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:
29231
Service:
LPD
Call Sign:
WXNY-LD
Channel:
23 (UHF)
File Number:
0000089493
FRN:
0001843697
Eligibility Status:
Not Determined
Date Submitted:
01/26/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

NEW YORK SPECTRUM HOLDING COMPANY, LLC

Doing Business As: NEW YORK SPECTRUM HOLDING COMPANY, LLC

Jeffrey Lai

12012 Sunrise Valley Drive

Suite 115

Reston, VA 20191

United States

+1 (571) 471-8806 jeffrey.lai@cmmb.com.hk 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

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. No
Briefly describe transition plan WXNY IS CHANGING CHANNELS TO CHANNEL 23 to ACCOMMODATE BROADCAST REPACK.

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 Maxiva UAX-1000AT
Year 2007
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1 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 EC-702HP-BB2
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2.2 kW
Justification for New Transmitter LICENSEE NEEDS NEW TRANSMITTER TO PRODUCE POWER TO MAKE AUTHORIZED SIGNAL USING NEW ANTENNA ON CHANNEL 23

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Other Transmitter Costs
Does the transmitter installation require a Transmitter Building Site Survey/Installation? Yes
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Rigid Conduit and Wiring No
Other Electrical Service Yes
Description INSTALLING NEW ELECTRIC RUNS TO NEW TRANSMITTER LOCATION IF NEEDED
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

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 Other
Other Antenna Type Custom Panel
ERP: 15.0 kW
Manufacturer
Model 4DR-16S
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? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model ATC-BCH04P5S-23
Year 2020
Justification for New Antenna NEW ANTENNA NEEDED FOR CHANGE IN CHANNEL

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? Yes
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

Alive Telecom

Engineering and Material Expense Associated with Antenna

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 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 Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 2
Length 60 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 Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 260 feet per run
Justification for New Transmission Line New transmission line required for new antenna/transmitter combination
Interior RF Systems Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators? No

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

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? Located on Building
Is this tower currently shared with any other stations? No
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? No
Coordinates (NAD83) Latitude (NAD83) 40° 44' 50.3" N-
Longitude (NAD83) 073° 56' 36.4" W-
Overall Structure Height 704.00 feet
Support Structure Height 704.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 16.00 feet
Structure Type BANT - Building with an Antenna
Tower Owner CITIBANK, NA
Date Constructed 01/01/1990


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: Minor Reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower Located on Building
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 Yes
Quantity 1
Prepare Form 601 No
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
Negotiation of Lease and other Matter for Shared Locations 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 Yes
RF exposure measurements Yes
Additional Field Engineering Service Yes
Number of Days 3
Justification Engineering to change transmitter/antenna and other equipment and necessary measurements for signal coverage verification.

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 No
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

Sales Tax on Equipment

Sales Tax Charges on Equipment Purchases

Transmitter EAS Equipment

Transmitter EAS Equipment & Installation

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 $119,250.00 $84,000.00 N/A $48,750.00 N/A
Total for all systems $396,202.50 $357,362.50 N/A $98,351.80 N/A
Primary Transmitter EC-702HP-BB2 $119,250.00 $84,000.00 $48,750.00
Transmitter Building Site Survey/Installation $10,000.00 $10,000.00 N/A N/A N/A
Other Electrical Service: INSTALLING NEW ELECTRIC RUNS TO NEW TRANSMITTER LOCATION IF NEEDED $5,000.00 $5,000.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $48,750.00 QUOTE AND EXPLANATION FOR EC702HP-BB2 AIR COOLED 2200 WATT TRANSMITTER REQUIRED FOR REPACK CHANNEL 23 ATTACHED $48,750.00 N/A
5 Ton system $20,250.00 $20,250.00 N/A N/A N/A

Components

Actual Information Description File Name
Transmitter Building Site Survey/Installation Information not provided.
Other Electrical Service: INSTALLING NEW ELECTRIC RUNS TO NEW TRANSMITTER LOCATION IF NEEDED Information not provided.
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
2nd & final 50% of additional cost of change to EC-702 from EC-701 transmitter
Amount:
$7,922.50

Component Description:
50% of originally ordered EC-701 Transmitter
Amount:
$16,452.50

Component Description:
2nd & final 50% installment of originally ordered EC-701 transmitter
Amount:
$16,452.50

Component Description:
50% of additional cost of change to EC-702 from EC-701 transmitter
Amount:
$7,922.50
5 Ton system 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 $18,280.00 $18,280.00 N/A $7,550.00 N/A
Total for all systems $396,202.50 $357,362.50 N/A $98,351.80 N/A
Primary Antenna ATC-BCH04P5S-23 $18,280.00 $18,280.00 $7,550.00
Alive Telecom $1,150.00 $1,150.00 Engineering and Material Expense $1,150.00 N/A
Pattern scatter analysis for side mount (if not included in antenna base cost) $5,000.00 $5,000.00 N/A N/A N/A
UHF-Low Power, Top Mount, Slotted Coaxial, 15.0kW input, Horizontal $6,400.00 $6,400.00 ***System Notice: Estimate adjusted and locked because line has been superseded.*** $6,400.00 N/A
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A

Components

Actual Information Description File Name
Alive Telecom

Component Description:
Installment 2 of 2 of Engineering charge for antenna
Amount:
$345.00

Component Description:
Portion of engineering charge for change to antenna design from 8 bay to 4 bay
Amount:
$805.00
Pattern scatter analysis for side mount (if not included in antenna base cost) Information not provided.
UHF-Low Power, Top Mount, Slotted Coaxial, 15.0kW input, Horizontal

Component Description:
Installment 4 of 4 for new antenna
Amount:
$1,920.00

Component Description:
Installment 1 of 4 for new antenna
Amount:
$640.00

Component Description:
Installment 2 of 4 for new antenna
Amount:
$1,920.00

Component Description:
Installment 3 of 4 for new antenna
Amount:
$1,920.00
Sweep test of transmission line and antenna Information not provided.

