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:
70415
Service:
DCA
Call Sign:
WZXZ-CD
Channel:
20 (UHF)
File Number:
0000027560
FRN:
0014037857
Date Submitted:
09/08/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

L4 MEDIA GROUP, LLC

Doing Business As: L4 MEDIA GROUP, LLC

PO Box 60606

Suite 2450

Chicago, IL 60606

United States

+1 (612) 202-4980 ssaldana@sktytrading.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

Tim Wolak

Director

Banded IT Solutions

2425 Bentshire Dr

Jacksonville, FL 32246

United States

+1 (312) 231-7895 twolak@bandeditsolutions.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. No
Briefly describe transition plan Current transmission system consists of a single transmitter feeding a flexible transmission line which connects to an antenna on the tower. Work includes tower study/rehabilitation to support new antenna, mounting antenna and retuning transmitter.

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 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 Elettronika
Model TXUD1000
Year 2015
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.0 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 3 kW
Other Power N/A
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

Information not provided.

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? No
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 Class A
Mounting Side Mount
Antenna position in stack Middle
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 15.0 kW
Manufacturer Dielectric
Model ANT DLP8B
Year 2019

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?

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?
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? 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)
Description of Use N/A
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 Yes
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 1034290
Coordinates (NAD83) Latitude (NAD83) 28° 34' 07.8" N-
Longitude (NAD83) 081° 13' 53.8" W-
Overall Structure Height 359.90 feet
Support Structure Height 359.90 feet
Ground Elevation Above Mean Sea Level (AMSL) 73.16 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Lovelace Tower, Inc.
Date Constructed 03/11/2005

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
10549 WRCF-CD DTV

Other Types of Users

Users
LPFM

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 undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor 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 200
Explanation Applicant has no internal resources capable of overseeing, identifying, purchasing, installing and commissioning this repack project. It will rely solely on outside services to manage all work required.
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 No
Quantity N/A
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 No
Quantity N/A
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

ACME RF

Project Management services, research and project coordination

Fletcher, Heald and Hildreth

Attorney for repack services to prepare, file all required FCC forms and coordination of repack efforts.

MSW reports

MSW services to prepare files for FCC reporting post repack

Progress Reporting

Prepare and file 9 required progress reports on FCC Form 2100, Schedule 387 on a quarterly basis with the FCC.

ACME

Line sweep services post install

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 Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
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)? 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? No

Other Expenses

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Other Expenses Not Listed

Name Description

Construction Drawings

Provide construction drawing set for local building permit

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 $109,355.00 $19,340.00 N/A $19,340.00 N/A
Total for all systems $598,970.00 $366,383.75 N/A $121,911.39 N/A
Primary Transmitter TXUD1000 $109,355.00 $19,340.00 $19,340.00
UHF and VHF - minor banding issues $105,200.00 $15,000.00 N/A $15,000.00 N/A
3 kW mask filter $4,155.00 $4,340.00 the predetermined budget did not equal the actual expense $4,340.00 N/A

Components

Actual Information Description File Name
UHF and VHF - minor banding issues

Component Description:
TRANSMITTER - UHF and 15,000.00 15,000.00 VHF - MINOR BANDING ISSUES - TRANSMITTER SERVICES
Amount:
$15,000.00
3 kW mask filter

Component Description:
mask filter
Amount:
$4,340.00

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 $6,730.00 $4,500.00 N/A $4,500.00 N/A
Total for all systems $598,970.00 $366,383.75 N/A $121,911.39 N/A
Primary Antenna ANT DLP8B $6,730.00 $4,500.00 $4,500.00
Sweep test of existing antenna $6,730.00 $4,500.00 N/A $4,500.00 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
post install sweep test.
Amount:
$4,500.00

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 $268,500.00 $188,000.00 N/A $6,420.00 N/A
Total for all systems $598,970.00 $366,383.75 N/A $121,911.39 N/A
Primary Tower TOWER $268,500.00 $188,000.00 $6,420.00
Minor tower reinforcement/modifications $158,000.00 $100,000.00 N/A N/A N/A
Short Tower (less than 500') $84,200.00 $63,000.00 N/A N/A N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $25,000.00 N/A $6,420.00 N/A

Components

Actual Information Description File Name
Minor tower reinforcement/modifications Information not provided.
Short Tower (less than 500') Information not provided.
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study

Component Description:
ATC application fee
Amount:
$4,920.00

Component Description:
this POR request two line items, each invoiced separately, see ATC invoices 460204809 & 460204897
Amount:
$6,480.00

Component Description:
Structural engineering pro-rated portion.
Amount:
$1,500.00

