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:
167755
Service:
LPT
Call Sign:
KXKW-LD
Channel:
30 (UHF)
File Number:
0000089113
FRN:
0008774135
Eligibility Status:
Eligible
Date Submitted:
10/07/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

DELTA MEDIA CORPORATION

Applicant

Doing Business As: DELTA MEDIA CORPORATION

3501 N.W. EVANGELINE THRUWAY

CARENCRO, LA 70520

United States

+1 (337) 896-1600 charles@delta-network.com Other

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

The Preparer is same as the reimbursement contact.

 

 

 

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 Transition plan is to replace existing transmission line and antenna for channel 32 and install replacement antenna and transmission line for channel 30.

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 NV7500
Year 2005
Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power Capacity 5 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? No
Manufacturer
Model EC702HP-BB2
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2.2 kW
Justification for New Transmitter Rohde $ Schwarz no longer provides technical support for the NV7500 transmitter series. Our consulting engineer stated that the existing transmitter should be replaced for this reason.

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 Yes
Size 1.5 inches
Length 50.0 feet
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

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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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Ownership Owned
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model ALP16L3-HSOC-32
Year 2008

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 TLP-16M/VP-R
Year 2020
Justification for New Antenna Existing antenna is not broadbanded to be able to go from RF channel 32 to RF channel 30 and cannot be retuned in the field.

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 4 1/16 inches inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? Yes
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

Name Description

Louisiana State and Local Sales Taxes

Louisiana State and Local Sales Taxes associated with purchase of new antenna

Louisiana State and Local Sales Taxes

Louisiana State and Local Sales Taxes associated with antenna shipping costs

Freight and Shipping

Freight and Shipping costs for the antenna from Raymond, Maine to Wilderness Trail tower site Carencro, LA

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? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Dielectric
Type Rigid
Diameter 4 1/16 inches
Segment Length 19 1/2 inches
Number of parallel runs 1
Length 970 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Reducer 4-50 X 1-50

Reducer 4-50 X 1-50 for Antenna Input

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Ownership Owned
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
Type Rigid
Diameter 4 1/16 inches
Segment Length 20 inches
Number of parallel runs 1
Length 970 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Rigid
Diameter 4 1/16 inches
Segment Length 19 1/2 inches
Number of parallel runs 1
Length 1050 feet per run
Justification for New Transmission Line The existing transmission line lengths of 20 feet are not the correct length for RF channel 30.
Interior RF Systems Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators? Yes

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Louisiana State and Local Sales Taxes

Louisiana State and Local Sales Taxes associated with shipping and handling costs of new transmission line

Louisiana State and Local Sales Taxes

Louisiana State and Local Sales Taxes associated with purchase of new transmission line

RF Sweep of Existing Transmission Line

Perform an RF Sweep of the existing transmission line to determine whether it is acceptable to use for RF channel 30

Shipping and Handling

Shipping and handling costs associated with purchase of new transmission line

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 Move Equipment
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 Yes
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1251823
Coordinates (NAD83) Latitude (NAD83) 30° 20' 33.0" N-
Longitude (NAD83) 091° 57' 46.6" W-
Overall Structure Height 1025.91 feet
Support Structure Height 966.20 feet
Ground Elevation Above Mean Sea Level (AMSL) 22.97 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Delta Media Corp.
Date Constructed 05/01/2006

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
183335 KLWB-FM FM
153132 K249EY FX
33220 KOGM FM
202534 K253CO FX
349 KDCG-CD DTV
201208 K258DQ FX
82476 KLWB DTV

Other Types of Users

Users
Two-way radio

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? No
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 Yes
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 No
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 No
RF exposure measurements No
Additional Field Engineering Service No

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Attorney Fees

Attorney fees related to transition of channel 32 to channel 30

Project Management

Project Management for time involved in supervision of channel transition

Prepare and review reimbursement form

Expenses related to preparation of reimbursement form

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)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? No
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

Portable Toilet Rental

Transmitter site does not have permanent facilities

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 $86,500.00 $70,255.56 N/A $67,755.56 N/A
Total for all systems $341,270.46 $320,146.29 N/A $114,496.29 N/A
Primary Transmitter EC702HP-BB2 $86,500.00 $70,255.56 $67,755.56
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $67,755.56 N/A $67,755.56 N/A
1.5" Rigid Conduit and Wiring $2,500.00 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Hitachi Comark Invoice # S10573-1 for 50% payment due initial order for transmitter
Amount:
$33,877.78

Component Description:
Comark Invoice S10573-3 for remaining 5% due for the purchase of the channel 30 transmitter.
Amount:
$3,387.78

Component Description:
Comark invoice S10573-2 for payment due prior to shipment of transmitter
Amount:
$30,490.00
1.5" Rigid Conduit and Wiring Information not provided.