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $6,240.00 $2,650.00 N/A $2,650.00 N/A
Total for all systems $396,202.50 $357,362.50 N/A $98,351.80 N/A
Primary Transmission Line $6,240.00 $2,650.00 $2,650.00
Flexible Foam Transmission Line - dielectric, 1 5/8" $6,240.00 $2,650.00 N/A $2,650.00 N/A

Components

Actual Information Description File Name
Flexible Foam Transmission Line - dielectric, 1 5/8"

Component Description:
Installment #3 of 4 for new TX line for WXNY ($2,650.00 total)
Amount:
$795.00

Component Description:
Installment #4 of 4 (Final) for WXNY TX line ($2,650.00 total)
Amount:
$795.00

Component Description:
Installment #1 of 4 for WXNY new TX line ($2,650.00 total)
Amount:
$265.00

Component Description:
Installment #2 of 4 for New TX line for WXNY ($2650.00 Total)
Amount:
$795.00

Component Description:
Installment 1 of 4 for New TX line
Amount:
$265.00

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 $76,200.00 $76,200.00 N/A $27,120.00 N/A
Total for all systems $396,202.50 $357,362.50 N/A $98,351.80 N/A
Primary Tower BANT $76,200.00 $76,200.00 $27,120.00
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas) $45,200.00 $45,200.00 Based on Steam Valley Communications Proposal/Quote for installation services $27,120.00 N/A
Minor tower reinforcement/modifications $10,000.00 $10,000.00 N/A N/A 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
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas)

Component Description:
60% of total labor cost for installation on 81st Floor Empire State building Transmitter, Antenna, etc.
Amount:
$27,120.00
Minor tower reinforcement/modifications Information not provided.
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 $87,982.50 $87,982.50 N/A $5,515.00 N/A
Total for all systems $396,202.50 $357,362.50 N/A $98,351.80 N/A
Outside Professional Services $87,982.50 $87,982.50 $5,515.00
Additional Field Engineering Service, 3 Days $6,000.00 $6,000.00 N/A $5,515.00 N/A
RF Exposure Measurements $12,100.00 $12,100.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $52,600.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $2,235.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A 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 N/A N/A
Form 399 assistance or other Program Management costs $2,500.00 $2,500.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A

Components

Actual Information Description File Name
Additional Field Engineering Service, 3 Days

Component Description:
Labor expense for installation of Channel 23 facility on Empire State Building (partial)
Amount:
$5,515.00
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Perform engineering study for displacement application Information not provided.
Form 399 assistance or other Program Management costs Information not provided.
Prepare/ Review 399 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 $88,250.00 $88,250.00 N/A $6,766.80 N/A
Total for all systems $396,202.50 $357,362.50 N/A $98,351.80 N/A
Other Expenses $88,250.00 $88,250.00 $6,766.80
Transmitter EAS Equipment $56,805.00 $56,805.00 N/A $0.00 N/A
Sales Tax on Equipment $15,000.00 $15,000.00 N/A $3,371.80 N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 N/A $3,395.00 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $10,000.00 $10,000.00 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
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,110.00 N/A N/A N/A

Components

Actual Information Description File Name
Transmitter EAS Equipment

Component Description:
REIMBURSEABLE PORTION OF INVOICE FOR EQUIPMENT & LABOR FOR INSTALL AT EMPIRE STATE BLDG.
Amount:
$14,961.00

Component Description:
Transmitter EAS equipment expenses and installation labor costs for same, excluding encoder not reimburseable per FCC Staff.
Amount:
$25,965.00
Sales Tax on Equipment

Component Description:
2nd 50% installment of sales tax on increased cost of EC-702 transmitter
Amount:
$524.87

Component Description:
initial 50% of sales tax on originally ordered EC-701 Transmitter
Amount:
$1,161.03

Component Description:
2nd 50% installment of sales tax on originally ordered EC-701
Amount:
$1,161.03

Component Description:
Additional initial 50% sales tax on modification to EC-702 transmitter
Amount:
$524.87
Equipment Delivery and Handling Charges

Component Description:
Shipping Charges Alive Telecom for Antenna and TX line - Invoice and original quote - merged.
Amount:
$1,250.00

Component Description:
Initial 50% of Shipping Charges for new transmitter
Amount:
$1,072.50

Component Description:
2nd 50% installment of Shipping Charges for new transmitter
Amount:
$1,072.50
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $396,202.50 $357,362.50 $98,351.80

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. 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.

JEFFREY LAI

CFO


01/26/2022

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.

JEFFREY LAI

CFO


01/26/2022

Attachments

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