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:
73101
Service:
DTV
Call Sign:
KAVU-TV
Channel:
20 (UHF)
File Number:
0000028105
FRN:
0026531335
Date Submitted:
04/20/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

QueenB Television of Texas, LLC

Doing Business As: KAVU TV

Danny Aguilar

3808 North Navarro

Victoria, TX 77901

United States

+1 (361) 575-2500 daguilar@victoriatelevision.com Limited Liability Company

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

Bill Vickery , CBTE .

Corp Director of Engineering

Morgan Murphy Media

Bill Vickery

PO Box 659

Pittsburg, KS 66762

United States

+1 (417) 624-0233 bill@morganmurphymedia.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 Modification of the KAVU transmitting facility to accommodate the channel change from 15 to 20. This will require replacing the KAVU CH.15 portion of combiner and mask filter, re-tune exiting transmitter, and installation of a new tuned elbow on the tower

Question Response
Sharee Station Facility ID 57866
Call Sign KUNU-LD
Type
Licensee Name QueenB Television of Texas, LLC
Status LICENSED
DTS No
Community of License VICTORIA, TX
Pre-auction RF Channel 27
Post-auction RF Channel
Neilsen DMA
Network Affiliation
Question Response
Sharee Station Facility ID 128455
Call Sign KMOL-LD
Type
Licensee Name QueenB Television of Texas, LLC
Status LICENSED
DTS No
Community of License VICTORIA, TX
Pre-auction RF Channel 17
Post-auction RF Channel
Neilsen DMA
Network Affiliation
Question Response
Sharee Station Facility ID 127289
Call Sign KQZY-LP
Type
Licensee Name QueenB Television of Texas, LLC
Status LICENSED
DTS No
Community of License VICTORIA, TX
Pre-auction RF Channel 33
Post-auction RF Channel
Neilsen DMA
Network Affiliation
Question Response
Sharee Station Facility ID 31516
Call Sign KXTS-LD
Type
Licensee Name QueenB Television of Texas, LLC
Status LICENSED
DTS No
Community of License VICTORIA, TX
Pre-auction RF Channel 26
Post-auction RF Channel
Neilsen DMA
Network Affiliation

Transmitters

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

Primary Transmitter

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Add Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Retune Existing
Use Primary (Main)
Ownership Owned
Owner 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 Gates air
Model ULXTD-40
Year 2015
Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 40 kW

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed N/A
New Mask Filter
Power Other
Other Power 40.0 kW
New Exciter Is a new exciter needed? No

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

Combiner Modification Install

Installation charges for combiner modification

Antennas

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

Primary Antenna

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Add 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 this antenna currently shared with any other stations? Yes
Is this antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 6
Number of Panels 56
Design power capacity in use 51.0 %
Lower Limit 470.00 MHz
Upper Limit 722.00 MHz
Other Antenna Type N/A
ERP: 1064.0 kW
Manufacturer DIELECTRIC
Model TUA-04SP-15/55H-1-T-R
Year 2004

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID Call Sign
57866 KUNU-LD
127289 KQZY-LP
128455 KMOL-LD
31516 KXTS-LD
73101 KAVU-TV

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? Yes
Type Additional Module
Number of channels supported 6
Frequencies of channels supported RF channel
Frequency N/A

Enter a list of RF channel numbers.

RF Channel Number
15
17
20
25
26
27
33

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? Yes
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Dielectric
Type Rigid
Diameter 8 3/16 inches
Other Diameter N/A
Segment Length Broadband
Other Segment Length N/A
Number of parallel runs 1
Length 1020 feet per run

Facility ID's and Call Signs of all stations with whom the transmission line is shared.

Facility ID Call Sign
127289 KQZY-LP
128455 KMOL-LD
31516 KXTS-LD
57866 KUNU-LD
73101 KAVU-TV

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Tuned Elbow 8 Inch

8 inch tuned elbow Dielectric #R64682

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) Yes
Others Types of Users No
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1238711
Coordinates (NAD83) Latitude (NAD83) 28° 50' 43.4" N-
Longitude (NAD83) 097° 07' 34.0" W-
Overall Structure Height 1040.01 feet
Support Structure Height 981.94 feet
Ground Elevation Above Mean Sea Level (AMSL) 142.06 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Saga Broadcasting, LLC
Date Constructed 12/15/2004

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
35846 KVCT 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: Study needed for documented tower
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

Tower Rigging Cost

Installation of Tuned Elbow on tower

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 8
Explanation Original design of four phase KAVU-TV Ch 15 to Ch 20 Repack channel change. Marsand Engineering
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development No
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 No
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

SITE SURVEY

NEEDED FOR SPECIFYING FINAL EQUIPMENT NEEDS AND INSTALLATION PLANNING

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? No
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change Yes
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
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

Name Description

Interim Facility Construction Labor

Interior UHF RF Systems including coaxial switching to accommodate transmitting on Ch. 15 while the CH.20 system is built and tested.

