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:
35676
Service:
LPT
Call Sign:
W34FC-D
Channel:
34 (UHF)
File Number:
0000089006
FRN:
0018223693
Eligibility Status:
Eligible
Date Submitted:
07/22/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

KTTC License, LLC

Doing Business As: KTTC License, LLC

Brady Dreasler

P.O. BOX 909

QUINCY, IL 62301

United States

+1 (217) 223-5100 bdreasler@quincymedia.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

Tony zumMallen

President

QCommunications, LLC

705B SE Melody LN #314

Lee's Summit, MO 64063

United States

+1 (816) 729-1177 tony@qcomm.tv

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 Replace the transmitter per the channel reassignment with reasonable and customary engineering and business practices.

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 DHD15P1
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 15 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model ULXTE-8
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 5.5 kW
Justification for New Transmitter New transmitter required for new channel.

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? Yes
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

Switch installation

Install of the switch

Transmitter Decommissioning

Harvesting and removal of old transmitter

RF Load and Patch Panel

RF Load and Patch Panel

Transmitter Taxes

Sales tax for new transmitter

Transmitter Shipping fee

Shipping fees for new transmitter

Transmitter Misc. Equipment

Ancillary transmitter equipment, associated cables, etc.

RF Filter Test

Test RF filter for factory specifications for use of W34FC as translator

Transmitter Switch

Costs for new transmitter switch

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? No

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)
Ownership Owned
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 Flexible Air
Diameter 5 inches
Number of parallel runs 1
Length 1050 feet per run

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

Facility ID Call Sign
167664 KUVM-LD

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Test Line

Test Line after installation of new transmitter

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 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 1035149
Coordinates (NAD83) Latitude (NAD83) 43° 48' 23.0" N-
Longitude (NAD83) 091° 22' 03.0" W-
Overall Structure Height 819.22 feet
Support Structure Height 763.44 feet
Ground Elevation Above Mean Sea Level (AMSL) 1225.71 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner WXOW-WQOW Television, Inc.
Date Constructed 10/23/1982

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
64549 WXOW 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: Tower mapping and report for structural engineer
Tower Reinforcements Please select whether tower reinforcements are needed: No reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 350
Explanation Required to assist in the turnkey management of the channel relocation project in order that the existing internal personal can maintain and operate the stations daily operational requirements and plans.
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 Yes
Quantity 1
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 Yes
Quantity 1
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 Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 5
Justification Estimated field engineering services during transition activities. Actual costs to be determined.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

General Legal

General Legal services not covered in other categories

RF Filter Test

Test RF Filter for factory specification

General Consulting Engineer Services

General consulting engineer services

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 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
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

Name Description

Internal Expenses

Internal Expenses station incurred due to Repack

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 $333,682.90 $242,272.03 N/A $214,245.89 N/A
Total for all systems $699,108.29 $616,594.42 N/A $234,768.90 N/A
Primary Transmitter ULXTE-8 $333,682.90 $242,272.03 $214,245.89
RF Load and Patch Panel $9,088.60 $9,088.60 Per INV US0316280 (PO 20255). Invoice includes shipping not included on PO/quote. $9,088.60 N/A
Transmitter Decommissioning $18,000.00 $18,000.00 Per attached QCommunications PO. $18,000.00 N/A
Switch installation $12,000.00 $12,000.00 Per attached QCommunications quote. $0.00 N/A
Transmitter Building Site Survey/Installation $10,000.00 $26,766.25 Per Actual invoices from GatesAir. $26,766.25 N/A
UHF - Liquid Cooled Solid State Transmitter 4.9 - 6.5 kW $255,000.00 $146,822.88 ULXTE-8 liquid cooled, solid state transmitter per Q-76011 $142,273.62 N/A
Transmitter Shipping fee $3,799.99 $3,799.99 Per attached GatesAir PO. 5/7/20 Changed amount to actual freight. $3,799.99 N/A
Transmitter Misc. Equipment $1,888.00 $1,888.00 Actual costs for miscellaneous transmitter equipment per invoices. $1,888.00 N/A
RF Filter Test $775.18 $775.18 Actual costs per Resonant Results Invoice # RR3224 $775.18 N/A
Transmitter Taxes $13,121.69 $13,121.69 Actual sales tax calculated on final invoice from GatesAir. $11,654.25 N/A
Transmitter Switch $10,009.44 $10,009.44 Actual costs per attached GatesAir PO and invoices. Includes freight and sales tax on invoices. $0.00 N/A

Components

Actual Information Description File Name
RF Load and Patch Panel

Component Description:
RF Load and Patch panel; Gates INV US0316280
Amount:
$9,088.60
Transmitter Decommissioning

Component Description:
Decommissioning of old transmitter - QComm - QC19-009
Amount:
$18,000.00
Switch installation Information not provided.
Transmitter Building Site Survey/Installation

Component Description:
3rd Installation invoice - Gates - JW30004375-3
Amount:
$9,100.53

