Go to the Federal Communications Commission homepage at www.fcc.gov

FCC Form 399: Incentive Auction Relocation Reimbursement Fund System

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

(REFERENCE COPY - Not for submission)FCC Form 399: Incentive Auction Relocation Reimbursement Fund System

File Number:
0000027360
FRN:
0022163661
Facility ID:
12855
Repack Channel:
23 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
07/10/2017

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

UNIVERSITY OF CENTRAL FLORIDA

Doing Business As: UNIVERSITY OF CENTRAL FLORIDA

Michael Herring

12461 RESEARCH PKWY

SUITE 550

ORLANDO, FL 32826

United States

+1 (407) 823-3371 Michael.Herring@wucftv.org Government Entity

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

Robert Gehman

ConsultingEngineer

Kessler and Gehman Associates, Inc.

Robert Gehman

Kessler and Gehman Associates, Inc.

507 NW 60 Street, Suite D

Gainesville, FL 32607

United States

+1 (352) 332-3157 bob@kesslerandgehman.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 Re-tune existing MSDC IOT transmitter, replace antenna, re-use existing line. Acquire interim transmitter, antenna and line for pre-auction channel while construction in process and during assigned phase. Map and analyze tower; design & modify if needed.

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 Retune Existing
Use Primary (Main)
Description of Use  
Ownership Owned
Owner  
Site  
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer Comark
Model Paragon DCXP-2
Year 2003
Type Inductive Output Tube
IOT Power Type Two
Description  
Power capacity 50 kw
Solid State Cooling  
Solid State Power Capacity  
Other Transmitter Type  

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed 2
New Mask Filter Power 60 kw
Other Power  
New Exciter Is a new exciter needed? Yes
Exciter Type Dual exciter with changeover

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power
Rigid Conduit and Wiring No
Size
Length
Other Electrical Service No
Description  
HVAC Service Does the replacement transmitter require HVAC Service? No
Type
Size
Other Size  
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size
Channel 14 Costs Is an RF Consulting Engineer needed?
Is a channel 14 Mask Filer needed?
Is additional field engineering time needed?
Number of Days  

Primary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use  
Change Type Purchase
Manufacturer
Model DCX Paragon 2
Transmitter Type Inductive Output Tube
IOT Power Type Two
Other  
Power capacity 50 kw
Solid State Cooling  
Solid State Power Capacity  
Other Transmitter Type  
Justification for New Transmitter To keep the station on the air with reasonable coverage during re-tuning and throughout the assigned phase.

Interim Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) Yes
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 100.0 feet
Other Electrical Service No
Description  
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 10 tons
Other Size  
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 176.0 square feet
Channel 14 Costs Is an RF Consulting Engineer needed?
Is a channel 14 Mask Filer needed?
Is additional field engineering time needed?
Number of Days  
Inside RF System Is an additional interior RF system required to support this interim transmitter? Yes

Interim 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)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
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 Class Full Power
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 950.00 kW
Manufacturer
Model TFU-30DSC-R 3C 152 DC
Year 2003

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Ownership Owned
Owner N/A
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 Type Class Full Power
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 1000.00 kW
Manufacturer
Model TFU-30DSC/VP-R 3C1502
Year 2019
Justification for New Antenna The existing primary antenna is a single channel slotted coaxial which cannot accommodate the assigned channel.

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
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 6 1/8 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? Yes
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.

Interim Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Interim
Description of Use N/A
Change Type Purchase New
Ownership Owned
Owner N/A
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 Type Class Full Power
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 950.00 kW
Manufacturer
Model TBD
Year 2018
Justification for New Antenna An interim antenna is necessary to keep station on the air during primary antenna replacement and for the duration of the assigned phase.

Interim 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
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 6 1/8 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? Yes
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Interim 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 Utilize Existing
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
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 Dielectric
Type Rigid
Diameter 6 1/8 inches
Segment Length Broadband
Other Segment Length
Number of parallel runs 1
Length 1290 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Sweep Tests

Sweep line to insure acceptable with assigned channel

Interim Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Rigid
Diameter 6 1/8 inches
Segment Length 19 ¾ '
Other Segment Length
Number of parallel runs 1
Length 1130 feet per run
Justification for New Transmission Line Required for interim operation

Interim 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)
Description of Use N/A
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 Yes
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1026744
Coordinates (NAD83) Latitude (NAD83) 28° 36' 08.0" N-
Longitude (NAD83) 081° 05' 36.0" W-
Overall Structure Height 1608.25 feet
Support Structure Height 1479.97 feet
Ground Elevation Above Mean Sea Level (AMSL) 64.96 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner WPOZ / Charitable Ministry Support Inc.
Date Constructed 01/01/1992

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
12857 WMFE-FM FM
9876 WPOZ FM

Other Types of Users

Users
Various mwave

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 needed for documented 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

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 150
Explanation It will be necessary to schedule and coordinate multiple vendors, complete progress reports, and update Schedule 399.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development 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
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
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
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 14
Justification It will be necessary to survey the site, plan the equipment, develop specifications for purchasing, and oversee multiple vendor RF projects.

