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:
182489
Service:
LPD
Call Sign:
KCDL-LD
Channel:
36 (UHF)
File Number:
0000089825
FRN:
0021629860
Eligibility Status:
Eligible
Date Submitted:
10/04/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

IMPACTO NETWORK, INC.

Doing Business As: IMPACTO NETWORK, INC.

Ambrosio Cruz

P.O. BOX 490

1014 3RD AVENUE NORTH

CALDWELL, ID 83606

United States

+1 (208) 283-6683 ncruz512@hotmail.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

The Preparer is same as the reimbursement contact.

 

 

 

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan Move from Channel 42 to Channel 36 Acquire new transmitter Acquire new antenna Acquire new coaxial cable Move to a new transmitter location

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 UFHXMITR 2KW-DTV
Year 2012
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 2 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 BE-TV3k0-FAVI
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 3 kW
Justification for New Transmitter Old transmitter brand doesn't exist any more, no parts available for a tune 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? 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 New circuit for 100 amps as need.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 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? No
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Middle
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 2
Design power capacity in use 80.0 %
Lower Limit 638.00 MHz
Upper Limit 644.00 MHz
ERP: 12.0 kW
Manufacturer
Model 723147X2
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? 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 Middle
Polarization Circular
Type Other
Other Antenna Type Slot
ERP: 5.0 kW
Manufacturer
Model JA/MS-8/15-SCO
Year 2020
Justification for New Antenna Change channel from channel 42 UHF to channel 36 UHF. Antenna cannot be retuned.

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? 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 Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 120 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 140 feet per run
Justification for New Transmission Line New installation
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 Move Equipment
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 1226408
Coordinates (NAD83) Latitude (NAD83) 43° 37' 50.6" N-
Longitude (NAD83) 116° 32' 58.5" W-
Overall Structure Height 193.90 feet
Support Structure Height 189.96 feet
Ground Elevation Above Mean Sea Level (AMSL) 2469.13 feet
Structure Type LTOWER - Lattice Tower
Tower Owner SpectraSite Communications, LLC. through American Towers, LLC.
Date Constructed 03/19/2001


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 200
Explanation Our church stuff does not have any knowledge for installation or arrangements to build a television station. Outside expertise will be needed.
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 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 No
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 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

Name Description

Consulting and Assistance

Assistance and consulting for the channel at the beginning through the end

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 No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? No
Does this relocation require Equipment Storage? No
Point to Point Microwave (STL/ICR) Frequency Coordination for Unidirection System No
Frequency Coordination for Bi-Direction System No
New Point to Point Microwave System No

Other Expenses

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Other Expenses Not Listed

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 $146,670.00 $175,097.72 N/A $157,610.85 N/A
Total for all systems $309,320.00 $293,012.12 N/A $215,592.75 N/A
Primary Transmitter BE-TV3k0-FAVI $146,670.00 $175,097.72 $157,610.85
Transmitter Building Site Survey/Installation $10,000.00 $7,250.00 This is the amount charged $0.00 This is the amount charged
5 Ton system $20,250.00 $20,250.00 N/A $10,013.13 N/A
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW $106,300.00 $137,477.72 This invoice includes accessories for transmitter as well $137,477.72 This is the amount charged
Other Electrical Service: New circuit for 100 amps as need. $10,120.00 $10,120.00 N/A $10,120.00 N/A

Components

Actual Information Description File Name
Transmitter Building Site Survey/Installation

Component Description:
Site Survey Expenses
Amount:
$7,250.00
5 Ton system

Component Description:
Invoice for 5 ton ac system
Amount:
$10,013.13
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW

Component Description:
line item DC3A39/2C-LK
Amount:
$832.00

Component Description:
Install/Check-out and Proof
Amount:
$5,250.00

Component Description:
SHIPPING
Amount:
$4,643.00

Component Description:
86705-1
Amount:
$7,600.00

Component Description:
HE6P300A-11
Amount:
$11,744.00

Component Description:
86705-1
Amount:
$7,600.00

Component Description:
taxes
Amount:
$10,477.52

Component Description:
LPF-3KW-VI
Amount:
$6,744.00

Component Description:
150775
Amount:
$2,216.00

Component Description:
shipping
Amount:
$4,643.00

Component Description:
line item 150775
Amount:
$2,216.00

Component Description:
HE6P300A-11
Amount:
$11,744.00

Component Description:
line item SPECIAL-BE-TV3k0-COAX_KIT
Amount:
$2,931.20

Component Description:
line item BE-TV3k0-FAVI
Amount:
$85,040.00

Component Description:
Sales Tax
Amount:
$10,477.52

Component Description:
SPECIAL-BE-TV3k0-COAX_KIT
Amount:
$2,931.20

Component Description:
DC3A39/2C-LK
Amount:
$832.00

Component Description:
LPF-3KW-VI
Amount:
$6,744.00

Component Description:
Install/Check out and proof
Amount:
$5,250.00

Component Description:
BE-TV3k0-FAVI
Amount:
$85,040.00
Other Electrical Service: New circuit for 100 amps as need.

