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:
4688-24
Service:
DRT
Call Sign:
WHSV-TV
Channel:
24 (UHF)
File Number:
0000089986
FRN:
0018223693
Eligibility Status:
Eligible
Date Submitted:
07/29/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GRAY TELEVISION LICENSEE, LLC

WHSV-TV

50 NORTH MAIN STREET

HARRISONBURG, VA 22802

United States

+1 (540) 433-9191 robert.folliard@gray.tv 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

Samuel Hariton

Widelity

4031 University Dr

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 WSHV will be purchasing an upgraded transmitter and antenna, while reusing the pre-displacement transmission line. The station will remain on the current tower.

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 Mxi 101
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 50 W

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model EC702HP-BB
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.7 kW
Justification for New Transmitter The existing transmitter could not function on the new channel. WHSV - Signal Knob's new purchased main transmitter will be an upgrade from its old, existing transmitter. Please see narrative and justification letter for further explanation

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 Yes
Description Splitter and other electrical expenses
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

Primary Transmitter - UPS

Primary Transmitter - UPS

Primary Transmitter- Inside UHF RF

Primary Transmitter- Inside UHF RF

Primary Transmitter - Receiver

Primary Transmitter - Receiver

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 Leased
Owner WVPY
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
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 1.0 kW
Manufacturer
Model PHP24C
Year 1996

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 AL8WR-24-E-R
Year 2019
Justification for New Antenna The pre-displacement antenna could not reach WHSV's new channel. The station acknowledges that the addition of V-Pol components is not reimbursable. Please see the narrative and justification letter for further information.

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
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

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? No

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change 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? No
Coordinates (NAD83) Latitude (NAD83) 38° 57' 37.21" N-
Longitude (NAD83) 078° 19' 51.6" W-
Overall Structure Height 75.00 feet
Support Structure Height 75.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 4340.50 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner WVPY
Date Constructed 01/01/1996

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
18862 W255CK FX
18881 W243AF FX

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 need for guyed or free-standing 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 Mapping

Tower Mapping

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 WHSV-Signal Knob requires the aid of outside project management services to fulfill the requirements of the repack. WHSV-Signal Knob will hire an outside firm to facilitate and support WHSV-Signal Knob in these tasks to ensure a timely 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 No
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 Yes
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 Yes
Type 7/13 GHz Licensed Part 74

Other Expenses

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Other Expenses Not Listed

Name Description

TSL Monitoring

Required due to layout changes at translator site

IT Equipment

Required due to layout changes at translator site

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 $93,046.91 $91,779.42 N/A $91,779.42 N/A
Total for all systems $398,552.02 $442,321.19 N/A $223,210.83 N/A
Primary Transmitter EC702HP-BB $93,046.91 $91,779.42 $91,779.42
Primary Transmitter - Receiver $3,751.41 $3,751.41 Please see Hitachi Kokusai Electric Comark LLC Proposal P#3740-EC702-190220-R2, plus actual freight on invoice 13110 $3,751.41 N/A
Primary Transmitter- Inside UHF RF $4,414.00 $4,414.00 Please see Hitachi Kokusai Electric Comark LLC proposal P#5108-WHSV-200414 $4,414.00 N/A
Primary Transmitter - UPS $750.50 $750.50 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $750.50 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $82,732.51 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $82,732.51 N/A
Other Electrical Service: Splitter and other electrical expenses $131.00 $131.00 Please see WHSV-TV1 Primary Transmitter - Other Electrical Service Budget Revision Justification Letter $131.00 N/A

Components

Actual Information Description File Name
Primary Transmitter - Receiver

Component Description:
Receiver, VSB-FRQ-200 8VSB-ASI/SMPT310
Amount:
$3,751.41
Primary Transmitter- Inside UHF RF

Component Description:
WSVF Harline Kit (SRO: CS3782)
Amount:
$4,414.00
Primary Transmitter - UPS

Component Description:
SMT1500RM2UC
Amount:
$750.50

Component Description:
Being replaced by INV 2020 4005
Amount:
N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
TRANSMITTER, UHF DOHERTY BROADBAND
Amount:
$4,136.62

Component Description:
TRANSMITTER, UHF DOHERTY BROADBAND
Amount:
$49,639.51

Component Description:
TRANSMITTER, UHF DOHERTY BROADBAND
Amount:
$28,956.38
Other Electrical Service: Splitter and other electrical expenses

Component Description:
LEN-LAMS01 LEN LAMS01 AES MADI AST Splitter
Amount:
$131.00

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 $78,540.86 $79,210.86 N/A $72,810.86 N/A
Total for all systems $398,552.02 $442,321.19 N/A $223,210.83 N/A
Primary Antenna AL8WR-24-E-R $78,540.86 $79,210.86 $72,810.86
Sweep test of transmission line and antenna $5,730.00 $6,400.00 Please see DTVPros Quote JEHQ1515 for Sweep Test quote $0.00 N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical $72,810.86 $72,810.86 ***System Notice: Estimate adjusted and locked because line has been superseded.***Please see DTVPros quote JEHQ1514-01 $72,810.86 N/A

Components

Actual Information Description File Name
Sweep test of transmission line and antenna

