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:
55049
Service:
DTV
Call Sign:
KASY-TV
Channel:
36 (UHF)
File Number:
0000028309
FRN:
0004284899
Date Submitted:
10/08/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

MISSION BROADCASTING, INC.

901 Indiana Avenue

Suite 375

Wichita Falls, TX 76301

United States

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

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. Yes
Briefly describe transition plan Replace transmitter using existing antenna and line. See attachment.

Question Response
Sharee Station Facility ID 40743
Call Sign K38IM
Type
Licensee Name EDGE SPECTRUM, INC.
Status LICENSED AND SILENT
DTS No
Community of License ALBUQUERQUE, NM
Pre-auction RF Channel 38
Post-auction RF Channel
Neilsen DMA
Network Affiliation
Question Response
Sharee Station Facility ID 32311
Call Sign KASA-TV
Type Commercial
Licensee Name RAMAR COMMUNICATIONS, INC.
Status LICENSED
DTS No
Community of License SANTA FE, NM
Pre-auction RF Channel 27
Post-auction RF Channel 27
Neilsen DMA Albuquerque-Santa Fe
Network Affiliation
Question Response
Sharee Station Facility ID 76268
Call Sign KWBQ
Type Commercial
Licensee Name Mission Broadcasting, Inc.
Status LICENSED
DTS No
Community of License SANTA FE, NM
Pre-auction RF Channel 29
Post-auction RF Channel 29
Neilsen DMA Albuquerque-Santa Fe
Network Affiliation
Question Response
Sharee Station Facility ID 55528
Call Sign KNME-TV
Type Noncommercial Educational
Licensee Name REGENTS/UNIVERSITY OF NEW MEXICO & BOARD OF EDUCATION/ALBQ.,
Status LICENSED
DTS No
Community of License ALBUQUERQUE, NM
Pre-auction RF Channel 35
Post-auction RF Channel 35
Neilsen DMA ALBUQUERQUE-SANTA FE
Network Affiliation

Transmitters

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

Primary Transmitter

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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 CTT-U-DCX-1H
Year 2002
Type Inductive Output Tube
IOT Power Type Single
Power Capacity 20 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-16
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 25.5 kW
Justification for New Transmitter The manufacturer of the existing IOT transmitter advises that the transmitter cannot be re-tuned to the assigned channel. See attached quotes. Request is for a SS one power step up from the required TPO.

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) Yes
Transformer (480V) Yes
Power 150 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 100.0 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? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Transmitter Electrical Work

Transmitter electrical work

Additional Transmitter Costs

Additional Transmitter Costs

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? Yes
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 Top Mount
Antenna position in stack Top
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 2
Number of Panels 40
Design power capacity in use 100.0 %
Lower Limit 470.00 MHz
Upper Limit 692.00 MHz
Other Antenna Type N/A
ERP: 245.0 kW
Manufacturer Dielectric
Model TUD-05-8/40H-T
Year 2007

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

Facility ID Call Sign
55528 KNME-TV

Primary Antenna

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Adjustment to Existing Antenna

Section Question Response
Sweep Test of Existing Antenna Do you need a sweep test of existing antenna? Yes

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? Yes
Type New
Number of channels supported 2
Frequencies of channels supported RF channel
Frequency N/A

Enter a list of RF channel numbers.

RF Channel Number
35
36

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Rigging

Rigging for sweep tests and possible elbow complex replacement

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 290 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Sweep Tests

Sweep tests for transmission line

Connect to new combiner

Misc line sections to connect to new combiner

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 173
Explanation It will be necessary to schedule and coordinate multiple vendors, complete progress reports, and update Schedule 399. Station does not have available personnel or personnel trained in project management for such complex projects.
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 Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 9
Justification It will be necessary to survey the site, plan the equipment, develop specifications for purchasing, and oversee multiple vendor RF projects. Station does not have available personnel or personnel trained in such services.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

American Tower Services

Engineering and management fees from American Tower. KASY share only.

Minor Modification of CP Application

Minor Modification of CP Application

License to Cover Application

License to Cover Application

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 No
Non-zoning permits Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
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? Yes

Other Expenses

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Other Expenses Not Listed

Name Description

Sales Tax

Sales tax on goods and service

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 $1,063,767.00 $781,867.00 N/A $716,367.00 N/A
Total for all systems $1,506,641.72 $1,227,005.72 N/A $1,085,254.48 N/A
Primary Transmitter THU9EVO-16 $1,063,767.00 $781,867.00 $716,367.00
Additional Transmitter Costs $5,317.00 $5,317.00 See Rohde & Schwarz quote 202174.1 and 182814.0 $5,317.00 N/A
Transmitter Electrical Work $42,500.00 $42,500.00 See Rohde & Schwarz quote 178932.0 $42,500.00 N/A
3" Rigid Conduit and Wiring (Cost per foot) $5,200.00 $4,900.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $24,300.00 N/A N/A N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW $947,000.00 $668,550.00 See Rohde & Schwarz quote 137498.2 attached. $668,550.00 N/A

