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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:
129800
Service:
LPD
Call Sign:
K15KO-D
Channel:
15 (UHF)
File Number:
0000089529
FRN:
0026977595
Eligibility Status:
Eligible
Date Submitted:
08/11/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

SINCLAIR-CALIFORNIA LICENSEE, LLC

Doing Business As: SINCLAIR-CALIFORNIA LICENSEE, LLC

Harvey Arnold

10706 Beaver Dam Road

Cockeysville, MD 21030

United States

 +1 (410) 568-1500 FCCContacts@sbgtv.com 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

Paul A Cicelski

Lerman Senter PLLC

Paul A Cicelski

2001 L Street, NW

30th Floor

WASHINGTON, DC 20036

United States

 +1 (202) 416-6756 Sinclair399s@SummitRidgeGroup.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 Replace transmitter, mask filter, and antenna.

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 DTT-500
Year 2009
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 UAXTE-2P-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 0.4 kW
Justification for New Transmitter Larcan no longer supported.

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 No
HVAC Service Does the replacement transmitter require HVAC Service? No
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No

Primary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Ownership Owned
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Circular
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model JA/LS-TB-4(CP)
Year 2004

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Change Type Purchase New
Ownership Owned
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Other
Other Antenna Type Scala Paraflector
ERP: 5.0 kW
Manufacturer
Model PR-450CU
Year 2019
Justification for New Antenna Antenna is frequency specific.

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? 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

Mask Filter

Mask Filter

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 Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? 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) 40° 39' 15.1" N-
Longitude (NAD83) 122° 31' 15.7" W-
Overall Structure Height 100.00 feet
Support Structure Height 100.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 3161.00 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Sinclair Media Licensee, LLC
Date Constructed 06/01/1999


Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: No study needed
Tower Reinforcements Please select whether tower reinforcements are needed: No 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

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? Yes
Number of Hours 225
Explanation Outside consulting engineering, legal work, and accounting services, as well as project management for regional and comprehensive repack execution.
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 Yes
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
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 Yes
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
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 No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
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? 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

Information not provided.

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 $28,100.00 $18,988.25 N/A $18,988.25 N/A
Total for all systems $163,833.22 $154,721.47 N/A $32,872.29 N/A
Primary Transmitter UAXTE-2P-C $28,100.00 $18,988.25 $18,988.25
UHF - Air Cooled Solid State Transmitter 320 - 700 Watts $28,100.00 $18,988.25 N/A $18,988.25 N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 320 - 700 Watts

Component Description:
Transmitter cost. #US0332203
Amount:
$18,988.25

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 $36,769.70 $36,769.70 N/A $614.70 N/A
Total for all systems $163,833.22 $154,721.47 N/A $32,872.29 N/A
Primary Antenna PR-450CU $36,769.70 $36,769.70 $614.70
Mask Filter $614.70 $614.70 N/A $614.70 N/A
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A
Side Mount antenna brackets $4,625.00 $4,625.00 N/A N/A N/A
UHF-Low Power, Side Mount, Other, 5.0kW input, Horizontal $25,800.00 $25,800.00 N/A N/A N/A

Components

Actual Information Description File Name
Mask Filter

Component Description:
Total invoice amount reduced by 31.7%. #558044
Amount:
$614.70
Sweep test of transmission line and antenna Information not provided.
Side Mount antenna brackets Information not provided.
UHF-Low Power, Side Mount, Other, 5.0kW input, Horizontal 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 $56,190.00 $56,190.00 N/A $0.00 N/A
Total for all systems $163,833.22 $154,721.47 N/A $32,872.29 N/A
Primary Tower TOWER $56,190.00 $56,190.00 $0.00
Tower Rigging Short Tower (less than 500') $56,190.00 $56,190.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate 		Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $42,537.50 $42,537.50 N/A $13,033.32 N/A
Total for all systems $163,833.22 $154,721.47 N/A $32,872.29 N/A
Outside Professional Services $42,537.50 $42,537.50 $13,033.32
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A $60.00 N/A
Project management of the transition $23,737.50 $23,737.50 N/A $12,973.32 N/A
Prepare Form 601 $755.00 $755.00 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 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
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 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 - 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 N/A N/A