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 $53,206.47 $48,329.24 N/A $41,929.24 N/A
Total for all systems $341,270.46 $320,146.29 N/A $114,496.29 N/A
Primary Antenna TLP-16M/VP-R $53,206.47 $48,329.24 $41,929.24
Freight and Shipping $1,179.72 $1,179.72 N/A $1,179.72 N/A
Louisiana State and Local Sales Taxes $1,560.75 $1,560.75 N/A $1,560.75 N/A
Side Mount antenna brackets $4,625.00 $3,540.00 N/A $3,540.00 N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical $30,541.00 $30,541.00 N/A $30,541.00 N/A
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed) $9,570.00 $5,107.77 N/A $5,107.77 N/A
Sweep test of transmission line and antenna $5,730.00 $6,400.00 The typical cost for sweep testing has been quoted at $6,400.00. $0.00 N/A

Components

Actual Information Description File Name
Freight and Shipping

Component Description:
Dielectric Invoice 1135028 - Covers freight and shipping for elbow complex on Dielectric Invoice 1133040
Amount:
$209.41

Component Description:
Freight and shipping charges for channel 30 antenna from Raymond, Maine to Wilderness Trail tower site Carencro, Louisiana via PAF Transportation
Amount:
$970.31
Louisiana State and Local Sales Taxes

Component Description:
Invoice ST886009 - Louisiana sales tax due for invoice 886009 adjusted to $1,560.75 as explained in cover letter
Amount:
$1,560.75
Side Mount antenna brackets

Component Description:
Invoice 886009 Line item #3 Standard Mounts (Side Mounts) for TLP-16M/VP-R antenna
Amount:
$3,540.00

Component Description:
Please disregard invoice MAN01618
Amount:
N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical

Component Description:
Invoice 886009 Line item #1 TLP-16M/VP-R KXKW-LP Channel 30 antenna
Amount:
$30,541.00
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed)

Component Description:
Dielectric Invoice 1133040 - For 4 1/16" 50 ohm elbows to comprise Elbow Complex to mate transmission line to new channel 30 antenna input
Amount:
$5,107.77
Sweep test of transmission line and antenna

Component Description:
Please disregard invoice MAN01618
Amount:
N/A

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 $992.00 $992.00 N/A $992.00 N/A
Total for all systems $341,270.46 $320,146.29 N/A $114,496.29 N/A
Primary Transmission Line $992.00 $992.00 $992.00
Reducer 4-50 X 1-50 $992.00 $992.00 N/A $992.00 N/A
Primary Transmission Line $0.00 $0.00 $0.00

Components

Actual Information Description File Name
Reducer 4-50 X 1-50

Component Description:
Invoice 886009 Line item #4 Reducer 4-50 x 1-50 for TLP-16M/VP-R antenna input
Amount:
$992.00

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 $157,750.00 $157,750.00 N/A $0.00 N/A
Total for all systems $341,270.46 $320,146.29 N/A $114,496.29 N/A
Primary Tower TOWER $157,750.00 $157,750.00 $0.00
Tower Rigging Tall Tower (greater than 500') $157,750.00 $157,750.00 N/A N/A N/A

Components

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 $29,022.50 $29,020.00 N/A $125.00 N/A
Total for all systems $341,270.46 $320,146.29 N/A $114,496.29 N/A
Outside Professional Services $29,022.50 $29,020.00 $125.00
Attorney Fees $5,000.00 $5,000.00 N/A $125.00 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
Prepare Form 601 $755.00 $755.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,100.00 N/A N/A N/A
Project Management $5,000.00 $5,000.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 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 and review reimbursement form $2,000.00 $2,000.00 N/A N/A N/A
Form 399 assistance or other Program Management costs $5,000.00 $5,000.00 N/A N/A N/A
Perform engineering study for displacement application $1,800.00 $1,800.00 N/A N/A N/A

Components

Actual Information Description File Name
Attorney Fees

Component Description:
Attorney services rendered for preparing draft for KXKW-LD license to cover displacement CP
Amount:
$125.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare Form 601 Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Project Management Information not provided.
Prepare/ Review 399 reimbursement form 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 and review reimbursement form Information not provided.
Form 399 assistance or other Program Management costs Information not provided.
Perform engineering study for displacement 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 $13,799.49 $13,799.49 N/A $3,694.49 N/A
Total for all systems $341,270.46 $320,146.29 N/A $114,496.29 N/A
Other Expenses $13,799.49 $13,799.49 $3,694.49
Portable Toilet Rental $700.00 $700.00 N/A N/A N/A
Equipment Delivery and Handling Charges $3,694.49 $3,694.49 N/A $3,694.49 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 - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $3,000.00 $3,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Portable Toilet Rental Information not provided.
Equipment Delivery and Handling Charges

Component Description:
Dielectric invoice 996025 for channel 30 antenna storage with PAF Transportation due to COVID-19 restrictions
Amount:
$3,295.00

Component Description:
Far Horizon Equipment - Invoice 54 - for skid steer rental to off load channel 30 antenna at KXKW transmitter site
Amount:
$399.49
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 - Form 2100 license to cover application Information not provided.
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 $341,270.46 $320,146.29 $114,496.29

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.

Arthur Lee Clardy , III .

Director of Engineering


10/07/2021

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.

Arthur Lee Clardy , III .

Director of Engineering


10/07/2021

Attachments

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