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:
168235
Service:
LPD
Call Sign:
KVHP-LD
Channel:
34 (UHF)
File Number:
0000089563
FRN:
0001569110
Eligibility Status:
Eligible
Date Submitted:
09/08/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

LSB BROADCASTING, INC.

Denise Branson, Sr. Paralegal

TEGNA, Inc.

8350 Broad Street, Suite 2000

Tysons, VA 22102

United States

+1 (703) 873-6606 dbranson@TEGNA.com Corporation

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

Gary Davis

Regional Head of Technology and Operat

TEGNA, Inc.

Gary Davis

8350 Broad Street, Suite 2000

Tysons, VA 22102

United States

+1 (404) 873-9199 gadavis@tegna.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 and mask filter, replace antenna with similar, including rigging for installation

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 Unknown
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 ULXTE-2
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.2 kW
Justification for New Transmitter To accommodate change in channels from 44 to 34

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) Yes
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? No
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 Horizontal
Type Slotted Coaxial
ERP: 7.8 kW
Manufacturer
Model AL8
Year 2008

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 AL8
Year 2019
Justification for New Antenna To accommodate change in channel from 44 to 34

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? No

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 Modify Existing
Tower Use Primary (Main)
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1053390
Coordinates (NAD83) Latitude (NAD83) 30° 58' 32.0" N-
Longitude (NAD83) 093° 59' 25.0" W-
Overall Structure Height 499.01 feet
Support Structure Height 479.98 feet
Ground Elevation Above Mean Sea Level (AMSL) 420.93 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner EIP Holdings II, LLC
Date Constructed 10/01/1991


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 12
Explanation Review progress, prepare and submit Form 387 quarterly, as well as three special FCC required reports
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 No
Additional Field Engineering Service No

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

ASR

ASR Amendment

FAA

FAA 7460-1 Notification of height and/or location as well as frequency and power changes

Other Engineering Services

Engineering services not specifically listed 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 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)? Yes
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

Andrew Connectors

Andrew Connectors

Coaxial Connectors, Metal Film Resistors

Coaxial Connectors, Metal Film Resistors

Electrical Supplies

Electrical Supplies

FCC Filing Fees - License to Cover Application

FCC Filing Fees - License to Cover Application

FCC Filing Fees - Special Temporary Authorization Extension Request

FCC Filing Fees - Special Temporary Authorization Extension Request

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 $122,200.00 $18,744.85 N/A $18,744.85 N/A
Total for all systems $236,752.27 $85,206.62 N/A $39,759.12 N/A
Primary Transmitter ULXTE-2 $122,200.00 $18,744.85 $18,744.85
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $18,550.00 N/A $18,550.00 N/A
Switchgear - industrial 800 amp $38,200.00 $194.85 N/A $194.85 N/A

Components

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

Component Description:
UBS A16865 v220906pmv1
Amount:
$9,500.00

Component Description:
UBS S00156 v220906pmv1
Amount:
$4,650.00

Component Description:
CMC 14746 v220908pmv2
Amount:
$4,400.00
Switchgear - industrial 800 amp

Component Description:
Minton 4712 v220906pmv1
Amount:
$194.85

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 $9,041.60 $9,041.60 N/A $4,416.60 N/A
Total for all systems $236,752.27 $85,206.62 N/A $39,759.12 N/A
Primary Antenna AL8 $9,041.60 $9,041.60 $4,416.60
Side Mount antenna brackets $4,625.00 $4,625.00 N/A N/A N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal $4,416.60 $4,416.60 N/A $4,416.60 N/A

Components

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

Component Description:
ERI 52272 v220906pmv1
Amount:
$2,376.60

Component Description:
ERI 36705 v220906pmv1
Amount:
$2,040.00

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 $2,381.50 N/A $2,381.50 N/A
Total for all systems $236,752.27 $85,206.62 N/A $39,759.12 N/A
Primary Tower TOWER $56,190.00 $2,381.50 $2,381.50
Tower Rigging Short Tower (less than 500') $56,190.00 $2,381.50 N/A $2,381.50 N/A

Components

Actual Information Description File Name
Tower Rigging Short Tower (less than 500')

Component Description:
Trico 30463 v220906pmv1
Amount:
$2,381.50

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 $37,148.50 $42,866.50 N/A $12,044.00 N/A
Total for all systems $236,752.27 $85,206.62 N/A $39,759.12 N/A
Outside Professional Services $37,148.50 $42,866.50 $12,044.00
ASR $550.00 $550.00 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 N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A $1,550.00 N/A
Prepare request for Special Temporary Authorization $1,280.00 $1,280.00 N/A N/A N/A
Other Engineering Services $10,000.00 $10,000.00 N/A N/A N/A
FAA $550.00 $550.00 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 $1,577.50 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $7,230.00 The cost estimate includes the initial 399 amendment, anticipated subsequent 399 amendments, and ongoing Actual Cost invoice prep and submission by KGA. $7,230.00 N/A
Project management of the transition $1,266.00 $1,314.00 See attached / uploaded pdf file named, "Osborn 41740 v210330pmv1". $1,314.00 N/A
Form 399 assistance or other Program Management costs $10,000.00 $10,000.00 N/A N/A N/A
Perform engineering study for displacement application $1,800.00 $1,950.00 See attached invoice and quote $1,950.00 N/A