Components

Actual Information Description File Name
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Engineering service cost. #6260
Amount:
$60.00
Project management of the transition

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #142
Amount:
$112.25

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #487962
Amount:
$1,103.46

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #477401
Amount:
$867.06

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #296
Amount:
$62.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #481393
Amount:
$314.85

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #486184
Amount:
$177.88

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #479898
Amount:
$297.73

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #1162
Amount:
$419.38

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #205
Amount:
$31.70

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #369
Amount:
$38.46

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #487614
Amount:
$512.98

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #1157
Amount:
$32.69

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #478344
Amount:
$1,392.45

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #482406
Amount:
$76.44

Component Description:
Project management cost. #5736
Amount:
$600.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #487077
Amount:
$19.90

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #171
Amount:
$4.84

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #307
Amount:
$60.09

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #481962
Amount:
$264.19

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #486771
Amount:
$360.76

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #289
Amount:
$115.38

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #401
Amount:
$394.07

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #274
Amount:
$4.80

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #480826
Amount:
$735.24

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #258
Amount:
$102.40

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #467
Amount:
$1,048.57

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #438
Amount:
$111.15

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #485675
Amount:
$157.98

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #248
Amount:
$36.05

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #489822
Amount:
$102.11

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #487960
Amount:
$119.25

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #477913
Amount:
$340.72

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #133
Amount:
$14.53

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #421
Amount:
$93.26

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #450
Amount:
$1,156.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #485232
Amount:
$97.69

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #487079
Amount:
$447.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #478862
Amount:
$190.59

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #489265
Amount:
$88.84

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #490791
Amount:
$30.57

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #154
Amount:
$9.11

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #479375
Amount:
$420.54

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #1168
Amount:
$7.19

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #354
Amount:
$67.30

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #488864
Amount:
$102.01

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #488527
Amount:
$230.86

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #473490
Amount:
$173.26

Component Description:
Delete.
Amount:
N/A

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #487962
Amount:
$1,129.61

Component Description:
Delete. An updated invoice was submitted.
Amount:
N/A

Component Description:
Delete. An updated invoice was submitted.
Amount:
N/A

Component Description:
Delete. An updated version was submitted.
Amount:
N/A

Component Description:
Delete. An updated invoice was submitted.
Amount:
N/A

Component Description:
Delete. An updated version was submitted.
Amount:
N/A

Component Description:
Delete. An updated version was submitted.
Amount:
N/A

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 26 stations. #488027
Amount:
$300.09

Component Description:
Delete. An updated version was submitted.
Amount:
N/A

Component Description:
Delete. An updated version was submitted.
Amount:
N/A
Prepare Form 601 Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Perform engineering study for displacement application Information not provided.
Prepare/ Review 399 reimbursement form Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization 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 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 $236.02 $236.02 N/A $236.02 N/A
Total for all systems $163,833.22 $154,721.47 N/A $32,872.29 N/A
Other Expenses $236.02 $236.02 $236.02
Equipment Delivery and Handling Charges $236.02 $236.02 N/A $236.02 N/A

Components

Actual Information Description File Name
Equipment Delivery and Handling Charges

Component Description:
Total invoice amount reduced by 31.7%. #579008
Amount:
$236.02

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $163,833.22 $154,721.47 $32,872.29

Reimbursement Status

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

Certification

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Section Question Response
Submission of Estimated Expenses Statements

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

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

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

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

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

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

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

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

  8. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Lucy Rutishauser

CFO


08/11/2022

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.

Lucy Rutishauser

CFO


08/11/2022

Attachments

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