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:
15657
Service:
LPA
Call Sign:
WEBU-LD
Channel:
22 (UHF)
File Number:
0000130254
FRN:
0003772860
Eligibility Status:
Eligible
Date Submitted:
06/10/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

David Ellington

Owner

Doing Business As: DAVID ELLINGTON

David Ellington

P. O. BOX 617

WEBB, MS 38966

United States

+1 (662) 375-2654 david@ellingtonbroadcasting.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

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 The station will not share equipment with any other broadcast station.

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 TVF-10
Year 1988
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 10 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? No
Manufacturer
Model TRN-U-2000-FA
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2.2 kW
Justification for New Transmitter The current transmitter cannot be re-channeled to meet new channel assignment. Current transmitter is a VHF 10 watt transmitter. A new UHF transmitter is needed to meet UHF Ch. 22 CP specifications.

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 Electrical needed in Transmitter Building: Material and labor to install in building a service panel for 200 AMP service with main breaker and receptacles. Surge arrestor is needed to protect transmitter.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size Other
Other Size 6 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

Building ElectricalHookup

The transmitter building will need to be connected to the electrical meter to supply electrical power for the transmitter. Trenching material and labor needed for job.

Building Installation

Labor and crane needed to secure the building to the concrete slab.

Building Sales Tax

MS State Sales Tax 7%

Transmitter Shipping Cost

Cost to ship the Transmitter

Encoder

A single channel encoder is needed to allow a analog station to convert to digital operation.

Transmitter Building Cost

The existing building can not be moved. A 8'x12' secure building is needed to house the new transmitter. Electrical and HVAC mini split air conditioner including back up AC is needed for proper transmitter building cooling and heat.

Building Shipping Cost

Cost to ship the Transmitter Building.

Building Foundation

A concrete slab and accessories are needed for the transmitter building foundation.

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? No
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 Cross Dipole
ERP: 28.0 W
Manufacturer
Model TVO-10
Year 1988

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? No
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model PSILP8OI-22
Year 2019
Justification for New Antenna A new UHF antenna is needed because existing antenna will not meet specifications for frequency and power as required by CP for UHF Channel 22.

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
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? No

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Antenna and Feed line Installation

Tower crew needed to install Antenna, Feed line, Ice bridge and all accessories needed for the antenna installation.

Antenna Shipping Cost

Cost to ship 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? No
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Foam
Diameter 7/8 inches
Number of parallel runs 1
Length 250 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 400 feet per run
Justification for New Transmission Line A 400 foot estimated run of new transmission line 1 5/8" is needed to meet CP specifications for 2 KW UHF Channel 22 Primary transmitter.
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? No

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 No
Prepare engineering section of Form FCC License to Cover Application No
Prepare request for Special Temporary Authority No
Prepare Form 601 No
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application No
Prepare and file Form FCC License to Cover Application No
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 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

Name Description

Additional Displacement Legal Services Not Otherwise Specified in Form 399

Additional Displacement Legal Services Not Otherwise Specified in Form 399

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 No
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)? 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 No
New Point to Point Microwave System No

Other Expenses

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Other Expenses Not Listed

Name Description

Miscellaneous Cost

General Contractor's miscellaneous cost estimate. Example: gravel to repair compound, equipment rental, storage cost, miscellaneous materials needed to fully complete job.

Tower structural analysis

American Tower requires a structural analysis before receiving a lease agreement.

Fiber Optic Cable Installation Cost

The cost to trench and bury the pipe that houses the fiber optic cable providing internet access to the transmitter. Internet connectivity is required for the transmitter to be remotely accessed by the engineers for startup and maintenance purposes.

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 $172,292.00 $134,172.00 N/A $134,172.00 N/A
Total for all systems $229,384.50 $192,195.50 N/A $188,754.50 N/A
Primary Transmitter TRN-U-2000-FA $172,292.00 $134,172.00 $134,172.00
Building Foundation $10,400.00 $10,400.00 N/A $10,400.00 N/A
Building Shipping Cost $2,300.00 $2,300.00 N/A $2,300.00 N/A
Transmitter Building Cost $26,400.00 $26,400.00 N/A $26,400.00 N/A
Encoder $9,000.00 $9,000.00 N/A $9,000.00 N/A
Transmitter Shipping Cost $1,500.00 $1,500.00 N/A $1,500.00 N/A
Building Sales Tax $3,192.00 $3,192.00 N/A $3,192.00 N/A
Building Installation $9,200.00 $9,200.00 N/A $9,200.00 N/A
Building ElectricalHookup $9,400.00 $9,400.00 N/A $9,400.00 N/A
Other -- HVAC Service Type: H Size:6 (Other) $7,650.00 $7,650.00 N/A $7,650.00 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $45,880.00 N/A $45,880.00 N/A
Other Electrical Service: Electrical needed in Transmitter Building: Material and labor to install in building a service panel for 200 AMP service with main breaker and receptacles. Surge arrestor is needed to protect transmitter. $9,250.00 $9,250.00 N/A $9,250.00 N/A

Components

Actual Information Description File Name
Building Foundation

Component Description:
Cost to install the concrete pad for building.
Amount:
$10,400.00
Building Shipping Cost

Component Description:
Transmitter Building Shipping Cost
Amount:
$2,300.00
Transmitter Building Cost

Component Description:
Transmitter Building Cost
Amount:
$26,400.00
Encoder

Component Description:
Encoder Cost
Amount:
$9,000.00
Transmitter Shipping Cost

Component Description:
Transmitter Shipping Cost
Amount:
$1,500.00
Building Sales Tax

Component Description:
Sales tax for Dupont Transmitter Building
Amount:
$3,192.00
Building Installation

Component Description:
Cost to install the transmitter building.
Amount:
$9,200.00
Building ElectricalHookup

Component Description:
Cost to install electrical service to building.
Amount:
$9,400.00
Other -- HVAC Service Type: H Size:6 (Other)

Component Description:
HVAC for Transmitter Building
Amount:
$7,650.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Transmitter Cost
Amount:
$45,880.00
Other Electrical Service: Electrical needed in Transmitter Building: Material and labor to install in building a service panel for 200 AMP service with main breaker and receptacles. Surge arrestor is needed to protect transmitter.

