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:
167155
Service:
LPT
Call Sign:
K23NW-D
Channel:
23 (UHF)
File Number:
0000089911
FRN:
0018223693
Eligibility Status:
Eligible
Date Submitted:
01/12/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GRAY TELEVISION LICENSEE, LLC

Robert Folliard

PO Box 30319

Atlanta, GA 30319

United States

+1 (701) 237-5211 robert.folliard@gray.tv Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Sam Hariton

Widelity

Sam Hariton

4031 University Dr

Suite 100

Fairfax, VA 22030

United States

+1 (339) 222-8107 sam.hariton@widelity.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. Yes
Briefly describe transition plan K23NW-D is planning to purchase an upgraded antenna and transmitter, to re-use its transmission line, and to install the equipment at a new transmitter location shared with a sister station K21JK-D (168357, low power).

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 Ranger CZ250
Year 2008
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 0.25 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 UAXTE-2R37
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.2 kW
Justification for New Transmitter K23NW-D cannot retune the transmitter.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Other Transmitter Costs
Does the transmitter installation require a Transmitter Building Site Survey/Installation? No
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Rigid Conduit and Wiring No
Other Electrical Service Yes
Description Modification of existing electrical service for installation of surge protector and flex conduit to transmitter
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 tons
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

Mask Filter

Mask Filter

Primary Transmitter - Other Additional Parts

Primary Transmitter - Other Additional Parts

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? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? Yes
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 1.0 kW
Manufacturer
Model SL-8
Year 2007

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? Yes
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 600.0 W
Manufacturer
Model TBD
Year 2019
Justification for New Antenna Sharing the antenna with sister station K21JK will cut costs in supporting two sites at same location. Also Better signal coverage, Directional Covering Front and Back Side to serve more population.

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 Upper and lower frequency
Frequency 512.0 MHz - 530.0 MHz
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Tower Equipment And Rigging Costs

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

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? No
Coordinates (NAD83) Latitude (NAD83) 38° 18' 55.0" N-
Longitude (NAD83) 108° 12' 17.4" W-
Overall Structure Height 184.00 feet
Support Structure Height 184.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 10174.00 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Southwest Colorado Television Translator Association
Date Constructed 01/01/1999

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
168357 K21JK-D LPD

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: Major Reinforcements needed

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Removal of Equipment

Removal of Equipment

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 254
Explanation K23NW-D does not have sufficient capacity and expertise in house to handle all reimbursement activities necessary to facilitate on-time completion of the station's build. As such, K23NW-D will hire an outside firm to support K23NW-D in these tasks.
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 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 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 No
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

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Permit and Filing Costs FCC Construction Permit Major Change Yes
FCC Construction Permit Minor Change Yes
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? No
Does this relocation require Equipment Storage? No
Point to Point Microwave (STL/ICR) Frequency Coordination for Unidirection System No
Frequency Coordination for Bi-Direction System Yes
New Point to Point Microwave System Yes
Type Unlicensed

Other Expenses

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Other Expenses Not Listed

Name Description

Use Tax

Use Tax

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 $112,595.66 $55,816.11 N/A $43,186.58 N/A
Total for all systems $354,471.68 $310,034.73 N/A $191,711.24 N/A
Primary Transmitter UAXTE-2R37 $112,595.66 $55,816.11 $43,186.58
Primary Transmitter - Other Additional Parts $164.13 $164.13 Please see K23NW-D Primary Transmitter - Other Additional Parts Budget Revision Justification Letter $164.13 N/A
Mask Filter $5,681.53 $5,681.53 Please see mask filter from Quote Q-766864 plus additional services on Quote Q-76684 N/A N/A
5 Ton system $20,250.00 $4,448.00 Please see Fortney Refrigeration Proposal Mini Split Rasberry mtn. Note that 5 Tons is the smallest size LMS allows to be entered. N/A N/A
Other Electrical Service: Modification of existing electrical service for installation of surge protector and flex conduit to transmitter $2,500.00 $2,500.00 Please see Est_812_from_A__J_Electric_Inc._1272 N/A N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $43,022.45 Estimated Cost Justification K23NW-D-110-Primary Transmitter - UHF - Air Cooled Solid State Transmitter 1 - 2.5kw v0 $43,022.45 N/A

