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:
65116
Service:
LPD
Call Sign:
WRID-LD
Channel:
36 (UHF)
File Number:
0000089367
FRN:
0018223693
Eligibility Status:
Eligible
Date Submitted:
08/31/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

Gray Television Licensee, LLC

4370 Peachtree Road, NE

Atlanta, GA 30319

United States

+1 (404) 266-3888 allfcclms@gray.tv Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Samuel Hariton

Widelity, Inc.

Samuel Hariton

4031 University Drive

Ste 100

Fairfax, VA 22030

United States

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

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan WRID will transition from channel 48 to channel 36 by changing its antenna and transmitter. WRID will not change tower sites.

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 AT75-2k5
Year 2013
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 2.5 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-8-G2
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 4.8 kW
Justification for New Transmitter Moving from channel 48 to channel 36 requires the purchase of a new transmitter because the current transmitter cannot be re-channeled to meet the new channel assignment.

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 Modification of electrical services and other expenses as required for the repack
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size Other
Other Size 13 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? Yes
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model SWLP12MC
Year 2013

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 Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model TLP-12A/VP-R
Year 2019
Justification for New Antenna Existing antenna cannot accommodate channel 36 operations.

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 4 1/16 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

Antenna removal and installation

Antenna removal and installation

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 Rigid
Diameter Other
Other Diameter 4 1/16 inches
Segment Length 20 inches
Number of parallel runs 1
Length 1150 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 Air
Diameter 1 5/8 inches
Number of parallel runs 1
Length 765 feet per run
Justification for New Transmission Line Pre-displacement line was unsuitable for use with post-displacement antenna location.
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? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1015246
Coordinates (NAD83) Latitude (NAD83) 37° 30' 23.0" N-
Longitude (NAD83) 077° 30' 11.0" W-
Overall Structure Height 791.99 feet
Support Structure Height 716.85 feet
Ground Elevation Above Mean Sea Level (AMSL) 210.96 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Gray Media Group, Inc.
Date Constructed 04/01/1956

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID Call Sign Service
9989 WCVW DTV
190695 WWBK-LD LPD
189114 WWTD-LD LPD
10016 WCVE-FM FM
182288 WUDW-LD LPD
57832 WTVR-TV DTV
412 WRLH-TV DTV
74168 WBTJ FM
182308 WFWG-LD LPD
10019 WNVT DTV
74416 WRIC-TV DTV
9987 WCVE-TV DTV

Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study need for guyed or free-standing tower
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 N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Pre-displacement Tower Rigging

Pre-displacement Tower Rigging and removal of equipment from tower ASRN 1018227

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 254
Explanation WRID-LD does not have sufficient resource capacity and expertise in house to handle all activities necessary for completion of the station's build by the construction deadline. WRID-LD will hire an outside firm to facilitate a timely transition.
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 No
RF exposure measurements Yes
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 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)? Yes
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

Permitting

Permitting

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 $238,835.46 $159,697.54 N/A $134,699.80 N/A
Total for all systems $665,253.60 $454,003.03 N/A $241,301.65 N/A
Primary Transmitter UAXTE-8-G2 $238,835.46 $159,697.54 $134,699.80
Transmitter Building Site Survey/Installation $10,000.00 $6,000.00 N/A N/A N/A
Other -- HVAC Service Type: C Size:13 (Other) $21,849.00 $21,849.00 Please see James River Air Conditioning Co. Proposal #P01342 & Invoice #J54379 $21,849.00 N/A
Other Electrical Service: Modification of electrical services and other expenses as required for the repack $6,236.46 $6,236.46 Please see WRID-LD Primary Transmitter - Other Electrical Service Budget Revision Justification Letter $0.00 N/A
UHF - Air Cooled Solid State Transmitter 4 - 6 kW $200,750.00 $125,612.08 Please see GatesAir Quote #Q-93719 & Invoice #US0352289 $112,850.80 N/A

Components

Actual Information Description File Name
Transmitter Building Site Survey/Installation Information not provided.
Other -- HVAC Service Type: C Size:13 (Other)

Component Description:
Replace a 12.5 -Ton Rooftop Unit
Amount:
$21,849.00
Other Electrical Service: Modification of electrical services and other expenses as required for the repack