Component Description:
Electrical Wiring for Transmitter Building
Amount:
$9,250.00

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 $22,930.00 $22,930.00 N/A $22,930.00 N/A
Total for all systems $229,384.50 $192,195.50 N/A $188,754.50 N/A
Primary Antenna PSILP8OI-22 $22,930.00 $22,930.00 $22,930.00
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal $0.00 $0.00 N/A N/A N/A
Antenna Shipping Cost $780.00 $780.00 Antenna Shipping Cost $780.00 N/A
Antenna and Feed line Installation $10,600.00 $10,600.00 N/A $10,600.00 N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal $11,550.00 $11,550.00 ***System Notice: Estimate adjusted and locked because line has been superseded.*** $11,550.00 N/A

Components

Actual Information Description File Name
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal Information not provided.
Antenna Shipping Cost

Component Description:
Antenna Shipping Cost
Amount:
$780.00
Antenna and Feed line Installation

Component Description:
Cost to install antenna and feed line.
Amount:
$10,600.00
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal

Component Description:
Antenna Cost
Amount:
$11,550.00

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 $9,600.00 $10,800.00 N/A $10,800.00 N/A
Total for all systems $229,384.50 $192,195.50 N/A $188,754.50 N/A
Primary Transmission Line $9,600.00 $10,800.00 $10,800.00
Flexible Foam Transmission Line - dielectric, 1 5/8" $9,600.00 $10,800.00 This is the Transmission line estimate from the General Contractor's current quote. $10,800.00 N/A

Components

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

Component Description:
Cost of Heliax feed line.
Amount:
$10,800.00

Cost Information

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Tower Equipment and Rigging Costs

Information not provided.

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $8,245.00 $8,096.00 N/A $4,655.00 N/A
Total for all systems $229,384.50 $192,195.50 N/A $188,754.50 N/A
Outside Professional Services $8,245.00 $8,096.00 $4,655.00
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A $238.50 N/A
Additional Displacement Legal Services Not Otherwise Specified in Form 399 $2,500.00 $2,500.00 N/A $530.50 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $3,091.00 Additional expenses were incurred as indicated in the attached invoices. $3,091.00 N/A
Perform engineering study for displacement application $1,800.00 $795.00 Cost for preforming engineering study for a displacement application and filling for the Construction Permit for channel 22. $795.00 N/A

Components

Actual Information Description File Name
Prepare/ Review 399 reimbursement form

Component Description:
Prepare/ Review 399 reimbursement form
Amount:
$238.50
Additional Displacement Legal Services Not Otherwise Specified in Form 399

Component Description:
Additional Displacement Legal Services Not Otherwise Specified in Form 399
Amount:
$174.00

Component Description:
Additional Displacement Legal Services Not Otherwise Specified in Form 399
Amount:
$356.50
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
Prepare and file STA Request
Amount:
$3,091.00
Perform engineering study for displacement application

Component Description:
Engineering cost for filing the displacement construction permit.
Amount:
$795.00

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 $16,317.50 $16,197.50 N/A $16,197.50 N/A
Total for all systems $229,384.50 $192,195.50 N/A $188,754.50 N/A
Other Expenses $16,317.50 $16,197.50 $16,197.50
FCC Filing Fees - Form 2100 license to cover application $335.00 $215.00 N/A $215.00 N/A
Miscellaneous Cost $10,182.50 $10,182.50 N/A $10,182.50 N/A
Tower structural analysis $1,500.00 $1,500.00 N/A $1,500.00 N/A
Fiber Optic Cable Installation Cost $4,300.00 $4,300.00 Additional expenses were incurred as indicated in the attached invoices. $4,300.00 Additional expenses were incurred as indicated in the attached invoices.

Components

Actual Information Description File Name
FCC Filing Fees - Form 2100 license to cover application

Component Description:
Application Fee for filing the License To Cover Application. Please note: The Vendor EIN/TIN number entered into this cost component is the EIN for David Ellington. I was instructed by the FCC that this was the correct way to enter that data.
Amount:
$215.00
Miscellaneous Cost

Component Description:
Cost for gravel, ice bridge, posts, equipment rental, and miscellaneous materials needed to complete the job.
Amount:
$10,182.50
Tower structural analysis

Component Description:
Cost of Tower Structural Analysis required by American Tower Corporation
Amount:
$1,500.00
Fiber Optic Cable Installation Cost

Component Description:
Charge relating to review of proposed route for fiber optics job.
Amount:
$500.00

Component Description:
The cost to trench and bury the pipe that houses the fiber optic cable providing internet access to the transmitter. Internet connectivity is required for the transmitter to be remotely accessed by the engineers for startup and maintenance purposes.
Amount:
$3,800.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $229,384.50 $192,195.50 $188,754.50

Reimbursement Status

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

David Ellington

Owner


06/10/2022

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.

David Ellington

Owner


06/10/2022

Certification

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Section Question Response
Submission of Final Allocation or Accounting Information Statements

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

  1. The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

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

  3. The above-named entity certifies that all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates.

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

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

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

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

David Ellington

Owner


06/10/2022

Attachments

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