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $182,800.00 $127,313.75 N/A $78,756.39 N/A
Total for all systems $598,970.00 $366,383.75 N/A $121,911.39 N/A
Outside Professional Services $182,800.00 $127,313.75 $78,756.39
ACME $5,000.00 $5,000.00 N/A $0.00 N/A
Progress Reporting $18,000.00 $18,000.00 Prepare and file 9 required progress reports on FCC Form 2100, Schedule 387 on a quarterly basis with the FCC. $1,192.50 N/A
MSW reports $1,650.00 $1,650.00 N/A $1,523.75 N/A
Fletcher, Heald and Hildreth $5,000.00 $5,000.00 N/A $2,097.69 N/A
ACME RF $15,000.00 $15,000.00 N/A $10,500.00 N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $30,000.00 N/A $30,000.00 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A $582.29 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $3,776.25 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 engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,716.25 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $8,413.75 additional RF modeling was required due to congestion in the DMA $8,413.75 Additional RF modeling was required due to congestion in the DMA
Project management of the transition $31,600.00 $30,000.00 N/A $17,953.91 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
ACME

Component Description:
post install line sweep
Amount:
$4,500.00
Progress Reporting

Component Description:
Prepare FCC Form 387 Repack Progress Report Filing
Amount:
$1,192.50
MSW reports

Component Description:
RF consulting services to prepare and file form 2100, 387 and temporary authority application.
Amount:
$1,523.75
Fletcher, Heald and Hildreth

Component Description:
Corrected information taking out station that is not part of the invoices, see new cover letter.
Amount:
$18.54

Component Description:
FCC Attorney Fees
Amount:
$62.50

Component Description:
FCC Attorney Fees
Amount:
$100.00

Component Description:
non reimbursable lines removed and corrected totals
Amount:
$260.00

Component Description:
FCC Attorney Fees
Amount:
$68.75

Component Description:
FCC Attorney Fees
Amount:
$92.71

Component Description:
Corrected Invoices
Amount:
$25.00

Component Description:
FCC Attorney Fees
Amount:
$195.00

Component Description:
FCC Attorney Fees
Amount:
$62.50

Component Description:
Credit memo for non reimbursable lines.
Amount:
($12.50)

Component Description:
Credit memo for non reimbursable lines.
Amount:
($356.25)

Component Description:
Credit memo for lines not reimbursable
Amount:
($25.85)

Component Description:
Credit memo for lines not reimbursable
Amount:
($18.75)

Component Description:
FCC Attorney Fees
Amount:
$385.42

Component Description:
Not reimbursable
Amount:
($100.00)

Component Description:
corrected which stations were invoiced and corrected requested amounts.
Amount:
$66.67

Component Description:
FCC Attorney Fees
Amount:
$250.00

Component Description:
corrected which stations were invoiced and corrected requested amounts.
Amount:
$116.46

Component Description:
FCC Attorney Fees
Amount:
$406.25

Component Description:
Credit memo for lines not reimbursable
Amount:
($12.50)

Component Description:
FCC Attorney Fees
Amount:
$395.83

Component Description:
FCC Attorney Fees
Amount:
$25.00

Component Description:
FCC Attorney Fees
Amount:
$712.50

Component Description:
FCC Attorney Fees
Amount:
$120.83

Component Description:
FCC Attorney Fees
Amount:
$229.17

Component Description:
FCC Attorney Fees
Amount:
$208.33

Component Description:
FCC Attorney fees
Amount:
$214.58

Component Description:
FCC Attorney fees
Amount:
$333.33

Component Description:
Line was not reimbursable and are issuing a credit memo.
Amount:
($7.08)

Component Description:
FCC Attorney Fees
Amount:
$393.75

Component Description:
FCC Attorney Fees
Amount:
$51.04

Component Description:
Credit memo for non reimbursable lines.
Amount:
($4.17)

Component Description:
FCC Attorney Fees
Amount:
$204.17
ACME RF

Component Description:
project management services, research and coordination
Amount:
$2,250.00

Component Description:
project management services, research and coordination
Amount:
$3,750.00

Component Description:
project management services, research and coordination
Amount:
$4,500.00

Component Description:
Repack Sweep test services
Amount:
$4,500.00
Comprehensive coverage verification via field study, if needed

Component Description:
FIELD TESTING
Amount:
$30,000.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Attorney fees, planning, engineering and consulting
Amount:
$582.29
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
WZXZ-CD Orlando, FL Prepare initial budgets, equipment list, and determine equipment replacements for new repack channel; Prepare FCC Form 2100 Schedule 399 Budget and Narrative for filing in initial CP Filing Window. 14.25 hours
Amount:
$3,776.25
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:
WZXZ-CD Orlando, FL Prepare technical portions of FCC Form 2100 Construction Permit Application and Engineering Exhibits required to be filed with initial Repack Construction Permit Application - filing window. 10.25 hours
Amount:
$2,716.25
Perform engineering study for new channel assignment and antenna development