Component Description:
Wired for 45KVA transformer from existing 480 volt panel.
Amount:
$6,236.46
UHF - Air Cooled Solid State Transmitter 4 - 6 kW

Component Description:
UAXTE-8 Transmitter
Amount:
$12,761.28

Component Description:
UAXTE-8 Transmitter
Amount:
$112,850.80

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 $46,746.50 $41,455.75 N/A $0.00 N/A
Total for all systems $665,253.60 $454,003.03 N/A $241,301.65 N/A
Primary Antenna TLP-12A/VP-R $46,746.50 $41,455.75 $0.00
Antenna removal and installation $0.00 $0.00 Previously approved antenna removal and installation budget moved to appropriate tower rigging category N/A N/A
Side Mount antenna brackets $4,625.00 $2,234.25 Please see Dielectric Quotes #1934578 & #CLE 655 $0.00 N/A
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed) $9,570.00 $6,000.00 N/A N/A N/A
Sweep test of transmission line and antenna $5,730.00 $6,400.00 per Dielectric Quote 1934578 $0.00 N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical $26,821.50 $26,821.50 Please see Dielectric Quote CLE 655 $0.00 N/A

Components

Actual Information Description File Name
Antenna removal and installation Information not provided.
Side Mount antenna brackets

Component Description:
WRID-LD-210-Primary Antenna - Side Mount antenna brackets
Amount:
$1,117.12

Component Description:
WRID-LD-210-Primary Antenna - Side Mount antenna brackets
Amount:
$1,117.12
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed) Information not provided.
Sweep test of transmission line and antenna

Component Description:
WRID-LD-210-Primary Antenna - Sweep Test
Amount:
$3,200.00

Component Description:
WRID-LD-210-Primary Antenna - Sweep Test
Amount:
$3,200.00
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical

Component Description:
Antenna TLP-12A/VP-R
Amount:
$13,410.75

Component Description:
Antenna TLP-12A/VP-R
Amount:
$12,456.96

Component Description:
Includes one field engineer on-site for one day
Amount:
$953.79

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 $25,245.00 $21,998.25 N/A $0.00 N/A
Total for all systems $665,253.60 $454,003.03 N/A $241,301.65 N/A
Primary Transmission Line $25,245.00 $21,998.25 $0.00
Flexible Air Transmission Line - dielectric, 1 5/8" $25,245.00 $21,998.25 Please See Dielectric Quotes #1934578 & #CLE 655 $0.00 N/A

Components

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

Component Description:
WRID-LD-310-Primary Transmission Line - Flexible Air Transmission Line - dielectric, 1 5/8"
Amount:
$10,999.09

Component Description:
WRID-LD-310-Primary Transmission Line - Flexible Air Transmission Line - dielectric, 1 5/8"
Amount:
$10,999.13

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 $259,105.00 $141,454.80 N/A $74,077.30 N/A
Total for all systems $665,253.60 $454,003.03 N/A $241,301.65 N/A
Primary Tower TOWER $259,105.00 $141,454.80 $74,077.30
Pre-displacement Tower Rigging $67,555.00 $67,555.00 Please see WRID Tower King II, Inc. Proposal C-22-044 $33,777.50 N/A
Study needed for guyed or free-standing tower $8,700.00 $8,500.00 Please see Turris Services Proposal Ref #21-0981 and Invoice #TE-7011 $0.00 N/A
Minor tower reinforcement/modifications $25,100.00 $25,100.00 Please see Estimated Cost Justification WRID-LD-410-Existing Tower - Minor Reinforcement_Modifications v0 $0.00 N/A
Tower Rigging Tall Tower (greater than 500') $157,750.00 $40,299.80 Per Estimated Cost Justification WRID-LD-410-Tower Rigging Tall v0 $40,299.80 N/A

Components

Actual Information Description File Name
Pre-displacement Tower Rigging

Component Description:
Tower service
Amount:
$33,777.50

Component Description:
Per agreement 50% Final Payment for the removal of the WRID Daystar Antenna and Line
Amount:
$33,777.50
Study needed for guyed or free-standing tower

Component Description:
Structural analysis and Report
Amount:
$8,500.00
Minor tower reinforcement/modifications