Components

Actual Information Description File Name
Primary Transmitter - Other Additional Parts

Component Description:
Amazon
Amount:
$164.13
Mask Filter Information not provided.
5 Ton system Information not provided.
Other Electrical Service: Modification of existing electrical service for installation of surge protector and flex conduit to transmitter Information not provided.
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Transmitter, Mask Filter System, Installation & Proof, Freight
Amount:
$14,581.52

Component Description:
Transmitter
Amount:
$28,440.93

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 $16,348.79 $16,348.79 N/A $1,218.79 N/A
Total for all systems $354,471.68 $310,034.73 N/A $191,711.24 N/A
Primary Antenna TBD $16,348.79 $16,348.79 $1,218.79
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 600.0watt input, Horizontal $1,218.79 $1,218.79 ***System Notice: Estimate adjusted and locked because line has been superseded.***The Est Cost has been established by like-for-like antenna information. See the station narrative and Justification K23NW-D Antenna Cost Like-For-Like for details. $1,218.79 N/A
1 kW UHF Combiner (per channel) $9,400.00 $9,400.00 N/A N/A N/A

Components

Actual Information Description File Name
Sweep test of transmission line and antenna Information not provided.
UHF-Low Power, Side Mount, Slotted Coaxial, 600.0watt input, Horizontal

Component Description:
Broadcast Antenna Mounting Brackets
Amount:
$1,218.79
1 kW UHF Combiner (per channel) Information not provided.

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 $168,709.15 $168,709.15 N/A $109,494.15 N/A
Total for all systems $354,471.68 $310,034.73 N/A $191,711.24 N/A
Primary Tower TOWER $168,709.15 $168,709.15 $109,494.15
Major tower reinforcement/modifications $87,869.15 $87,869.15 Please see Estimated Cost Justification K23NW-D-410-Existing Primary Tower - Major Tower Reinforcement Modifications v2 $87,869.15 N/A
Removal of Equipment $3,650.00 $3,650.00 Per Thin Air Estimate 3064_002_KKCO $3,650.00 N/A
Tower Rigging Short Tower (less than 500') $56,190.00 $56,190.00 N/A $17,975.00 N/A
Tower mapping and report for structural engineer $21,000.00 $21,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Major tower reinforcement/modifications

Component Description:
Raspberry 180FT Guyed Tower Modification Project
Amount:
$6,289.13

Component Description:
180FT-GUYED-KKCO RASPBERRY 180FT GUYED TOWER MODIFICATION PROJECT
Amount:
$17,293.69

Component Description:
Raspberry 180FT Guyed Tower Modification Project
Amount:
$3,312.50

Component Description:
KKCO Raspberry 180FT Guyed Tower Modification Project
Amount:
$60,973.83
Removal of Equipment

Component Description:
Raspberry Channel 49 and 2GHz Parabolic Antenna Removals (K49JX-D Repack)
Amount:
$3,650.00
Tower Rigging Short Tower (less than 500')

Component Description:
KKCO Raspberry Site TV Broadcast Antenna Replacement (K49JX-D Repack)
Amount:
$17,975.00
Tower mapping and report for structural engineer 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 $45,597.00 $57,939.60 N/A $36,650.65 N/A
Total for all systems $354,471.68 $310,034.73 N/A $191,711.24 N/A
Outside Professional Services $45,597.00 $57,939.60 $36,650.65
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 $492.10 Please see K23NW Attorney - Negotiation of Lease and Other Matters Budget Revision Justification Letter $492.10 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
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 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 $250.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 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 N/A N/A
Project management of the transition $26,797.00 $41,910.00 Please see K23NW-D-LPTV strategic support quote $35,908.55 N/A

Components

Actual Information Description File Name
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
For Professional Services Rendered
Amount:
$492.10
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare Form 601 Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Perform engineering study for displacement application

