500 Greg.Yadon@wandtv.com Other

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

Sam Hariton

Widelity, Inc.

Sam Hariton

4031 University Drive

Suite 100

Fairfax, VA, VA 22030

United States

+1 (339) 222-8107 sam.hariton@widelity.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. Yes
Briefly describe transition plan W29ES-D is planning to purchase a new upgraded transmitter, a new like-for-like antenna, and a new like-for-like transmission line.

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 Innovator 2000
Year 2011
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 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? No
Manufacturer
Model UAX-2000AT
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2.5 kW
Justification for New Transmitter Re-tuning the existing main transmitter is not an option because the manufacturer is bankrupt and unable to support the transmitter. See narrative for further details.

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

Transmitter - Proof

Transmitter - Proof

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 Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model DL-12B
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 Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model AL12-29-PLE
Year 2017
Justification for New Antenna The previous antenna was cut to frequency and could not be retuned.

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 3 1/8 inches inches
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? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Primary Antenna Other Expenses

Primary Antenna Other Expenses

Transmission Line

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

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Ownership Owned
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 3 1/8 inches
Segment Length 20 inches
Number of parallel runs 1
Length 900 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Rigid
Diameter 3 1/8 inches
Segment Length 19 1/2 inches
Number of parallel runs 1
Length 956 feet per run
Justification for New Transmission Line The new transmission line is required because a structural analysis found that the existing tower would not support the tower owner's antenna. W29ES-D is being forced to switch towers and get a new line as a result.
Interior RF Systems Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators? No

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

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)
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? Yes
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1221865
Coordinates (NAD83) Latitude (NAD83) 39° 36' 09.2" N-
Longitude (NAD83) 090° 02' 47.4" W-
Overall Structure Height 976.04 feet
Support Structure Height 915.67 feet
Ground Elevation Above Mean Sea Level (AMSL) 672.89 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner West Central Illinois Educational Telecommunications Corporation
Date Constructed 09/23/2002

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
70536 WSEC DTV

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

Name Description

Installation Work on Pre-Displacement Tower

Replacing original antenna with new antenna on original tower. W29ES-D installed post-displacement antenna on pre-displacement tower, then tower owner required them to move from that structure which forced them to deinstall and move to a new location

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 254
Explanation W29ES-D requires the aid of outside project management services to fulfill the requirements of the repack. W29ES-D will hire an outside firm to facilitate and support W29ES-D in these tasks and others to ensure a timely and well managed 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 Yes
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
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 No
RF exposure measurements No
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 Yes
FCC Construction Permit Minor Change Yes
FCC License to Cover Application Yes
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 $93,732.56 $27,873.85 N/A $27,873.84 N/A
Total for all systems $431,907.68 $342,363.11 N/A $311,126.30 N/A
Primary Transmitter UAX-2000AT $93,732.56 $27,873.85 $27,873.84
Mask Filter $5,182.56 $5,182.56 Please see Electronics Research, Inc. proposal 20171003-856, plus proportional freight and tax on invoice W40CV-D-50631 $5,182.56 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $18,141.29 Please see GatesAir quote GA-00024361, plus actual freight and tax on invoice US0310489 $18,141.28 N/A
Transmitter - Proof $4,550.00 $4,550.00 Please see GatesAir quote Q-88389. (Please note that this quote has a typo. This work was performed for a UAX-2000AT transmitter, not a UAXTE-6.) $4,550.00 N/A

Components

Actual Information Description File Name
Mask Filter

Component Description:
W29ES-D-110-New Primary Transmitter - Mask Filter
Amount:
$5,182.56
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Format UAX2000 Single LPU CHIN
Amount:
$18,141.28
Transmitter - Proof

Component Description:
FIELD SERVICE, TV
Amount:
$4,550.00

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 $26,528.48 $31,187.54 N/A $31,187.54 N/A
Total for all systems $431,907.68 $342,363.11 N/A $311,126.30 N/A
Primary Antenna AL12-29-PLE $26,528.48 $31,187.54 $31,187.54
Primary Antenna Other Expenses $4,156.27 $4,156.27 Please see Estimated Cost Justification W29ES-D-210-New Primary Antenna - Other Expenses v0 $4,156.27 N/A
Elbow complex, single channel, 3 1/8” input (if needed) $7,600.00 $5,274.15 Please see Estimated Cost Justification W29ES-D-210-New Primary Antenna - Elbow complex V0 $5,274.15 N/A
Sweep test of transmission line and antenna $5,730.00 $12,714.91 per Estimated Cost Justification W29ES-D-210-New Primary Antenna - Sweep Test v0 $12,714.91 N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical $9,042.21 $9,042.21 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $9,042.21 N/A

Components

Actual Information Description File Name
Primary Antenna Other Expenses

Component Description:
6-1/8" to 1-2/8" Plate reducer 50 OHM
Amount:
$399.73

Component Description:
W29ES-D-210-New Primary Antenna - Other Expenses
Amount:
$3,756.54
Elbow complex, single channel, 3 1/8” input (if needed)

Component Description:
W29ES-D-210-New Primary Antenna - Elbow complex
Amount:
$378.15

Component Description:
W29ES-D-210-New Primary Antenna - Elbow complex
Amount:
$2,448.00

Component Description:
W29ES-D-210-New Primary Antenna - Elbow complex
Amount:
$2,448.00
Sweep test of transmission line and antenna

Component Description:
W29ES-D-210-New Primary Antenna - Sweep Test
Amount:
$625.00

Component Description:
W29ES-D-210-New Primary Antenna - Sweep Test
Amount:
$3,125.00