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 $117,856.64 $74,670.60 N/A $74,669.60 N/A
Total for all systems $659,055.48 $509,429.19 N/A $354,952.38 N/A
Primary Transmitter ULXTD-40 $117,856.64 $74,670.60 $74,669.60
Combiner Modification Install $12,655.64 $12,655.64 Install Charges for Combiner modifications $12,655.64 N/A
Other 40.0 kW mask filter $1.00 $1.00 Included in Combiner modification costs from Dielectric See attachment CLE 163 KAVU Combiner N/A N/A
UHF and VHF - minor banding issues $105,200.00 $62,013.96 Install Air Cooled Reject Load-$6,038.44 Install CH20 MAsk Filter & Move B Xmtr to CH.20- $27,812.84 Install CH20 Magic T, Combiner, normalize system and proof - $28,162.68 $62,013.96 Marsand, Inc. Invoices #7263 and #7264 were rounded to the nearest whole dollar upon billiing. KAVU-TV is requesting the original estimated cost based on quotations provided.

Components

Actual Information Description File Name
Combiner Modification Install

Component Description:
Portion of invoice 7265 for channel combiner installation costs
Amount:
$12,655.64
Other 40.0 kW mask filter Information not provided.
UHF and VHF - minor banding issues

Component Description:
Portion of Invoice 7265 for installation of aircooled reject load
Amount:
$6,038.44

Component Description:
Installation cost for channel 20 magic tee.
Amount:
$28,162.68

Component Description:
Installation cost for channel 20 mask filter.
Amount:
$27,812.84

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 $90,930.00 $211,448.75 N/A $211,099.84 N/A
Total for all systems $659,055.48 $509,429.19 N/A $354,952.38 N/A
Primary Antenna TUA-04SP-15/55H-1-T-R $90,930.00 $211,448.75 $211,099.84
Adding a module to existing combiner (without antenna) $84,200.00 $204,948.75 Combiner modification costs. See attachment Dielectric Narrative spec_sheet_R-70196_KAVU.pdf for full justification. $204,599.84 N/A
Sweep test of existing antenna $6,730.00 $6,500.00 N/A $6,500.00 N/A

Components

Actual Information Description File Name
Adding a module to existing combiner (without antenna)

Component Description:
1st 45% prepayment upon order
Amount:
$92,248.00

Component Description:
Shipping and Freight Costs
Amount:
$6,191.25

Component Description:
2nd 45% prepayment before shipment
Amount:
$92,248.09

Component Description:
Final Payment Balance
Amount:
$13,912.50
Sweep test of existing antenna

Component Description:
Costs for antenna system sweep test
Amount:
$6,500.00

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 $3,600.00 $3,600.00 N/A $0.00 N/A
Total for all systems $659,055.48 $509,429.19 N/A $354,952.38 N/A
Primary Transmission Line $3,600.00 $3,600.00 $0.00
Tuned Elbow 8 Inch $3,600.00 $3,600.00 Dielectric Part R64682 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 $228,100.00 $5,000.00 N/A $0.00 N/A
Total for all systems $659,055.48 $509,429.19 N/A $354,952.38 N/A
Primary Tower TOWER $228,100.00 $5,000.00 $0.00
Structural engineering tower load study for well documented tower $12,600.00 $0.00 N/A N/A N/A
Tall Tower (greater than 500') $210,500.00 $0.00 Existing Tower N/A N/A
Tower Rigging Cost $5,000.00 $5,000.00 Installation of Tuned Elbow on Tower 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 $31,620.08 $28,886.08 N/A $9,636.08 N/A
Total for all systems $659,055.48 $509,429.19 N/A $354,952.38 N/A
Outside Professional Services $31,620.08 $28,886.08 $9,636.08
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
Project management of the transition $1,264.00 $0.00 N/A N/A N/A
SITE SURVEY $9,636.08 $9,636.08 Required for specifying the final equipment needs and installation planning $9,636.08 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 and or review reimbursement form $2,630.00 $2,500.00 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 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
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.
Project management of the transition Information not provided.
SITE SURVEY