Component Description:
Transmitter Install. Gates INV Jw30004375-2 - PO 20192
Amount:
$8,832.86

Component Description:
TX Install. Gates - INV JW30004375-1; PO 20192
Amount:
$8,832.86
UHF - Liquid Cooled Solid State Transmitter 4.9 - 6.5 kW

Component Description:
W34FC - Gates Air - 3rd transmitter invoice - JW30004375-3
Amount:
$36,454.66

Component Description:
1/3 down - W34FC - GatesAir - Transmitter - INV JW30004375-1
Amount:
$52,909.48

Component Description:
Revised - entered under new line - W34FC - GatesAir - INV JW30004375-2
Amount:
$52,909.48
Transmitter Shipping fee

Component Description:
Third transmitter shipping invoice - JW30004375-3
Amount:
$235.99

Component Description:
1/3 Freight for transmitter. GATES INV JW30004375-1
Amount:
$1,782.00

Component Description:
2nd 1/3 of freight costs for shipping transmitter; Gates INV JW30004375-2 - PO 20192
Amount:
$1,782.00
Transmitter Misc. Equipment

Component Description:
Reducer added at installation - Gates INV JW30004375-3 - Q-88230
Amount:
$1,888.00
RF Filter Test

Component Description:
RF filter test - W34FC - Resonant - INV RR3224
Amount:
$775.18

Component Description:
RF Filter Test - Resonant Results - INV RR3224
Amount:
$775.18
Transmitter Taxes

Component Description:
Sales tax for transmitter. GatesAir - JW30004375-3
Amount:
$11,654.25
Transmitter Switch

Component Description:
See cover sheet and letter for justification. Switch and sales tax - Gates - INV US0318964 - PO 20302
Amount:
$9,722.58

Component Description:
Freight for switch. Gates INV US0321646 - PO 20302
Amount:
$286.86

Cost Information

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Antennas

Information not provided.

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $6,000.00 $6,000.00 N/A $0.00 N/A
Total for all systems $699,108.29 $616,594.42 N/A $234,768.90 N/A
Primary Transmission Line $6,000.00 $6,000.00 $0.00
Test Line $6,000.00 $6,000.00 See QComm quote 745T. 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 $178,750.00 $178,750.00 N/A $0.00 N/A
Total for all systems $699,108.29 $616,594.42 N/A $234,768.90 N/A
Primary Tower TOWER $178,750.00 $178,750.00 $0.00
Tower mapping and report for structural engineer $21,000.00 $21,000.00 N/A N/A N/A
Tower Rigging Tall Tower (greater than 500') $157,750.00 $157,750.00 N/A $0.00 N/A

Components

Actual Information Description File Name
Tower mapping and report for structural engineer Information not provided.
Tower Rigging Tall Tower (greater than 500')

Component Description:
Radomes, freight, tax. Dielectric INV 276015 - Quote 1696091
Amount:
$21,278.51

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 $167,945.18 $176,842.18 N/A $20,147.80 N/A
Total for all systems $699,108.29 $616,594.42 N/A $234,768.90 N/A
Outside Professional Services $167,945.18 $176,842.18 $20,147.80
General Consulting Engineer Services $600.00 $600.00 General consulting engineering $600.00 N/A
RF Filter Test $775.18 $775.18 Per Resonant Results invoice RR3224 $0.00 N/A
General Legal $5,000.00 $5,000.00 Estimate costs for other legal expenses. $1,603.00 N/A
Additional Field Engineering Service, 5 Days $12,500.00 $12,500.00 Estimated field engineering services during transition activities. Actual costs to be determined. N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $43,732.00 Per Attached QForce quote: 702-R N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $2,235.00 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 $2,025.00 N/A
Prepare request for Special Temporary Authorization $1,280.00 $1,280.00 N/A N/A N/A
Perform engineering study for displacement application $1,800.00 $1,800.00 N/A $1,000.00 N/A
Form 399 assistance or other Program Management costs $41,500.00 $41,500.00 Per attached QCommunications quote. $12,419.80 N/A
Project management of the transition $36,925.00 $53,900.00 Estimated 350 hours at $150/hr. Actual costs to be determined. $0.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $2,500.00 Per attached QCommunications quote. $2,500.00 N/A

Components

Actual Information Description File Name
General Consulting Engineer Services

Component Description:
Gen Consulting Eng - Lohnes - INV 202008-0275-10
Amount:
$600.00
RF Filter Test

Component Description:
RF Filter Test - Resonant - INV RR3224
Amount:
$775.18
General Legal

Component Description:
Legal July 2017 - INV 3942207
Amount:
$141.00

Component Description:
General Legal Aug 2019 - Brooks INV 3971023
Amount:
$364.00

Component Description:
General Legal period ending January 31, 2020. Brooks INV 3977757
Amount:
$260.00

