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:
129306
Service:
LPD
Call Sign:
WVUX-LD
Channel:
10 (High VHF)
File Number:
0000085597
FRN:
0023594419
Eligibility Status:
Eligible
Date Submitted:
02/08/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

Michael Karr

owner

Doing Business As: WVUX

Michael Karr

4810 BROWNS CREEK ROAD

ST ALBANS, WV 25177

United States

+1 (304) 539-7975 Michaelfkarr@gmail.com Individual

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

Jennifer Scragg Karr

Attorney at Law

PO Box 194

Scott Depot, WV 25560

United States

+1 (304) 389-9795 jdscragg@yahoo.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan WVUX currently runs a Hitachi 650P into Elettronika AVTV1500(500w) into DRV array. To protect 1st adjacent and co-channels, we will reduce noise-limited contour and offset population loss with penetrating antennae and 1kw transmitter

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change 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 AVTV1500ST
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 500 W

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 LPTV-5000-1000V3
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1 kW
Justification for New Transmitter New contour requires boosted signal to maintain population level.

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 Yes
Size 3 inches
Length 12.0 feet
Other Electrical Service Yes
Description 200 amp service with breaker box, building ground rods at 6' intervals and conduit installed for $8500 per verbal estimate from Master electrician, Peter McCluskey
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? Yes
Size 225.0 square feet

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Auxiliary Equipment and Services

estimated cost 12520 for auxiliary equipment and services such as install assistance

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? Yes
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 2
Design power capacity in use 100.0 %
Lower Limit 174.00 MHz
Upper Limit 230.00 MHz
ERP: 2.7 kW
Manufacturer
Model DRV 174-230 mhz
Year 2015

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? No
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: 2.0 kW
Manufacturer
Model PSIVLP4OI-10
Year 2020
Justification for New Antenna new omnioid pattern requires new antennae and more penetration

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 1 5/8 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

Installation

remove old antenna and install new 4 bay antennae

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 1
Length 140 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? Yes
Type Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 460 feet per run
Justification for New Transmission Line Depending on possibility of building new tower, a 200' line will be adequate; but if license relocates to another existing facility, longer line will be required
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

Name Description

two way power divider

requires new two-way power divider

installation

install end connectors on both ends of line, install mounting brackets, install power divider and install 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 Construct New
Tower Use Primary (Main)
Ownership Leased
Is this tower consider Complex? Terrain Constrained
Is this tower currently shared with any other stations? No
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1248738
Coordinates (NAD83) Latitude (NAD83) 39° 16' 33.3" N-
Longitude (NAD83) 080° 17' 37.3" W-
Overall Structure Height 160.10 feet
Support Structure Height 149.93 feet
Ground Elevation Above Mean Sea Level (AMSL) 1499.33 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Communication Service, Inc.
Date Constructed 03/25/2005


Primary Tower

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Tower Construction Costs

Section Question Response
Construct New Tower Use Primary (Main)
Is this a request for upgraded equipment? Yes
Height 480.00 feet
Justification for New Tower current tower structure leaning and cannot hold weight of new 4-bay antenna nor is it structurally sound for a human to climb; see attached explanation along with Tower Inspection Report attached

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower Terrain constrained
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Tower Inspection

Existing tower needs inspected for repair if new tower construction is not an option

Land purchase

necessary because unable to locate suitable tower space to reach same population

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 80
Explanation need person to oversee installation, delivery, handle purchasing and verification and reimbursement forms submittal
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 Yes
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 No
Additional Field Engineering Service No

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Architect drawings

raw land construction drawings

Surveyor drawing

survey land boundaries

FAA and 1A certifications

Initial FAA Study, 1A Certification and Extended FAA Study for new location

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 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? Yes
Does this relocation require Equipment Storage? Yes
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