Components

Actual Information Description File Name
Additional Transmitter Costs

Component Description:
Additional transmitter components
Amount:
$3,717.00

Component Description:
Additional transmitter costs
Amount:
$1,600.00
Transmitter Electrical Work

Component Description:
Transmitter electrical work
Amount:
$42,500.00
3" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Transformer 3 phase/480v - 150 KVA Information not provided.
Switchgear - industrial 800 amp Information not provided.
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW

Component Description:
Transmitter, installment #2
Amount:
$501,412.50

Component Description:
Transmitter, installment #1
Amount:
$167,137.50

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 $126,402.18 $140,048.18 N/A $138,648.18 N/A
Total for all systems $1,506,641.72 $1,227,005.72 N/A $1,085,254.48 N/A
Primary Antenna TUD-05-8/40H-T $126,402.18 $140,048.18 $138,648.18
Rigging $27,872.18 $27,872.18 KASY share of costs to install new combiner based on quote from American Tower. $27,872.18 N/A
Elbow complex, single channel, at antenna input, per 3 1/8. feedline (if needed) $7,600.00 $6,790.00 See Dielectric order confirmation 1749120 $6,790.00 N/A
New combiner, cost per channel (without antenna) $84,200.00 $98,986.00 Quote from American Tower for KASY's share of new combiner expenses. $98,986.00 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $5,000.00 N/A

Components

Actual Information Description File Name
Rigging

Component Description:
KASY Share of combiner installation and materials
Amount:
$27,872.18
Elbow complex, single channel, at antenna input, per 3 1/8. feedline (if needed)

Component Description:
Elbow components
Amount:
$6,790.00
New combiner, cost per channel (without antenna)

Component Description:
KASY share of combiner cost
Amount:
$98,986.00
Sweep test of existing antenna

Component Description:
Sweep test
Amount:
$5,000.00

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 $20,346.54 $20,346.54 N/A $18,946.54 N/A
Total for all systems $1,506,641.72 $1,227,005.72 N/A $1,085,254.48 N/A
Primary Transmission Line $20,346.54 $20,346.54 $18,946.54
Connect to new combiner $13,946.54 $13,946.54 Tx line costs to connect to new combiner. $13,946.54 N/A
Sweep Tests $6,400.00 $6,400.00 N/A $5,000.00 N/A

Components

Actual Information Description File Name
Connect to new combiner

Component Description:
Combiner interconnect parts
Amount:
$13,946.54
Sweep Tests

Component Description:
Sweep test
Amount:
$5,000.00

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 $102,129.00 $99,305.00 N/A $58,818.50 N/A
Total for all systems $1,506,641.72 $1,227,005.72 N/A $1,085,254.48 N/A
Outside Professional Services $102,129.00 $99,305.00 $58,818.50
License to Cover Application $625.00 $625.00 Prepare engineering portion of a License to Cover a Post-Transition CP Application; see Osborn invoice 34505 $625.00 N/A
Additional Field Engineering Service, 9 Days $18,000.00 $18,000.00 N/A N/A N/A
Minor Modification of CP Application $2,500.00 $2,500.00 See Osborn invoice 34505; required due to request from American Tower to change antenna model from upper stack to lower stack. $2,500.00 N/A
American Tower Services $24,480.00 $24,480.00 KASY share of costs for American Tower services: engineering, permitting, project management. Based on American Tower Quote attached. $24,480.00 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 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
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 $3,000.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $7,000.00 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $2,500.00 N/A
Project management of the transition $27,334.00 $25,950.00 N/A $18,713.50 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

Components

Actual Information Description File Name
License to Cover Application

Component Description:
License to Cover application
Amount:
$625.00
Additional Field Engineering Service, 9 Days Information not provided.
Minor Modification of CP Application

Component Description:
Prepare engineering portion of minor modification of CP application
Amount:
$2,500.00
American Tower Services

Component Description:
Engineering and management fees
Amount:
$24,480.00
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.
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:
See cover letter item 4 - Prepare FCC Form 2100 construction permit application Including invoice from contractor Kessler and Gehman Associates.
Amount:
$3,000.00
Perform engineering study for new channel assignment and antenna development

Component Description:
See cover letter item 3 - Perform engineering study for new channel assignment and antenna development. Including invoice from contractor Kessler and Gehman Associates.
Amount:
$7,000.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Prepare and or review reimbursement form

Component Description:
See cover letter item 2 - Prep and review FCC form 399. Including invoice from contractor Kessler and Gehman Associates.
Amount:
$2,500.00
Project management of the transition