Component Description:
"Reimbursement support: Provide derivation of required Transmitter Power Output regarding displacement facility on Ch-23."
Amount:
$250.00
Prepare/ Review 399 reimbursement form 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 Information not provided.
Project management of the transition

Component Description:
Project Management
Amount:
$2,150.30

Component Description:
Project Management
Amount:
$2,528.70

Component Description:
Project Management
Amount:
$694.80

Component Description:
Project Management
Amount:
$389.85

Component Description:
Project Management
Amount:
$203.00

Component Description:
Project Management
Amount:
$1,381.60

Component Description:
Project management
Amount:
$3,329.15

Component Description:
Project Management
Amount:
$262.20

Component Description:
Project Management
Amount:
$1,353.25

Component Description:
Project Management
Amount:
$1,597.35

Component Description:
Project Management
Amount:
$632.95

Component Description:
Project Management
Amount:
$137.95

Component Description:
Project Management
Amount:
$2,655.40

Component Description:
Project Management
Amount:
$516.55

Component Description:
Project Management
Amount:
$114.45

Component Description:
Project Management
Amount:
$25.35

Component Description:
Project Management
Amount:
$1,424.65

Component Description:
Project Management
Amount:
$75.15

Component Description:
Project Management
Amount:
$80.25

Component Description:
Project Management
Amount:
$98.70

Component Description:
Project Management
Amount:
$1,969.55

Component Description:
Project Management
Amount:
$702.35

Component Description:
Project Management
Amount:
$2,355.15

Component Description:
Project Management
Amount:
$212.65

Component Description:
Project Management
Amount:
$2,214.45

Component Description:
Project Management
Amount:
$18.45

Component Description:
Project Management
Amount:
$2,397.15

Component Description:
Project Management
Amount:
$1,593.70

Component Description:
Project Management
Amount:
$729.60

Component Description:
Project Management
Amount:
$1,231.30

Component Description:
Project Management
Amount:
$12.40

Component Description:
Project Management
Amount:
$863.75

Component Description:
Project Management
Amount:
$175.55

Component Description:
Project Management
Amount:
$25.50

Component Description:
Project Management
Amount:
$493.80

Component Description:
Project Management
Amount:
$1,261.60

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 $11,221.08 $11,221.08 N/A $1,161.07 N/A
Total for all systems $354,471.68 $310,034.73 N/A $191,711.24 N/A
Other Expenses $11,221.08 $11,221.08 $1,161.07
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A
FCC Filing Fees - Form 2100 Major change CP application $4,960.00 $4,960.00 N/A N/A N/A
FCC Filing Fees - Form 2100 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 N/A N/A
Point to Point Microwave (STL/ICR): Frequency Coordination for Bi-Direction System $1,100.00 $1,100.00 N/A N/A N/A
New Point to Point Microwave System: Unlicensed $2,250.00 $2,250.00 N/A N/A N/A
Use Tax $1,161.08 $1,161.08 Please see K23NW-D Use Tax Budget Revision Justification Letter $1,161.07 N/A

Components

Actual Information Description File Name
FCC Filing Fees - Form 2100 license to cover application Information not provided.
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 Information not provided.
Point to Point Microwave (STL/ICR): Frequency Coordination for Bi-Direction System Information not provided.
New Point to Point Microwave System: Unlicensed Information not provided.
Use Tax

Component Description:
KKCO USE TAX
Amount:
$1,161.07

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $354,471.68 $310,034.73 $191,711.24

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
Construction of final facilities or all necessary modifications are complete. No
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator. No

Certification

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Section Question Response
Submission of Estimated Expenses Statements

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.

  1. The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  3. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  4. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).

  5. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  6. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.

  7. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  8. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Robert Folliard , III .

Assistant Secretary


01/12/2022

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).

  1. The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

  3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  4. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  5. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .

  6. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  7. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

  8. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  9. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Robert Folliard , III .

Assistant Secretary


01/12/2022

Attachments

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