FAA

FAA, extended FAA study & certification prior to ASR registration

ASR registration

ASR registration

Shippo NEPA

Thpo environmental study

soil sample

soil study for foundation design

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 $91,894.00 $102,767.60 N/A $53,393.60 N/A
Total for all systems $1,181,199.00 $860,862.60 N/A $105,098.60 N/A
Primary Transmitter LPTV-5000-1000V3 $91,894.00 $102,767.60 $53,393.60
Auxiliary Equipment and Services $12,520.00 $12,520.00 Hitachi-Comark adds this cost on top of cost of purchasing transmitter $12,520.00 N/A
Transmitter Building Site Survey/Installation $10,000.00 $10,000.00 N/A N/A N/A
Other -- Building Addition Size: 225.0 $10,000.00 $10,000.00 N/A N/A N/A
5 Ton system $20,250.00 $20,250.00 N/A N/A N/A
Other Electrical Service: 200 amp service with breaker box, building ground rods at 6' intervals and conduit installed for $8500 per verbal estimate from Master electrician, Peter McCluskey $8,500.00 $8,500.00 3" conduit with 200 amp service with breaker box, building ground rods at 6' intervals and conduit installed for $8500 per verbal estimate from Master electrician, Peter McCluskey N/A N/A
High VHF - Air Cooled Solid State Transmitter 400 - 1000 Watts $30,000.00 $40,873.60 See attached estimate from Hitachi plus the final invoice which added $2313.60 in sales tax to the $38,560 quote for a total $40873.60; see also re-verification by Hitachi letter of May 29, 2020 $40,873.60 The quote is the same as estimated but typographical error input $30k instead of $38560, plus the estimated quote failed to include sales tax. With $2313.60 in sales tax, the total for the transmitter is $40,873.60.
3" Rigid Conduit and Wiring (Cost per foot) $624.00 $624.00 N/A N/A N/A

Components

Actual Information Description File Name
Auxiliary Equipment and Services

Component Description:
Installation & Certification of Performance by transmitter vendor is $12,520.
Amount:
$12,520.00
Transmitter Building Site Survey/Installation Information not provided.
Other -- Building Addition Size: 225.0 Information not provided.
5 Ton system Information not provided.
Other Electrical Service: 200 amp service with breaker box, building ground rods at 6' intervals and conduit installed for $8500 per verbal estimate from Master electrician, Peter McCluskey Information not provided.
High VHF - Air Cooled Solid State Transmitter 400 - 1000 Watts

Component Description:
1KW transmitter ($38,560) plus tax ($2313.60)
Amount:
$40,873.60
3" Rigid Conduit and Wiring (Cost per foot) 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 $53,855.00 $53,855.00 N/A $26,600.00 N/A
Total for all systems $1,181,199.00 $860,862.60 N/A $105,098.60 N/A
Primary Antenna PSIVLP4OI-10 $53,855.00 $53,855.00 $26,600.00
Installation $10,000.00 $10,000.00 N/A N/A N/A
Side Mount antenna brackets $4,625.00 $4,625.00 N/A N/A N/A
Elbow complex, single channel, 1 5/8” input (if needed) $6,900.00 $6,900.00 N/A N/A N/A
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A
High VHF-Low Power, Side Mount, Slotted Coaxial, 2.0kW input, Horizontal $26,600.00 $26,600.00 N/A $26,600.00 N/A

Components

Actual Information Description File Name
Installation Information not provided.
Side Mount antenna brackets Information not provided.
Elbow complex, single channel, 1 5/8” input (if needed) Information not provided.
Sweep test of transmission line and antenna Information not provided.
High VHF-Low Power, Side Mount, Slotted Coaxial, 2.0kW input, Horizontal

Component Description:
Antenna $25,500 plus freight cost of $1100 for a total $26,600
Amount:
$26,600.00

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 $18,640.00 $18,640.00 N/A $0.00 N/A
Total for all systems $1,181,199.00 $860,862.60 N/A $105,098.60 N/A
Primary Transmission Line $18,640.00 $18,640.00 $0.00
installation $5,000.00 $5,000.00 N/A N/A N/A
two way power divider $2,600.00 $2,600.00 N/A N/A N/A
Flexible Foam Transmission Line - dielectric, 1 5/8" $11,040.00 $11,040.00 N/A N/A N/A

Components

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 $903,200.00 $592,105.00 N/A $7,200.00 N/A
Total for all systems $1,181,199.00 $860,862.60 N/A $105,098.60 N/A
Primary Tower TOWER $0.00 $0.00 $0.00
Primary Tower $903,200.00 $592,105.00 $7,200.00
New tower shorter than 500' $816,000.00 $504,905.00 quote of $513785 included tower rigging so subtracted the install antenna and line from it to equal $504905 N/A N/A
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas) $10,000.00 $10,000.00 N/A N/A N/A
Tower Inspection $7,200.00 $7,200.00 N/A $7,200.00 N/A
Land purchase $70,000.00 $70,000.00 unable to relocate to any other tower in area so must build tower which necessitates the purchase of land upon which to build N/A N/A