Component Description:
General legal March, 2019. Brooks INV 3965353
Amount:
$52.00

Component Description:
General Legal Nov 2019 - Brooks - INV 3975578
Amount:
$156.00

Component Description:
5-13-2021 Request zeroed out. Not for this station. Legal June 2017 - INV 3941312
Amount:
N/A

Component Description:
General Legal Sept 2019 - Brooks INV 3972820
Amount:
$52.00

Component Description:
Gen Legal August 2020 - INV 3987331
Amount:
$92.00

Component Description:
W34FC - Brooks - Gen Legal Aug 2018 - INV 3957124
Amount:
$627.00
Additional Field Engineering Service, 5 Days Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization 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:
W34FC - Lohnes - Engineering services - INV 201808-0275-10-2
Amount:
$525.00

Component Description:
Prepare Eng section of Form 2100 - Lohnes - INV 201804-0275-10. Note: Vendor Name is Lohnes & Culver; "and" was substituted for special character "&".
Amount:
$1,500.00
Prepare request for Special Temporary Authorization Information not provided.
Perform engineering study for displacement application

Component Description:
Technical studies for replacement channel - Lohnes - INV 201804-0275-10. NOTE: Vendor name is Lohnes & Culver; "and" was substituted for special character "&".
Amount:
$1,000.00
Form 399 assistance or other Program Management costs

Component Description:
July 2021 PM hours - QC21-908
Amount:
$1,147.50

Component Description:
Project Management hours for June 2020 - QComm - INV QC20-357
Amount:
$677.60

Component Description:
October 399 PM Hours - QComm - QC20-514
Amount:
$723.80

Component Description:
Project management hours May 2020 - QComm - QC20-324
Amount:
$1,008.70

Component Description:
Nov 2020 399 PM Hours - QComm - QC20-621
Amount:
$877.80

Component Description:
Dec 2020 399 PM Hours - QComm - INV QC20-693
Amount:
$61.60

Component Description:
January 2021 399 PM Hours - QComm - QC21-747
Amount:
$770.00

Component Description:
July 2020 399 invoice processing PM hours. QC20-448
Amount:
$1,316.70

Component Description:
February 2021 399 PM Hours - QComm - QC21-782
Amount:
$438.90

Component Description:
Project Management hours for April 2020 - QComm - QC20-288
Amount:
$2,256.10

Component Description:
August 2020 399 PM hours - QComm - QC20-493
Amount:
$1,108.80

Component Description:
March 2021 PM Hours - QC21-830
Amount:
$785.40

Component Description:
For 399 eligibility activities - including submitting supporting documentation for initial eligibility application. QC20-242
Amount:
$500.00

Component Description:
September 2020 399 PM Hours - QComm - QC20-494
Amount:
$746.90
Project management of the transition

Component Description:
8-5-20 Zeroed out. Resubmitted under different line. Project Mgmt hours - transition - QComm - INV QC20-288
Amount:
N/A

Component Description:
8-5-20 Zeroed out and resubmitted under another line. May proj mgmt hours - QComm - INV QC20-324
Amount:
N/A
Prepare/ Review 399 reimbursement form

Component Description:
Costs to assist station in preparing initial 399 application with estimates, quotes and invoices. QC20-242. 399 Eligibility under different component
Amount:
$2,500.00

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 $12,730.21 $12,730.21 N/A $375.21 N/A
Total for all systems $699,108.29 $616,594.42 N/A $234,768.90 N/A
Other Expenses $12,730.21 $12,730.21 $375.21
Equipment Storage $2,000.00 $2,000.00 Expecting multiple staggered equipment deliveries from different vendors and need to store and stage new equipment prior to installation date. N/A N/A
Equipment Delivery and Handling Charges $2,000.00 $2,000.00 Estimated transport, forklift rental and handling fees from staging area to transmitter site. Actuals to be determined. N/A N/A
Internal Expenses $20.21 $20.21 Actual costs $20.21 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 minor change CP application $1,110.00 $1,110.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $305.00 N/A $190.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A $165.00 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $2,000.00 $2,000.00 Estimated 4-6 yard disposal bin on site to capture all waste from on site system integration and tower vendors. Actual costs to be determined. N/A N/A

Components

Actual Information Description File Name
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Internal Expenses

Component Description:
Meal - site visit - Pizza Ranch -
Amount:
$20.21
FCC Filing Fees - Form 2100 Major change CP application Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
FCC Filing Fees - Special Temporary Authorization request

Component Description:
STA application - LMS0000055283
Amount:
$190.00
FCC Filing Fees - Form 2100 license to cover application

Component Description:
License to cover application - W34FC - LMS0000058890
Amount:
$165.00
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $699,108.29 $616,594.42 $234,768.90

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.

BRADY DREASLER

CORPORATE DIRECTOR OF ENGINEERING


07/22/2021

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.

BRADY DREASLER

CORPORATE DIRECTOR OF ENGINEERING


07/22/2021

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