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:
36533
Service:
DTV
Call Sign:
WLAJ
Channel:
25 (UHF)
File Number:
0000028312
FRN:
0004284899
Date Submitted:
08/18/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

MISSION BROADCASTING, INC.

Dennis Thatcher

901 INDIANA AVENUE

SUITE 375

WICHITA FALLS, TX 76301

United States

+1 (940) 228-7861 missionbroadcasting@gmail.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

Gregory L. Masters , Esq .

FCC Counsel

Wiley Rein LLP

1776 K Street, N.W.

Washington, DC 20006

United States

+1 (202) 719-7370 gmasters@wiley.law

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 See attached Transition Plan Document.

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-20
Year 2015
Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power Capacity 12 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 THU9EVO-40
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 61 kW
Justification for New Transmitter Existing could be retuned but Gates informs that the transmitter would off-air for multiple days for this activity. It is more cost and time effective to replace the transmitter and avoid interim facilities, tower rigging, etc.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) Yes
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring Yes
Size 3 inches
Length 60.0 feet
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? Yes
Size 100.0 square feet
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

Transmitter Installation Services

Site Survey, Drawings, Proj. Management, Transmitter Installation, and Electrical. Please see Land Communications estimate # 1077 attached

Additional Transmitter Costs

Additional Transmitter Costs

Ice Shield Modifications

Ice Shield Modifications

Transmitter Floor Leveling

Leveling of Transmitter Floor as requested by by the installer. Please see United Commercial Flooring Inc. Estimate # 2963 Attached

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? 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 Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 40
Design power capacity in use 25.0 %
Lower Limit 470.00 MHz
Upper Limit 700.00 MHz
Other Antenna Type N/A
ERP: 480.0 kW
Manufacturer DIELECTRIC
Model TUF-C4-10/40H-1-T
Year 2015

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 7 3/16 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1050 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Transmission Line Sweep Test

Transmission Line Sweep Test

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? No

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 200
Explanation Outside Project Management of transition required due to limited staffing availability at station.
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 No
RF Field Engineering Services Comprehensive coverage verification via field study Yes
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

FCC Progress Report Prep

Prepare and file FCC quarterly Progress Reports.

CHANNEL 14 ISSUES

Engineering support and other both direct and indirect costs to resolve channel 14 interference to LM services. This can include equipment, and service expenses to relocate LM facilities, re-license equipment coverage studies, and other associated tasks.

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 Yes
Non-zoning permits No
BLM or NFS Coordination 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? No
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? No
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Name Description

Land Mobile Facilities Notification

Land Mobile Facilities Notification

Sales and Use Tax Due

Sales and Use Tax Due

Tower Crew

Expenses for tower crew to climb and to readjust/replace tuners on the antenna.

Viewer Notification

Costs to produce materials for viewer notification.

Equipment Rentals

Equipment Rentals

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 $2,047,602.77 $637,132.77 N/A $632,132.77 N/A
Total for all systems $2,516,267.77 $1,092,697.77 N/A $812,031.47 N/A
Primary Transmitter THU9EVO-40 $2,047,602.77 $637,132.77 $632,132.77
Transmitter Floor Leveling $9,780.02 $9,780.02 Leveling of Transmitter Floor as requested by by the installer. Please see United Commercial Flooring Inc. Estimate # 2963 Attached $9,780.02 N/A
Ice Shield Modifications $8,516.00 $8,516.00 See Clery Fence quote March 18, 2020 $8,516.00 N/A
Additional Transmitter Costs $39,065.00 $39,065.00 See Rohde & Schwarz quotes 257791.0 and 255492.0 $39,065.00 N/A
Transmitter Installation Services $141,521.75 $141,521.75 Site Survey, Drawings, Proj. Management, Transmitter Installation, and Electrical. Please see Land Communications estimate # 1077 attached $141,521.75 N/A
Other -- Building Addition Size: 100.0 $5,000.00 $5,000.00 Need to move walls, plumbing, electrical wiring, lighting fixtures, etc. N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $3,120.00 $0.00 See Transmitter Installation Services N/A N/A
Switchgear - industrial 800 amp $38,200.00 $0.00 See Transmitter Installation Services N/A N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $0.00 See Transmitter Installation Services N/A N/A
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW $1,788,000.00 $433,250.00 See Rohde & Schwarz quote 208212.0, less upgrade cost $433,250.00 N/A

