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:
168782
Service:
LPD
Call Sign:
KZCO-LD
Channel:
30 (UHF)
File Number:
0000090027
FRN:
0002710192
Eligibility Status:
Eligible
Date Submitted:
09/06/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

SCRIPPS BROADCASTING HOLDINGS LLC

Chief Engineer

312 WALNUT STREET

28TH FLOOR

CINCINNATI, OH 45202

United States

+1 (513) 977-3000 DAVE.GILES@SCRIPPS.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

Samuel Hariton

Widelity

4031 University Dr

Suite 100

Fairfax, VA, 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. Yes
Briefly describe transition plan Due to the repack, KZCO must share a channel with KLPD; however previous tower owners wouldn't allow KLPD to move to it. KZCO must move to a new tower and upgrade equipment. KZCO is purchasing a new transmission line and upgraded transmitter and antenna.

Question Response
Sharee Station Facility ID 23074
Call Sign KUSA
Type Commercial
Licensee Name MULTIMEDIA HOLDINGS CORPORATION
Status LICENSED
DTS No
Community of License DENVER, CO
Pre-auction RF Channel 9
Post-auction RF Channel 9
Neilsen DMA Denver
Network Affiliation
Question Response
Sharee Station Facility ID 47903
Call Sign KCNC-TV
Type Commercial
Licensee Name CBS TELEVISION STATIONS INC.
Status LICENSED
DTS No
Community of License DENVER, CO
Pre-auction RF Channel 35
Post-auction RF Channel 35
Neilsen DMA Denver
Network Affiliation
Question Response
Sharee Station Facility ID 67539
Call Sign KLPD-LD
Type
Licensee Name SYNCOM MEDIA GROUP, INC.
Status LICENSED
DTS No
Community of License DENVER, CO
Pre-auction RF Channel 30
Post-auction RF Channel
Neilsen DMA
Network Affiliation

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 Ranger
Year 2004
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-4R37
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2.4 kW
Justification for New Transmitter New transmitter required for operation on shared post-displacement channel.

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? Yes
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 Top
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 3
Number of Panels 12
Design power capacity in use 0.5 %
Lower Limit 470.00 MHz
Upper Limit 608.00 MHz
ERP: 15.0 kW
Manufacturer
Model TUA/C3/12/36U-1-S
Year 2008

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID Call Sign
47903 KCNC-TV
23074 KUSA

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? Yes
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 ALP4L-ESER-30
Year 2019
Justification for New Antenna New antenna required due to KZCO moving to new tower and channel sharing agreement with KLPD.

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
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? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

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 Move Equipment
Tower Use Primary (Main)
Ownership Leased
Is this tower consider Complex? Located on Building
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? Yes
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? No
Coordinates (NAD83) Latitude (NAD83) 39° 43' 45.9" N-
Longitude (NAD83) 105° 14' 09.9" W-
Overall Structure Height 45.93 feet
Support Structure Height 45.93 feet
Ground Elevation Above Mean Sea Level (AMSL) 7372.00 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Mauna Towers
Date Constructed 04/12/2019

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
67539 KLPD-LD LPD

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower Located on Building
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 254
Explanation KZCO-LD requires the aid of outside project management services in order to fulfill the requirements of the repack. KZCO-LD does not have sufficient resource capacity and expertise in house to handle all of the reimbursement filing, expense tracking, etc.
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 No
Prepare Form 601 Yes
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 No
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

Name Description

Transition Timing and Coordination

Transition Timing and Coordination

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

Name Description

Broadcast Integrated Receiver-Decoder System

Parts required for repeater station to receive and decode the broadcast signal

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 $84,000.00 $74,462.36 N/A $74,336.45 N/A
Total for all systems $252,462.50 $286,707.81 N/A $207,805.89 N/A
Primary Transmitter UAXTE-4R37 $84,000.00 $74,462.36 $74,336.45
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $74,462.36 Please see GatesAir, Inc. Quote #Q-80364 & Invoice #US0324165 $74,336.45 N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
UAXTE-4R37 HIGH EFFICIENCY TRA TRANSMITTER
Amount:
$61,708.10