Component Description:
WHSV-TV-210-Primary Antenna - Sweep Test
Amount:
$3,200.00

Component Description:
WHSV-TV1-210-Primary Antenna - Sweep Test
Amount:
$3,200.00
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical

Component Description:
Antenna
Amount:
$36,405.43

Component Description:
UHF-Lower Power Power Side Mount
Amount:
$36,405.43

Cost Information

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Transmission Line

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $74,140.00 $94,300.00 N/A $14,350.00 N/A
Total for all systems $398,552.02 $442,321.19 N/A $223,210.83 N/A
Primary Tower TOWER $74,140.00 $94,300.00 $14,350.00
Study needed for guyed or free-standing tower $8,700.00 $5,100.00 see Estimated Cost Justification WHSV-TV1-410-Existing Primary Tower - Structural Analysis Study v1 $5,100.00 N/A
Tower Mapping $9,250.00 $9,250.00 Please see WHSV-TV ERI proposal 20190321-031 $9,250.00 N/A
Tower Rigging Short Tower (less than 500') $56,190.00 $79,950.00 Please see SRI Proposal - Tower Rigging N/A N/A

Components

Actual Information Description File Name
Study needed for guyed or free-standing tower

Component Description:
Change Order#1 - Structural Analysis
Amount:
$2,100.00

Component Description:
STRUCTURAL ANALY AND REPORT
Amount:
$3,000.00
Tower Mapping

Component Description:
ENGINEERING INSPECTION
Amount:
$9,250.00
Tower Rigging Short Tower (less than 500') 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 $93,927.00 $109,058.30 N/A $43,078.30 N/A
Total for all systems $398,552.02 $442,321.19 N/A $223,210.83 N/A
Outside Professional Services $93,927.00 $109,058.30 $43,078.30
Project management of the transition $26,797.00 $36,605.80 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $36,605.80 N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $52,600.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $3,262.50 N/A N/A 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 $225.00 N/A
Perform engineering study for displacement application $1,800.00 $7,122.50 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $6,247.50 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$621.25

Component Description:
Project Management
Amount:
$350.00

Component Description:
Project Management
Amount:
$143.60

Component Description:
Project Management
Amount:
$725.15

Component Description:
Project Management
Amount:
$1,919.45

Component Description:
Project Management
Amount:
$4,106.25

Component Description:
Project Management
Amount:
$1,574.05

Component Description:
Project Management
Amount:
$732.50

Component Description:
Project management
Amount:
$2,574.80

Component Description:
Project Management
Amount:
$6,898.75

Component Description:
Project Management
Amount:
$3,059.15

Component Description:
Project Management
Amount:
$492.65

Component Description:
Project Management
Amount:
$3,347.45

Component Description:
Project Management
Amount:
$1,829.55

Component Description:
Project Management
Amount:
$3,397.50

Component Description:
Project Management
Amount:
$2,818.15

Component Description:
Project Management
Amount:
$1,535.00

Component Description:
Project Management
Amount:
$390.00

Component Description:
Project Management
Amount:
$1,143.75

Component Description:
Project Management
Amount:
$663.40

Component Description:
Project Management
Amount:
$476.10

Component Description:
Project Management
Amount:
$625.45
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations 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 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:
Consulting Engineer - J. Davis - Hourly (@ $250/hr)
Amount:
$225.00
Perform engineering study for displacement application

Component Description:
Conduct Channel studies
Amount:
$3,937.50

Component Description:
Frequency Study
Amount:
$2,310.00

Component Description:
Invoice to be resubmitted per NMI message.
Amount:
N/A
Prepare/ Review 399 reimbursement form 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 $58,897.25 $67,972.61 N/A $1,192.25 N/A
Total for all systems $398,552.02 $442,321.19 N/A $223,210.83 N/A
Other Expenses $58,897.25 $67,972.61 $1,192.25
TSL Monitoring $297.00 $297.00 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $297.00 N/A
IT Equipment $895.25 $895.25 Please see Estimated Cost Justification WHSV-TV1-610-IT Equipment v0 $895.25 N/A
New Point to Point Microwave System: 7/13 GHz Licensed Part 74 $51,300.00 $60,375.36 Please see Heartland Video Systems Quote WISQ52594. The estimated cost above represents WHSV - Signal Knob's portion of the cost. N/A N/A
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

Actual Information Description File Name
TSL Monitoring

Component Description:
TSL Monitoring
Amount:
$297.00

Component Description:
SW-24P GIG Netgear SMT POE192W
Amount:
$297.00
IT Equipment

Component Description:
Signal Knob network
Amount:
$100.00

Component Description:
Task/Ticket: Signal Knob network equipment
Amount:
$175.00

Component Description:
Task/Ticket: Signal Knob network equipment - Scott T20200612.0005
Amount:
$620.25
New Point to Point Microwave System: 7/13 GHz Licensed Part 74 Information not provided.
FCC Filing Fees - Form 2100 Major change CP application Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $398,552.02 $442,321.19 $223,210.83

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.

Robert Folliard , III .

Assistant Secretary


07/29/2021

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.

Robert Folliard , III .

Assistant Secretary


07/29/2021

Attachments

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