Component Description:
Invoice is for electricity installation
Amount:
$10,120.00

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $12,115.00 $9,240.00 N/A $9,240.00 N/A
Total for all systems $309,320.00 $293,012.12 N/A $215,592.75 N/A
Primary Antenna JA/MS-8/15-SCO $12,115.00 $9,240.00 $9,240.00
UHF-Low Power, Side Mount, Other, 5.0kW input, Circular $7,490.00 $7,490.00 This is the amount charged $7,490.00 This is the amount charged
Side Mount antenna brackets $4,625.00 $1,750.00 N/A $1,750.00 N/A

Components

Actual Information Description File Name
UHF-Low Power, Side Mount, Other, 5.0kW input, Circular

Component Description:
Jampro JA-SS-8 Super Slot Low Power Horizontally Polarized UHF Slot Antenna
Amount:
$7,490.00
Side Mount antenna brackets

Component Description:
Brackets for a 5" pipe
Amount:
$1,750.00

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $3,360.00 $2,564.40 N/A $2,564.40 N/A
Total for all systems $309,320.00 $293,012.12 N/A $215,592.75 N/A
Primary Transmission Line $3,360.00 $2,564.40 $2,564.40
Flexible Foam Transmission Line - dielectric, 1 5/8" $3,360.00 $2,564.40 N/A $2,564.40 N/A

Components

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

Component Description:
Invoice for 200ft 1-5/8 foam transmission line
Amount:
$2,564.40

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 $16,400.00 N/A $16,400.00 N/A
Total for all systems $309,320.00 $293,012.12 N/A $215,592.75 N/A
Primary Tower LTOWER $56,190.00 $16,400.00 $16,400.00
Tower Rigging Short Tower (less than 500') $56,190.00 $16,400.00 N/A $16,400.00 N/A

Components

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

Component Description:
TOWER CREW INVOICE FOR INSTALLATION OF ANTENNA & CABLE PLUS MATERIAL
Amount:
$16,400.00

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 $89,540.00 $88,385.00 N/A $29,562.50 N/A
Total for all systems $309,320.00 $293,012.12 N/A $215,592.75 N/A
Outside Professional Services $89,540.00 $88,385.00 $29,562.50
Consulting and Assistance $41,000.00 $41,000.00 N/A $0.00 This is the amount charged
RF Exposure Measurements $12,100.00 $12,100.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $3,262.50 This is the amount charged $3,262.50 Amount charges
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $2,375.00 This is the amount charged $2,375.00 This is the amount charged
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $4,162.50 This is the amount charged $4,162.50 This is the amount charged
Form 399 assistance or other Program Management costs $810.00 $810.00 This is the amount charged $0.00 This is the amount charged
Prepare/ Review 399 reimbursement form $1,710.00 $15,237.50 This is the amount charged $14,762.50 This is the amount charged based on the time spent
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $2,000.00 This is the amount charged $2,000.00 This is the amount charged
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $3,000.00 This is the amount charged $3,000.00 this is the amount charged
Perform engineering study for displacement application $1,800.00 $1,800.00 N/A N/A N/A
Project management of the transition $21,100.00 $2,637.50 N/A N/A N/A

Components

Actual Information Description File Name
Consulting and Assistance

Component Description:
Reimbursement for consulting and assistance for KCDL CH 36
Amount:
$41,000.00
RF Exposure Measurements Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
Lease work
Amount:
$3,262.50
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Legal fees -- license to cover
Amount:
$2,375.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Construction Permit Legal Work
Amount:
$4,162.50
Form 399 assistance or other Program Management costs

Component Description:
FCC Form 399 ancillary assistance
Amount:
$337.50

Component Description:
FCC Form 399 ancillary assistance
Amount:
$472.50
Prepare/ Review 399 reimbursement form

Component Description:
FCC Work - FCC Form 399
Amount:
$237.50

Component Description:
Additional fees re FCC form 399
Amount:
$1,662.50

Component Description:
Legal fees - FCC Form 399
Amount:
$475.00

Component Description:
Additional fees re FCC Form 399
Amount:
$237.50

Component Description:
Repack Process Legal Fees
Amount:
$10,012.50

Component Description:
Additional legal fees re FCC Form 399
Amount:
$2,612.50
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Engineering fees license to cover
Amount:
$2,000.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Engineering work re construction permit application
Amount:
$3,000.00
Perform engineering study for displacement application Information not provided.
Project management of the transition 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 $1,445.00 $1,325.00 N/A $215.00 N/A
Total for all systems $309,320.00 $293,012.12 N/A $215,592.75 N/A
Other Expenses $1,445.00 $1,325.00 $215.00
FCC Filing Fees - Form 2100 license to cover application $335.00 $215.00 N/A $215.00 N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,110.00 N/A N/A N/A

Components

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

Component Description:
FCC filing fee - License to Cover
Amount:
$215.00
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 $309,320.00 $293,012.12 $215,592.75

Reimbursement Status

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

Certification

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Section Question Response
Submission of Estimated Expenses Statements

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

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

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

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

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

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

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

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

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

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

Ambrocio Cruz

President


10/04/2022

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.

Ambrocio Cruz

President


10/04/2022

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.

Ambrocio Cruz

President


10/04/2022

Attachments

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