Components

Actual Information Description File Name
ASR 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

Component Description:
Osborn 32452 v211227pmv3
Amount:
$1,550.00
Prepare request for Special Temporary Authorization Information not provided.
Other Engineering Services Information not provided.
FAA 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.
Prepare/ Review 399 reimbursement form

Component Description:
KGA 980-354 v220906jgv1
Amount:
$1,320.00

Component Description:
Osborn 40010 v201215pmv1
Amount:
$850.00

Component Description:
Osborn 39386 v201116pmv1
Amount:
$25.00

Component Description:
Osborn 37038 v210330pmv1
Amount:
$3,585.00

Component Description:
KGA 980-305 v220113pmv1
Amount:
$440.00

Component Description:
Osborn 38328 v200724pmv1
Amount:
$75.00

Component Description:
Osborn 37934 v210330pmv1
Amount:
$165.00

Component Description:
Osborn 38625 v200716pmv1
Amount:
$50.00

Component Description:
Osborn 41740 v210330pmv1
Amount:
$190.00

Component Description:
Osborn 41446 v210330pmv1
Amount:
$60.00

Component Description:
Osborn 36551 V200427pmv1
Amount:
$225.00

Component Description:
Osborn 39681 v201215pmv1
Amount:
$25.00

Component Description:
Osborn 38990 v200716pmv1
Amount:
$220.00
Project management of the transition

Component Description:
Osborn 41740 v210330pmv1
Amount:
$79.00

Component Description:
Osborn 38625 v200716pmv1
Amount:
$287.00

Component Description:
Osborn 38328 v200724pmv1
Amount:
$79.00

Component Description:
Osborn 42166 v210330pmv1
Amount:
$79.00

Component Description:
Osborn 39386 v201116pmv1
Amount:
$79.00

Component Description:
Osborn 40298 v201215pmv1
Amount:
$79.00

Component Description:
Osborn 39681 v201215pmv1
Amount:
$474.00

Component Description:
Osborn 40010 v201215pmv1
Amount:
$158.00
Form 399 assistance or other Program Management costs Information not provided.
Perform engineering study for displacement application

Component Description:
Osborn 32452 v211227pmv3
Amount:
$1,950.00

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 $12,172.17 $12,172.17 N/A $2,172.17 N/A
Total for all systems $236,752.27 $85,206.62 N/A $39,759.12 N/A
Other Expenses $12,172.17 $12,172.17 $2,172.17
Coaxial Connectors, Metal Film Resistors $243.81 $243.81 N/A $243.81 N/A
FCC Filing Fees - Special Temporary Authorization Extension Request $200.00 $200.00 N/A $200.00 N/A
FCC Filing Fees - License to Cover Application $170.00 $170.00 N/A $170.00 N/A
Electrical Supplies $824.54 $824.54 N/A $824.54 N/A
Andrew Connectors $352.90 $352.90 N/A $352.90 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $10,000.00 $10,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $380.92 $380.92 N/A $380.92 N/A

Components

Actual Information Description File Name
Coaxial Connectors, Metal Film Resistors

Component Description:
Mouser 52872045 v220906pmv1
Amount:
$243.81
FCC Filing Fees - Special Temporary Authorization Extension Request

Component Description:
FCC PGC3406995 v220906pmv1
Amount:
$200.00
FCC Filing Fees - License to Cover Application

Component Description:
FCC 3604386 v220906pmv1
Amount:
$170.00
Electrical Supplies

Component Description:
Wholesale Electric 0068-10452850 v220906pmv1
Amount:
$82.82

Component Description:
Rexel S127364749 v220906pmv1
Amount:
$393.76

Component Description:
Rexel S125563052.001 v220906pmv1
Amount:
$329.11

Component Description:
Rexel S126557491.001 v220906pmv1
Amount:
$18.85
Andrew Connectors

Component Description:
GBS 516092 v220906pmv1
Amount:
$352.90
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Equipment Delivery and Handling Charges

Component Description:
ERI 52272 v220906pmv1
Amount:
$300.60

Component Description:
Mouser 52872045 v220906pmv1
Amount:
$10.60

Component Description:
CMC 14746 v220908pmv2
Amount:
$30.00

Component Description:
Rexel S125563052.001 v220906pmv1
Amount:
$22.46

Component Description:
GBS 516092 v220906pmv1
Amount:
$17.26

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $236,752.27 $85,206.62 $39,759.12

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.

Jeffrey C Gehman

Engineering Associate


09/08/2022

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).

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

  2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

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

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

  5. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .

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

  7. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

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

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

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

Jeffrey C Gehman

Engineering Associate


09/08/2022

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.

Jeffrey C Gehman

Engineering Associate


09/08/2022

Attachments

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