Component Description:
W29ES-D-210-New Primary Antenna - Sweep Test
Amount:
$6,464.91

Component Description:
W29ES-D-210-New Primary Antenna - Sweep Test
Amount:
$2,500.00
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical

Component Description:
AL12-29-PL
Amount:
$9,042.21

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 $88,430.00 $95,633.70 N/A $95,633.70 N/A
Total for all systems $431,907.68 $342,363.11 N/A $311,126.30 N/A
Primary Transmission Line $88,430.00 $95,633.70 $95,633.70
Rigid Transmission Line - copper, 3 1/8" $88,430.00 $95,633.70 Please see Estimated Cost Justification W29ES-D-310-New Primary Transmission Line - Rigid Copper, 3 ⅛ V3 $95,633.70 N/A

Components

Actual Information Description File Name
Rigid Transmission Line - copper, 3 1/8"

Component Description:
3" VERTICAL SPRING HANGER
Amount:
$3,179.00

Component Description:
W29ES-D-310-New Primary Transmission Line - Rigid Copper, 3 1/8"
Amount:
$39,791.90

Component Description:
W29ES-D-310-New Primary Transmission Line - Rigid Copper, 3 1/8"
Amount:
$1,590.50

Component Description:
Reducer Tapered
Amount:
$540.97

Component Description:
3" 50 OHM Heliax Assembly
Amount:
$3,792.91

Component Description:
Freight Cost
Amount:
$3,537.53

Component Description:
W29ES-D-310-New Primary Transmission Line - Rigid Copper, 3 1/8"
Amount:
$3,408.99

Component Description:
W29ES-D-310-New Primary Transmission Line - Rigid Copper, 3 1/8"
Amount:
$39,791.90

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 $174,729.64 $116,049.92 N/A $116,049.92 N/A
Total for all systems $431,907.68 $342,363.11 N/A $311,126.30 N/A
Primary Tower TOWER $174,729.64 $116,049.92 $116,049.92
Tower Rigging Tall Tower (greater than 500') $157,750.00 $99,070.28 Estimated Cost Justification W29ES-D-410-Existing Primary Tower - Tower Rigging, Tall Tower V1 $99,070.28 N/A
Installation Work on Pre-Displacement Tower $16,979.64 $16,979.64 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time $16,979.64 N/A

Components

Actual Information Description File Name
Tower Rigging Tall Tower (greater than 500')

Component Description:
Removal of antenna services
Amount:
$38,076.00

Component Description:
BRACKETS
Amount:
$3,880.28

Component Description:
Removal of antenna services
Amount:
$47,595.00

Component Description:
Removal of Antenna Services
Amount:
$9,519.00
Installation Work on Pre-Displacement Tower

Component Description:
W29ES-D-410-Existing Primary Tower - Installation Work on Pre-Displacement Tower
Amount:
$11,089.64

Component Description:
WEATHER DAY (10/28/17)
Amount:
$5,890.00

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 $42,082.00 $65,213.10 N/A $40,381.30 N/A
Total for all systems $431,907.68 $342,363.11 N/A $311,126.30 N/A
Outside Professional Services $42,082.00 $65,213.10 $40,381.30
Prepare Form 601 $755.00 $755.00 N/A N/A N/A
Perform engineering study for displacement application $1,800.00 $9,818.10 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $9,818.10 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A
Project management of the transition $26,797.00 $41,910.00 See quote from Widelity $30,215.70 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $3,262.50 N/A $347.50 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A N/A N/A

Components

Actual Information Description File Name
Prepare Form 601 Information not provided.
Perform engineering study for displacement application

Component Description:
Consulting Engineering Services
Amount:
$4,245.78

Component Description:
Professional Services
Amount:
$562.80

Component Description:
Consulting Engineering Services
Amount:
$170.20

Component Description:
Consulting Engineering Services
Amount:
$2,065.62

Component Description:
Professional Services
Amount:
$1,013.70

Component Description:
Consulting engineering services
Amount:
$1,760.00
Prepare/ Review 399 reimbursement form Information not provided.
Project management of the transition

Component Description:
Project Management
Amount:
$1,786.25

Component Description:
Project management
Amount:
$40.00

Component Description:
Project management
Amount:
$6,429.00

Component Description:
Project Management
Amount:
$181.60

Component Description:
Project management
Amount:
$5,638.00

Component Description:
Project Management
Amount:
$126.45

Component Description:
Project Management
Amount:
$3,772.75

Component Description:
Project Management
Amount:
$344.25

Component Description:
Project Management
Amount:
$256.05

Component Description:
Project Management
Amount:
$440.95

Component Description:
Project Management
Amount:
$90.25

Component Description:
Project Management
Amount:
$2,247.20

Component Description:
Project Management
Amount:
$1,936.55

Component Description:
Project Management
Amount:
$925.05

Component Description:
Project Management
Amount:
$1,673.90

Component Description:
Project management
Amount:
$3,913.70

Component Description:
Project Management
Amount:
$311.25

Component Description:
Project Management
Amount:
$102.50
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
Research qualification for FCC repack reimbursements
Amount:
$347.50
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 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 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 $6,405.00 $6,405.00 N/A $0.00 N/A
Total for all systems $431,907.68 $342,363.11 N/A $311,126.30 N/A
Other Expenses $6,405.00 $6,405.00 $0.00
FCC Filing Fees - Form 2100 Major change CP application $4,960.00 $4,960.00 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
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,110.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $431,907.68 $342,363.11 $311,126.30

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.

Keith Wilkowski

VP, Legal & Governmental Affairs


04/19/2021

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 Wilkowski

VP, Legal & Governmental Affairs


04/19/2021

Attachments

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