Components

Actual Information Description File Name
Transmitter Floor Leveling

Component Description:
Transmitter building floor leveling
Amount:
$9,780.02
Ice Shield Modifications

Component Description:
Ice shield modifications
Amount:
$8,516.00
Additional Transmitter Costs

Component Description:
Additional transmitter costs
Amount:
$19,718.00

Component Description:
Additional transmitter costs
Amount:
$19,347.00
Transmitter Installation Services

Component Description:
Transmitter electrical and installation, installment #1
Amount:
$70,760.88

Component Description:
Transmitter electrical and installation, installment #2
Amount:
$70,760.87
Other -- Building Addition Size: 100.0 Information not provided.
3" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Switchgear - industrial 800 amp Information not provided.
Service entrance 3 phase/800 amp/208 volt Information not provided.
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW

Component Description:
Transmitter, installment #2
Amount:
$324,937.50

Component Description:
Transmitter, installment #1
Amount:
$108,312.50

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 $20,630.00 $19,600.00 N/A $3,200.00 N/A
Total for all systems $2,516,267.77 $1,092,697.77 N/A $812,031.47 N/A
Primary Antenna TUF-C4-10/40H-1-T $20,630.00 $19,600.00 $3,200.00
Elbow complex, single channel, at antenna input, per 7 3/16. feedline (if needed) $13,900.00 $13,200.00 N/A N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $3,200.00 N/A

Components

Actual Information Description File Name
Elbow complex, single channel, at antenna input, per 7 3/16. feedline (if needed) Information not provided.
Sweep test of existing antenna

Component Description:
Sweep test
Amount:
$3,200.00

Component Description:
Sweep test
Amount:
$3,200.00

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 $6,400.00 $6,400.00 N/A $6,400.00 N/A
Total for all systems $2,516,267.77 $1,092,697.77 N/A $812,031.47 N/A
Primary Transmission Line $6,400.00 $6,400.00 $6,400.00
Transmission Line Sweep Test $6,400.00 $6,400.00 Sweep test $6,400.00 N/A

Components

Actual Information Description File Name
Transmission Line Sweep Test

Component Description:
Transmission line sweep test
Amount:
$6,400.00

Cost Information

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Tower Equipment and Rigging Costs

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 $296,880.00 $288,375.00 N/A $57,366.79 N/A
Total for all systems $2,516,267.77 $1,092,697.77 N/A $812,031.47 N/A
Outside Professional Services $296,880.00 $288,375.00 $57,366.79
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $875.00 N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 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
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $625.00 N/A $625.00 N/A
CHANNEL 14 ISSUES $150,000.00 $150,000.00 Engineering support and other both direct and indirect costs to resolve channel 14 interference to LM services. See attached letter from MSW. $34,980.00 N/A
FCC Progress Report Prep $3,000.00 $3,000.00 Prepare and file Quarterly FCC progress reports. N/A N/A
Project management of the transition $31,600.00 $30,000.00 N/A $20,136.79 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $750.00 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
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

Components

Actual Information Description File Name
Perform engineering study for new channel assignment and antenna development

Component Description:
Repack engineering services
Amount:
$875.00
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Prepare License to Cover application
Amount:
$625.00
CHANNEL 14 ISSUES

Component Description:
Consulting services for interference issues
Amount:
$34,980.00
FCC Progress Report Prep Information not provided.
Project management of the transition

Component Description:
Engineering consulting fees Nov 2019
Amount:
$80.00

Component Description:
Project management services
Amount:
$255.00

Component Description:
Project management services Jul 2019
Amount:
$130.00

Component Description:
Project management services
Amount:
$316.00

Component Description:
Engineering consulting fees Jan 2020
Amount:
$130.00

Component Description:
Project management costs
Amount:
$809.00

Component Description:
Project management services
Amount:
$4,938.79

Component Description:
Project management services 6.1.19 through 6.28.19
Amount:
$1,875.00

Component Description:
Project management services 4.27.19 through 5.31.19
Amount:
$300.00

Component Description:
Project management services 3.2.19 through 3.29.19
Amount:
$75.00

Component Description:
Project management services 3.30.19 through 4.26.19
Amount:
$225.00

Component Description:
Project management services through 7/14/17
Amount:
$1,575.00

Component Description:
Engineering consulting fees Dec 2019
Amount:
$65.00

Component Description:
Project management services
Amount:
$571.00

Component Description:
Project management services April 2019
Amount:
$45.50

Component Description:
Project management services 9.29.18 through 10.26.18 and Form 387 Transition Plan Progress Report preparation 2018 Q3.
Amount:
$225.00