Component Description:
Material for tower reinforcing
Amount:
$16,765.00

Component Description:
Material for Tower Reinforcing for WWBT-TV 722'
Amount:
$8,335.00
Tower Rigging Tall Tower (greater than 500')

Component Description:
Reinforce 9 bays of mid bay bracing section 22
Amount:
$40,299.80

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 $54,679.50 $48,764.55 N/A $26,329.55 N/A
Total for all systems $665,253.60 $454,003.03 N/A $241,301.65 N/A
Outside Professional Services $54,679.50 $48,764.55 $26,329.55
RF Exposure Measurements $12,100.00 $7,500.00 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 $1,500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,280.00 $1,200.00 N/A N/A N/A
Perform engineering study for displacement application $1,800.00 $1,500.00 N/A N/A N/A
Form 399 assistance or other Program Management costs $1,000.00 $1,000.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,500.00 N/A N/A N/A
Project management of the transition $26,797.00 $26,329.55 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $26,329.55 N/A

Components

Actual Information Description File Name
RF Exposure Measurements 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.
Project management of the transition

Component Description:
Project Management
Amount:
$930.00

Component Description:
Project Management
Amount:
$1,616.65

Component Description:
Project Management
Amount:
$4,725.65

Component Description:
Project Management
Amount:
$77.50

Component Description:
Project Management
Amount:
$2,295.25

Component Description:
Project Management
Amount:
$38.75

Component Description:
Project Management
Amount:
$554.75

Component Description:
Project Management
Amount:
$77.50

Component Description:
Project Management
Amount:
$116.25

Component Description:
Project Management
Amount:
$304.30

Component Description:
Project Management
Amount:
$13,355.80

Component Description:
Project Management
Amount:
$77.50

Component Description:
Project Management
Amount:
$38.75

Component Description:
Project Management
Amount:
$189.90

Component Description:
Project management
Amount:
$163.75

Component Description:
Project management
Amount:
$116.25

Component Description:
Project Management
Amount:
$31.25

Component Description:
Project Management
Amount:
$51.25

Component Description:
Project Management
Amount:
$542.55

Component Description:
Project Management
Amount:
$193.75

Component Description:
Project Management
Amount:
$38.75

Component Description:
Project management
Amount:
$358.05

Component Description:
Project Management
Amount:
$77.50

Component Description:
Project Management
Amount:
$38.75

Component Description:
Project Management
Amount:
$319.15

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 $40,642.14 $40,632.14 N/A $6,195.00 N/A
Total for all systems $665,253.60 $454,003.03 N/A $241,301.65 N/A
Other Expenses $40,642.14 $40,632.14 $6,195.00
Equipment Delivery and Handling Charges $18,990.46 $18,990.46 Please see Estimated Cost Justification WRID-LD-610-Equipment Delivery and Handling v3 $3,750.00 N/A
Permitting $12,456.68 $12,456.68 Please see AFF Consulting, LLC Proposal #160426 & Invoice #20221006 $0.00 N/A
Equipment Storage $2,445.00 $2,445.00 per Dielectric Quote 1934578 $2,445.00 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $5,000.00 $5,000.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $305.00 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 $1,100.00 N/A N/A N/A

Components

Actual Information Description File Name
Equipment Delivery and Handling Charges

Component Description:
Freight
Amount:
$4,300.00

Component Description:
42' Telehandler Forklift
Amount:
$1,006.03

Component Description:
Telehandler Forklift
Amount:
$974.05

Component Description:
55' Telehandler Forklift
Amount:
$5,711.91

Component Description:
55' Telehandler Forklift
Amount:
$3,248.47

Component Description:
PAF Van Storage
Amount:
$3,750.00
Permitting

Component Description:
Permitting Review
Amount:
$12,456.68
Equipment Storage

Component Description:
WRID-LD-610-Equipment Storage
Amount:
$2,445.00
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
FCC Filing Fees - Special Temporary Authorization request 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 $665,253.60 $454,003.03 $241,301.65

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. Yes

Certification

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Section Question Response
Submission of Estimated Expenses Statements

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

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

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

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

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

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

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

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

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

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

Robert Folliard , III .

Assistant Secretary


08/31/2022

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.

Robert Folliard , III .

Assistant Secretary


08/31/2022

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