Components

Actual Information Description File Name
New tower shorter than 500' Information not provided.
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas) Information not provided.
Tower Inspection

Component Description:
tower inspection
Amount:
$7,200.00
Land purchase 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 $92,685.00 $72,570.00 N/A $17,635.00 N/A
Total for all systems $1,181,199.00 $860,862.60 N/A $105,098.60 N/A
Outside Professional Services $92,685.00 $72,570.00 $17,635.00
Prepare request for Special Temporary Authorization $1,280.00 $2,500.00 Engineer had to conduct additional analysis for multiple towers $2,500.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $3,500.00 STA required two additional amendments $3,500.00 N/A
FAA and 1A certifications $3,000.00 $3,000.00 For new location the initial FAA study, 1A certification and extended FAA study were required $3,000.00 N/A
Surveyor drawing $3,900.00 $3,900.00 border survey for property boundaries N/A N/A
Architect drawings $2,700.00 $2,700.00 raw land construction drawings N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $30,000.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $3,262.50 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 $3,025.00 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 $2,100.00 N/A
Perform engineering study for displacement application $1,800.00 $1,800.00 N/A $1,800.00 N/A
Form 399 assistance or other Program Management costs $4,000.00 $4,000.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A $1,710.00 N/A
Project management of the transition $8,440.00 $8,440.00 N/A N/A N/A

Components

Actual Information Description File Name
Prepare request for Special Temporary Authorization

Component Description:
STA application and two amendments
Amount:
$2,500.00
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
Attorney fees for STA and filing two amendments thereto
Amount:
$3,500.00
FAA and 1A certifications

Component Description:
initial FAA study, A1 certification and extended FAA study for new location
Amount:
$3,000.00
Surveyor drawing Information not provided.
Architect drawings Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
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.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Attorney fees for prep and filing Construction Permit Application
Amount:
$3,025.00

Component Description:
Attached is the associated party transaction notice
Amount:
N/A
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:
Preparation of Engineering section of Form 2100
Amount:
$2,100.00

Component Description:
Feb 2018 Engineering section of Form 2100 by Jimmy McPhetridge
Amount:
N/A

Component Description:
Engineering fee for preparing engineering section on Construction Permit Application
Amount:
$2,100.00
Perform engineering study for displacement application

Component Description:
Performed Engineering Study for Displacement
Amount:
$1,800.00

Component Description:
updated info on invoice but it wouldn't reattach to the proper line so used this to add updated invoice
Amount:
N/A

Component Description:
Engineering study for displacement
Amount:
$1,800.00
Form 399 assistance or other Program Management costs Information not provided.
Prepare/ Review 399 reimbursement form

Component Description:
Preparation and filing of initial reimbursement form
Amount:
$1,710.00

Component Description:
attached is the notice of related associated transaction
Amount:
N/A
Project management of the transition 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 $20,925.00 $20,925.00 N/A $270.00 N/A
Total for all systems $1,181,199.00 $860,862.60 N/A $105,098.60 N/A
Other Expenses $20,925.00 $20,925.00 $270.00
FCC Filing Fees - Special Temporary Authorization request $305.00 $305.00 N/A $270.00 N/A
soil sample $5,800.00 $5,800.00 soil sample for foundation design N/A N/A
Shippo NEPA $7,400.00 $7,400.00 Shippo NEPA Thpo Environmental N/A N/A
ASR registration $1,000.00 $1,000.00 required for new tower N/A N/A
FAA $3,000.00 $3,000.00 $1000 FAA, $1000 Extended FAA study and $1000 certification of tower prior to ASR registration $0.00 initial FAA study, 1A certification and extended FAA study for the new tower
Equipment Storage $975.00 $975.00 $65 storage rental fee per month for 15 months N/A N/A
Equipment Delivery and Handling Charges $1,000.00 $1,000.00 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
FCC Filing Fees - Special Temporary Authorization request

Component Description:
FCC Filing Fee for STA
Amount:
$270.00
soil sample Information not provided.
Shippo NEPA Information not provided.
ASR registration Information not provided.
FAA Information not provided.
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges 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 $1,181,199.00 $860,862.60 $105,098.60

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.

Jennifer Scragg Karr

attorney


02/08/2022

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.

Jennifer Scragg Karr

attorney


02/08/2022

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