Component Description:
Project management services, items 2-5 on invoice summary
Amount:
$712.50

Component Description:
Project management services
Amount:
$5,238.79

Component Description:
Project management services 1.1.19 through 1.31.19 and Form 387 Transition Plan Progress Report preparation 2018 Q4.
Amount:
$300.00

Component Description:
Project management services 7.28.18 through 9.28.18.
Amount:
$1,125.00

Component Description:
Project management services
Amount:
$237.00

Component Description:
Project Management for Structural Analysis and Tower Modifications including consultants Kessler and Gehman Associates. Services from October 27, 2017 through January 26, 2018 and April 28, 2018 through May 25, 2018.
Amount:
$5,238.79

Component Description:
Project management services
Amount:
$595.00

Component Description:
Project management services
Amount:
$2,063.00

Component Description:
Project management services February 2019
Amount:
$123.50

Component Description:
Project management services 5.26.18 through 6.29.18 and Form 387 Transition Plan Progress Report preparation June 2018
Amount:
$225.00

Component Description:
Project management services 6.29.19 through 7.26.19
Amount:
$703.00

Component Description:
Project management services
Amount:
$875.00

Component Description:
Project management services through 5/5/17
Amount:
$787.50

Component Description:
Project management services
Amount:
$375.00

Component Description:
Project Management services by subcontractor Kessler and Gehman Associates.
Amount:
$1,650.00
Prepare and or review reimbursement form Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Prepare engineering portion of a minor change application
Amount:
$750.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover 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 $144,755.00 $141,190.00 N/A $112,931.91 N/A
Total for all systems $2,516,267.77 $1,092,697.77 N/A $812,031.47 N/A
Other Expenses $144,755.00 $141,190.00 $112,931.91
Equipment Rentals $3,125.00 $3,125.00 Forklift required for transmitter installation $3,120.49 N/A
Viewer Notification $1,500.00 $1,500.00 N/A N/A N/A
Tower Crew $20,000.00 $20,000.00 Tower crew must mobilize to site, climb tower, adjust tuners at antenna, and at elbows, and travel home. N/A N/A
Land Mobile Facilities Notification $17,495.00 $17,495.00 See DTV Notification EST-001678; pursuant to FCC Construction permit requirements $17,495.00 N/A
Sales and Use Tax Due $30,500.00 $30,500.00 Estimated sales and use tax due. $30,389.42 N/A
MVPD Notification of Channel Change $1,500.00 $1,500.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 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
Local Zoning $500.00 $500.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $27,000.00 $27,000.00 See USA Commercial quote 32. $27,000.00 N/A
DTV Medical Facility Notification $11,550.00 $8,000.00 See related quotes from DTVNotification $3,872.00 N/A
Equipment Delivery and Handling Charges $31,055.00 $31,055.00 See Rohde & Schwarz quote 246196.0 $31,055.00 N/A

Components

Actual Information Description File Name
Equipment Rentals

Component Description:
Forklift rental
Amount:
$2,614.89

Component Description:
Forklift rental
Amount:
$505.60
Viewer Notification Information not provided.
Tower Crew Information not provided.
Land Mobile Facilities Notification

Component Description:
Land Mobile Facilities Notification
Amount:
$17,495.00
Sales and Use Tax Due

Component Description:
Tax due on additional transmitter costs
Amount:
$1,183.08

Component Description:
Tax due on additional transmitter costs
Amount:
$1,160.82

Component Description:
Tax due on transmitter consolidation services
Amount:
$1,863.30

Component Description:
Tax on forklift rental
Amount:
$30.34

Component Description:
Tax on forklift rental
Amount:
$156.90

Component Description:
Tax due on transmitter, less tax on upgrade cost
Amount:
$25,994.98
MVPD Notification of Channel Change 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.
Local Zoning Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
Disposal services
Amount:
$27,000.00
DTV Medical Facility Notification

Component Description:
Notification of medical facilities
Amount:
$3,872.00

Component Description:
Notification of medical facilities
Amount:
$3,872.00
Equipment Delivery and Handling Charges

Component Description:
Transmitter consolidation services
Amount:
$31,055.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $2,516,267.77 $1,092,697.77 $812,031.47

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
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.

Dennis P. Thatcher

President


08/18/2021

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.

Dennis P. Thatcher

President


08/18/2021

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