Component Description:
KZCO-LD-110-Primary Transmitter - UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW
Amount:
$12,628.35

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 $20,460.06 $14,730.06 N/A $8,623.16 N/A
Total for all systems $252,462.50 $286,707.81 N/A $207,805.89 N/A
Primary Antenna ALP4L-ESER-30 $20,460.06 $14,730.06 $8,623.16
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical $14,730.06 $14,730.06 Please see Estimated Cost Justification KZCO-LD-210-Primary Antenna - UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical v0 (1) $8,623.16 N/A
Sweep test of transmission line and antenna $5,730.00 $0.00 Cost for sweep test will be included once supporting documents are provided. N/A N/A

Components

Actual Information Description File Name
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical

Component Description:
ANTENNA
Amount:
$3,888.75

Component Description:
ANTENNA
Amount:
$4,734.41
Sweep test of transmission line and antenna 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 $81,190.00 $81,190.00 N/A $19,948.20 N/A
Total for all systems $252,462.50 $286,707.81 N/A $207,805.89 N/A
Primary Tower TOWER $81,190.00 $81,190.00 $19,948.20
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas) $81,190.00 $81,190.00 LPTV Catalog pricing for antenna removal $19,948.20 N/A

Components

Actual Information Description File Name
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas)

Component Description:
Labor to perform several site visits
Amount:
$9,974.10

Component Description:
Labor to perform site survey for location and materials
Amount:
$14,826.17

Component Description:
Labor to perform site survey for location and materials
Amount:
$15,005.54

Component Description:
Labor to perform several site visits
Amount:
$9,974.10

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 $57,542.00 $107,054.95 N/A $97,151.11 N/A
Total for all systems $252,462.50 $286,707.81 N/A $207,805.89 N/A
Outside Professional Services $57,542.00 $107,054.95 $97,151.11
Transition Timing and Coordination $1,125.00 $1,125.00 Please see KZCO-LD Transition Timing and Coordination Budget Revision Justification Letter $1,125.00 N/A
Project management of the transition $26,797.00 $48,859.95 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $48,859.95 N/A
RF Exposure Measurements $12,100.00 $1,000.00 Please see JB Schoedler Associates Proposal 20190219a $1,000.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $462.40 Please see KZCO-LD Attorney STA Budget Revision Justification Letter $462.40 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $31,255.10 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $31,255.10 x
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A $93.66 N/A
Prepare Form 601 $755.00 $755.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A $225.00 N/A
Perform engineering study for displacement application $1,800.00 $14,130.00 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $14,130.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A N/A N/A

Components

Actual Information Description File Name
Transition Timing and Coordination

Component Description:
LPTV/Translator Studies
Amount:
$1,125.00
Project management of the transition