Component Description:
Conduct Study for alternative antenna; Prepare and File FCC Modification of Construction Permit Application Form 2100; Prepare TPO and Tech Summary Calculations for WZXZ-CD
Amount:
$1,987.50

Component Description:
WZXZ-CD Orlando, FL Develop azimuth antenna patterns and determine antenna required for FCC Form 2100 Construction Permit Application for initial Repack Channel CP Filing. 5.5 hours
Amount:
$1.00

Component Description:
WZXZ-CD Orlando, FL Conduct TVStudy analysis of initial channel assignment and analyze interference issues with new repack channel. 16.5 hours
Amount:
$5,830.00

Component Description:
Conduct Study and Analyze Potential early transition date for WZXZ-CD
Amount:
$596.25
Project management of the transition

Component Description:
Project management services
Amount:
$4,200.00

Component Description:
PROJECT MANAGEMENT SERVICES
Amount:
$2,250.00

Component Description:
Project Management services, research and coordination w/rf engineering, equipment vendors and site owners
Amount:
$2,250.00

Component Description:
This invoice has been replaced with a corrected version
Amount:
$3,983.48

Component Description:
Project Management services, research and coordination w/rf engineering, equipment vendors and site owners
Amount:
$1,500.00

Component Description:
Project Management services, research and coordination w/rf engineering, equipment vendors and site owners
Amount:
$1,500.00

Component Description:
Project management, lease modification and installation planning.
Amount:
$750.00

Component Description:
Project Management services, research and coordination w/rf engineering, equipment vendors and site owners
Amount:
$1,500.00

Component Description:
PM services, ATC required on site meeting to coordinate with all repacks
Amount:
$4,003.91

Component Description:
PROJECT MANAGEMENT SERVICES
Amount:
$1,500.00
Prepare and or review 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 $31,585.00 $27,230.00 N/A $12,895.00 N/A
Total for all systems $598,970.00 $366,383.75 N/A $121,911.39 N/A
Other Expenses $31,585.00 $27,230.00 $12,895.00
Construction Drawings $4,700.00 $4,700.00 required for building permit process $4,700.00 N/A
Develop and air announcement of upcoming channel change $2,500.00 $2,500.00 It is required that the applicant give notification to viewers of the repack channel change. Applicant has limited internal resources to create and produce such notifications and will most likely have to obtain the services from an outside vendor. N/A N/A
Equipment Storage $2,500.00 $2,500.00 Applicant may receive antenna and transmitter parts prior to set installation dates. There is no on-site storage available and applicant may be forced to use outside temporary storage facilities. N/A N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 There will be shipping charges for the antenna and transmitter costs. Precise costs will not be known until the carrier issues an invoice. Currently, applicant does not estimate costs to be more than this estimate. N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $1,000.00 $1,000.00 Applicant will be required to dispose of the current pre-repack antenna and parts that were replaced for transmitter retuning. The exact costs are not known at this time. N/A N/A
Non-zoning permits $2,000.00 $2,000.00 It is currently unknown what the city or county may levy on applicant in terms of a building permit to perform the tower work required. It is felt this estimate should cover the associated costs for any required permits. N/A N/A
Local Zoning $2,000.00 $2,000.00 It is currently unknown what the local zoning authority or city/county may levy on applicant to perform the tower work required. It is felt this estimate should cover the associated costs for any required permits. $1,000.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 the fcc changed the fee $0.00 N/A
DTV Medical Facility Notification $11,550.00 $7,195.00 N/A $7,195.00 BUDGET WAS ESTIMATED BEFORE WE RECEIVED THE ACTUAL QUOTE FROM THE VENDOR

Components

Actual Information Description File Name
Construction Drawings

Component Description:
construction drawing set
Amount:
$4,700.00
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Non-zoning permits Information not provided.
Local Zoning

Component Description:
Permit application fee
Amount:
$1,000.00
FCC Filing Fees - Form 2100 license to cover application

Component Description:
license fee
Amount:
$335.00
DTV Medical Facility Notification

Component Description:
DTV Notification Service Notification of Medical Facilities Transmitter Medical Facility Notification per proposal
Amount:
$7,195.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $598,970.00 $366,383.75 $121,911.39

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.

Tim Wolak

Director


09/08/2021

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.

Tim Wolak

Director


09/08/2021

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