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
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits Yes
BLM or NFS Coordination 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? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

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 $1,974,550.00 $2,533,480.00 N/A $0.00 N/A
Total for all systems $3,306,585.00 $3,866,290.00 N/A $0.00 N/A
Interim Transmitter DCX Paragon 2 $1,246,450.00 $1,699,370.00 $0.00
Transformer 3 phase/480v - 300 KVA $35,850.00 $35,000.00 N/A N/A N/A
Service entrance 3 phase/800 amp/208 volt $14,050.00 $13,700.00 N/A N/A N/A
Switchgear - industrial 800 amp $37,150.00 $36,300.00 N/A N/A N/A
UHF inside RF system including switching $143,500.00 $140,000.00 N/A N/A N/A
Two IOT system (50 kW) $929,000.00 $1,388,470.00 This is the cost for a new 2-tube, DCX Paragon-2 MSDC-IOT digital UHF transmitter from the most recent Comark price list. N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $5,000.00 $4,900.00 N/A N/A N/A
Other -- Building Addition Size: 176.0 $44,000.00 $44,000.00 There is no space for a the interim transmitter or heat exchangers. This additional space will accommodate a 38 kW transmitter and outdoor heat exchangers. The cost is based on $250/sq ft for everything except electrical and HVAC. N/A N/A
10 Ton system $37,900.00 $37,000.00 Cooling is required for the additional building space to accommodate the interim transmitter. N/A N/A
Primary Transmitter Paragon DCXP-2 $728,100.00 $834,110.00 $0.00
Dual exciter system with change over $46,100.00 $45,250.00 Quote attached from Comark N/A N/A
2 IOT Tubes $248,000.00 $242,000.00 N/A N/A N/A
Two IOT system (50 kW) $347,000.00 $461,860.00 Quote attached from Comark, including mask filter N/A N/A
60 kW mask filter $87,000.00 $85,000.00 Included in re-tuning price quote attached from Comark N/A N/A

Components

Information not provided.

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 $452,440.00 $450,200.00 N/A $0.00 N/A
Total for all systems $3,306,585.00 $3,866,290.00 N/A $0.00 N/A
Interim Antenna TBD $226,220.00 $225,100.00 $0.00
UHF - High Power, Side Mount, basic slot antenna, 950 kW input, directional,, horizontally polarized $180,000.00 $180,000.00 N/A N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,120.00 $5,000.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,000.00 $11,700.00 N/A N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $22,550.00 $22,000.00 N/A N/A N/A
Primary Antenna TFU-30DSC/VP-R 3C1502 $226,220.00 $225,100.00 $0.00
UHF - High Power, Side Mount, basic slot antenna, 1000 kW input, directional,, horizontally polarized $180,000.00 $180,000.00 N/A N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,000.00 $11,700.00 N/A N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $22,550.00 $22,000.00 N/A N/A N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,120.00 $5,000.00 N/A N/A N/A

Components

Information not provided.

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 $229,010.00 $223,360.00 N/A $0.00 N/A
Total for all systems $3,306,585.00 $3,866,290.00 N/A $0.00 N/A
Interim Transmission Line $222,610.00 $216,960.00 $0.00
Rigid Transmission Line - copper, 6 1/8" $222,610.00 $216,960.00 N/A N/A N/A
Primary Transmission Line $6,400.00 $6,400.00 $0.00
Sweep Tests $6,400.00 $6,400.00 N/A N/A N/A

Components

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 $370,800.00 $362,000.00 N/A $0.00 N/A
Total for all systems $3,306,585.00 $3,866,290.00 N/A $0.00 N/A
Primary Tower TOWER $370,800.00 $362,000.00 $0.00
Structural engineering tower load study for well documented tower $12,300.00 $12,000.00 N/A N/A N/A
Minor tower reinforcement/modifications $153,500.00 $150,000.00 N/A N/A N/A
Tall Tower (greater than 500') $205,000.00 $200,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $166,535.00 $184,250.00 N/A $0.00 N/A
Total for all systems $3,306,585.00 $3,866,290.00 N/A $0.00 N/A
Outside Professional Services $166,535.00 $184,250.00 $0.00
Attorney Fees - Negotiation of lease and other matters for shared locations $4,095.00 $25,000.00 The station's legal representative recommends $25,000 to cover this effort. N/A N/A
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,535.00 $1,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,560.00 $2,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $1,500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,305.00 $2,250.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,585.00 $3,500.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $81,900.00 $80,000.00 N/A N/A N/A
Additional Field Engineering Service, 14 Days $28,000.00 $28,000.00 N/A N/A N/A
Project management of the transition $23,100.00 $22,500.00 N/A N/A N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A N/A N/A

Components

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 $113,250.00 $113,000.00 N/A $0.00 N/A
Total for all systems $3,306,585.00 $3,866,290.00 N/A $0.00 N/A
Other Expenses $113,250.00 $113,000.00 $0.00
Disposal Costs (for equipment and other waste, net of any salvage value) $10,000.00 $10,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A N/A N/A
Non-zoning permits $10,000.00 $10,000.00 N/A N/A N/A
MVPD Notification of Channel Change $2,000.00 $2,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $10,000.00 $10,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $50,000.00 $50,000.00 N/A N/A N/A
Equipment Storage $20,000.00 $20,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $3,306,585.00 $3,866,290.00 $0.00

Construction Status

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Question Response
Is construction complete? 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.

W. Scott Cole

Vice President and General Counsel


07/10/2017

Attachments

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