Component Description:
Project Management
Amount:
$3,571.60

Component Description:
Project Management
Amount:
$155.00

Component Description:
Project Management
Amount:
$105.40

Component Description:
Project Management
Amount:
$38.75

Component Description:
Project Management
Amount:
$38.75

Component Description:
Project Management
Amount:
$193.75

Component Description:
Project Management
Amount:
$2,114.70

Component Description:
Project Management
Amount:
$292.90

Component Description:
Project management
Amount:
$831.80

Component Description:
Project Management
Amount:
$2,306.90

Component Description:
Project Management
Amount:
$2,159.05

Component Description:
Project Management
Amount:
$2,224.75

Component Description:
Project Management
Amount:
$175.05

Component Description:
Project Management
Amount:
$487.50

Component Description:
Project Management
Amount:
$193.75

Component Description:
Project Management
Amount:
$445.05

Component Description:
Project Management
Amount:
$410.10

Component Description:
Project Management
Amount:
$954.25

Component Description:
Project Management
Amount:
$2,221.25

Component Description:
Project Management
Amount:
$77.50

Component Description:
Project Management
Amount:
$13.80

Component Description:
Project Management
Amount:
$302.25

Component Description:
Project Management
Amount:
$1,573.75

Component Description:
Project Management
Amount:
$278.85

Component Description:
Project Management
Amount:
$940.40

Component Description:
Project Management
Amount:
$3,130.90

Component Description:
Project Management
Amount:
$128.45

Component Description:
Project Management
Amount:
$3,566.40

Component Description:
Project Management
Amount:
$10,880.15

Component Description:
Project Management
Amount:
$2,835.30

Component Description:
Project Management
Amount:
$3,495.20

Component Description:
LPTV/Translator Studies
Amount:
$150.00

Component Description:
KZCO-LD-510-Project Management
Amount:
$75.00

Component Description:
Project Management
Amount:
$237.50

Component Description:
Project Management
Amount:
$827.70

Component Description:
KCKZ - Calls on Ch. Sharing Discussions with Larry Rogow (KDBK)
Amount:
$150.00

Component Description:
Project Management
Amount:
$440.25

Component Description:
Project management
Amount:
$836.25
RF Exposure Measurements

Component Description:
Fee for making NIER measurements
Amount:
$1,000.00
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
For professional services rendered through February 28, 2019
Amount:
$462.40
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
KZCO-LD-550-Attorney - Negotiate Lease and Other Matters
Amount:
$1,900.80

Component Description:
For professional services rendered through January 31, 2019
Amount:
$12,941.50

Component Description:
For professional services rendered through July 31, 2018
Amount:
$1,190.40

Component Description:
For professional services rendered through May 31, 2018
Amount:
$268.00

Component Description:
For professional services rendered through December 31, 2018
Amount:
$14,954.40
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
For professional services rendered through May 31, 2019
Amount:
$93.66
Prepare Form 601 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

Component Description:
LPTV/Translator Studies
Amount:
$225.00
Perform engineering study for displacement application

Component Description:
KZCO-LD-530-RF Eng - Engineering Study for Displacement Application
Amount:
$1,350.00

Component Description:
FOR SERVICES RENDERED THROUGHL November 2018
Amount:
$1,362.50

Component Description:
KZKC Interference Study of Displacement Application
Amount:
$97.50

Component Description:
LPTV/Translator Studies
Amount:
$480.00

Component Description:
FOR SERVICES RENDERED THROUGH: October 2019
Amount:
$800.00

Component Description:
LPTV/Translator Studies
Amount:
$3,525.00

Component Description:
KZKC Displacement Discussion
Amount:
$117.50

Component Description:
LPTV/Translator Studies
Amount:
$1,950.00

Component Description:
LPTV/Translator Studies
Amount:
$1,575.00

Component Description:
Professional Services
Amount:
$2,122.50

Component Description:
KZCO-LD-530-RF Eng - Engineering Study for Displacement Application
Amount:
$750.00
Prepare/ Review 399 reimbursement form Information not provided.
Prepare engineering section of 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 $9,270.44 $9,270.44 N/A $7,746.97 N/A
Total for all systems $252,462.50 $286,707.81 N/A $207,805.89 N/A
Other Expenses $9,270.44 $9,270.44 $7,746.97
Broadcast Integrated Receiver-Decoder System $3,046.94 $3,046.94 Please see KZCO-LD Broadcast Integrated Receiver/Decoder System Budget Justification Cover Letter $1,523.47 N/A
Equipment Delivery and Handling Charges $6,223.50 $6,223.50 Please see Estimated Cost Justification KZCO-LD-610-Equipment Delivery and Handling v0 $6,223.50 N/A

Components

Actual Information Description File Name
Broadcast Integrated Receiver-Decoder System

Component Description:
THOR ATSC IRD F/8VSB/DVB-ASI/IP-3G-SDI/HDMI
Amount:
$1,523.47
Equipment Delivery and Handling Charges

Component Description:
UAXTE-1 - UAXTE-8 Install Serv
Amount:
$3,853.50

Component Description:
Labor to transfer new transmitter from LCG to Tower House. To include the use of skidsteer, forks, pallet jack and trailer.
Amount:
$2,370.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $252,462.50 $286,707.81 $207,805.89

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.

sravan varakantam reddy

Senior Director, General Accounting


09/06/2022

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.

sravan varakantam reddy

Senior Director, General Accounting


09/06/2022

Attachments

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