Component Description:
Professional Services Site Survey
Amount:
$9,636.08
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare and or review reimbursement form Information not provided.
Prepare engineering section of 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 $186,948.76 $185,823.76 N/A $59,546.86 N/A
Total for all systems $659,055.48 $509,429.19 N/A $354,952.38 N/A
Other Expenses $186,948.76 $185,823.76 $59,546.86
Interim Facility Construction Labor $130,000.00 $130,000.00 Interim UHF RF systems and switching to accommodate operation on ch.15 while the Ch.20 facility is built and tested $11,539.00 N/A
MVPD Notification of Channel Change $1,000.00 $1,000.00 Prepare and deliver notice to all cable and satellite companies: 8 hours @ $125 N/A N/A
Develop and air announcement of upcoming channel change $350.00 $350.00 Video production of announcement: $350 N/A N/A
Equipment Storage $3,600.00 $3,600.00 On Site container to store equipment to be installed. $1,833.19 N/A
Equipment Delivery and Handling Charges $8,500.00 $8,500.00 Shipping, fork lift, labor. $4,645.49 N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $0.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $41,858.76 $41,858.76 REMOVE OLD IOT TRANSMITTER AND DISPOSE ($16,067.04) REMOVE AND DISPOSE OF CH15 RF SYSTEM AND OLD HIGH POWER CHANNEL COMBINER ($14,965.68) DUMPSTER RENTAL AND MANAGEMENT ($10826.04) $41,529.18 N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A

Components

Actual Information Description File Name
Interim Facility Construction Labor

Component Description:
Labor Costs for Interim Facility Configuration during channel change
Amount:
$11,539.00
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage

Component Description:
Equipment storage container and fees.
Amount:
$161.15

Component Description:
Equipment storage container and fees
Amount:
$177.38

Component Description:
Equipment storage container and fees.
Amount:
$161.15

Component Description:
Equipment storage container and fees
Amount:
$1,172.36

Component Description:
Equipment Storage Container and fees
Amount:
$161.15
Equipment Delivery and Handling Charges

Component Description:
Equipment Handling. Final Invoice for boom lift rental.
Amount:
$98.24

Component Description:
Equipment Handling. Boom Forklift Rental.
Amount:
$3,506.47

Component Description:
Equipment Handling. Forklift rental and operator for 2.5 hours
Amount:
$263.72

Component Description:
Equipment Handling. Forklift rental and operator for 3.5 hours
Amount:
$451.03

Component Description:
Equipment Handling. Forklift rental and operator for 2.5 hours
Amount:
$326.03
FCC Filing Fees - Form 2100 minor change CP application 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)

Component Description:
Disposal container rental and fees
Amount:
$328.37

Component Description:
Equipment Disposal Costs
Amount:
$31,032.72

Component Description:
Disposal container rental and fees. Current due balance.
Amount:
$1,097.07

Component Description:
Disposal container rental and fees. Current Due Balance
Amount:
$329.38

Component Description:
Disposal container rental and fees
Amount:
$329.16

Component Description:
Disposal container rental and fees
Amount:
$1,075.63

Component Description:
Disposal container rental and fees
Amount:
$575.45

Component Description:
Disposal container rental and fees
Amount:
$1,076.41

Component Description:
Disposal container rental and fees
Amount:
$1,077.85

Component Description:
Disposal container rental and fees
Amount:
$328.57

Component Description:
Disposal container rental and fees
Amount:
$328.97

Component Description:
Disposal container rental and fees. Current due balance
Amount:
$328.17

Component Description:
Disposal container rental and fees
Amount:
$1,097.07

Component Description:
Disposal container rental and fees
Amount:
$1,098.10

Component Description:
Disposal container rental and fees
Amount:
$1,097.88

Component Description:
Disposal container rental and fees
Amount:
$328.38
FCC Filing Fees - Special Temporary Authorization request Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $659,055.48 $509,429.19 $354,952.38

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.

William Vickery

Corp. Director of Engineering


04/20/2021

Certification

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Section Question Response
Submission of Final Allocation or Accounting Information Statements

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

  1. The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

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

  3. The above-named entity certifies that all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates.

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

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

  6. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

William Vickery

Corp. Director of Engineering


04/20/2021

Attachments

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