Component Description:
Project management services January 2019
Amount:
$65.00

Component Description:
Project management services
Amount:
$50.00

Component Description:
See cover letter items 1, 5-8: Project Management for Structural Analysis and Tower Modifications and progress reporting including from constractor Kessler and Gehman Associates.
Amount:
$10,203.00

Component Description:
Project management services 2.1.19 through 3.1.19
Amount:
$225.00

Component Description:
Project Management for Structural Analysis and Tower Modifications from October 27, 2018 through November 30, 2018. Invoice from consultants Kessler and Gehman Associates also included.
Amount:
$875.00

Component Description:
Project Management for Structural Analysis and Tower Modifications including Kessler and Gehman Associates. Services from May 26, 2018 through June 29, 2018
Amount:
$600.00

Component Description:
Project Management for Structural Analysis and Tower Modifications. Services from December 1, 2018 through December 31, 2018.
Amount:
$150.00

Component Description:
Project management services 3.30.19 through 4.26.19
Amount:
$300.00

Component Description:
Project management services 10.18
Amount:
$50.00

Component Description:
Project management services March 2019
Amount:
$71.50

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

Component Description:
Project management services 6.1.19 through 6.28.19
Amount:
$450.00

Component Description:
Project Management for Structural Analysis and Tower Modifications including Kessler and Gehman Associates. Services from January 1, 2019 through January 31, 2019 for Form 387 Transition Plan Progress Report 2018 Q4 preparation
Amount:
$150.00

Component Description:
Project Management for Structural Analysis and Tower Modifications. Services from June 30, 2018 through July 27, 2018.
Amount:
$225.00

Component Description:
Project management services 3.2.19 through 3.29.19
Amount:
$225.00

Component Description:
Project Management for Structural Analysis and Tower Modifications including consultants Kessler and Gehman Associates. Services from September 29, 2018 through October 26, 2018.
Amount:
$300.00

Component Description:
Project management services 4.27.19 through 5.31.19
Amount:
$150.00

Component Description:
Project management services
Amount:
$4,272.50

Component Description:
Project management services April 2019
Amount:
$78.00

Component Description:
Project Management for Structural Analysis and Tower Modifications. Services from July 28, 2018 through September 28, 2018.
Amount:
$150.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit 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 $193,997.00 $185,439.00 N/A $152,474.26 N/A
Total for all systems $1,506,641.72 $1,227,005.72 N/A $1,085,254.48 N/A
Other Expenses $193,997.00 $185,439.00 $152,474.26
Sales Tax $66,000.00 $66,000.00 Sales tax for goods and services based on NM tax rate of 5.125% plus county tax. See related invoices. $65,535.69 N/A
MVPD Notification of Channel Change $2,000.00 $2,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $3,500.00 $3,500.00 Costs to produce spots and crawls for viewer notification. N/A N/A
Equipment Storage $25,000.00 $25,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $33,997.00 $33,997.00 See Rohde & Schwarz quotes 169822.0, 185625.0, 222485.0 and Dielectric order confirmation 1749120 $33,996.57 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $49,950.00 $49,950.00 See USA Commercial and Jaytec quotes attached. $49,950.00 N/A
Non-zoning permits $2,000.00 $2,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $2,992.00 See DTVNotification EST-000892 $2,992.00 N/A

Components

Actual Information Description File Name
Sales Tax

Component Description:
Tax on additional transmitter components
Amount:
$190.50

Component Description:
KASY Sales and Use Tax
Amount:
$12,199.00

Component Description:
Tax due on mountain delivery
Amount:
$636.01

Component Description:
Tax due on transmitter
Amount:
$34,263.19

Component Description:
Tax on additional transmitter costs
Amount:
$82.00

Component Description:
Tax on transmitter disposal services
Amount:
$3,146.06

Component Description:
Tax due on transmitter electrical work
Amount:
$2,178.13

Component Description:
Tax on transportation/consolidation services
Amount:
$1,342.11

Component Description:
Tax on American Tower services
Amount:
$11,283.95

Component Description:
Tax on transmitter equipment delivery
Amount:
$214.74
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges

Component Description:
Elbow components shipping cost
Amount:
$1,128.57

Component Description:
Transmitter transportation/consolidation services
Amount:
$16,268.00

Component Description:
Transmitter equipment delivery costs
Amount:
$4,190.00

Component Description:
Mountain delivery services
Amount:
$12,410.00
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
Disposal costs
Amount:
$10,000.00

Component Description:
Transmitter disposal costs
Amount:
$39,950.00
Non-zoning permits Information not provided.
DTV Medical Facility Notification

Component Description:
Notification of Medical Facilities
Amount:
$2,992.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,506,641.72 $1,227,005.72 $1,085,254.48

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. Yes

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.

Dennis P. Thatcher

President


10/08/2021

Attachments

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