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:
51991
Service:
DTV
Call Sign:
WPSD-TV
Channel:
19 (UHF)
File Number:
0000027228
FRN:
0003763927
Date Submitted:
07/10/2017

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WPSD-TV, LLC

Doing Business As: WPSD-TV, LLC

Richard E. Paxton

201 SOUTH 4TH STREET

PADUCAH, KY 42002

United States

+1 (202) 662-5120 RPAXTON@PAXTONMEDIA.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

Dan Wilson

WPSD Chief Engineer

WPSD TV, LLC

100 Television Lane

Paducah , KY 42003

United States

+1 (270) 415-1938 dwilson@wpsdlocal6.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 We will install a DTV 32 aux TX in the existing building feeding a side mount antenna with 4" flex @ 800' level with a ERP of 200 kW. Once the aux is online, we will then remove the main DTV 32 TX and install a new DTV 19 TX that will feed a new antenna

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)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model CD3200P2-CF
Year 2003
Type Inductive Output Tube
IOT Power Type Two
Power Capacity 50 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 80
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 50 kW
Justification for New Transmitter Our existing DTV channel 32 is not tunable or upgradable to channel 19.

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) Yes
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 tons
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 500.0 square feet
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

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 N/A
Change Type Purchase
Manufacturer
Model ULXTE-30
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 20 kW
Justification for New Transmitter We will need a temporary TX to operate on ch. 32 while the new main ch. 19 is installed. The TX building doesn't have space or utilities for 2 main TX's to co-exist. There would be enough space for a small temporary TX.

Interim 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) Yes
Power 150 kVA
Rigid Conduit and Wiring Yes
Size 2 inches
Length 50.0 feet
Other Electrical Service Yes
Description 200A disconnect and distribution panel
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A
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? 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 Class Full Power
Mounting Top 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: 906.0 kW
Manufacturer
Model TUV-36GTH/4MR O4
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? No
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Elliptical
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: 679.0 kW
Manufacturer
Model TFU-31JTH/VP-R 04
Year 2017
Justification for New Antenna Existing DTV 32 antenna is not tunable and stacked with a NTSC channel 6.

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 inches
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.

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? No
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 8
Lower Limit 473.00 MHz
Upper Limit 695.00 MHz
Design power capacity in use 95.0 %
Other Antenna Type N/A
ERP: 200.0 kW
Manufacturer
Model TFU-8WB-C160
Year 2017
Justification for New Antenna Needed for continued operation on ch. 32 while the existing main TX 32 is removed and then replaced with the new ch. 19 TX. The temporary TX will be retunable to ch. 19 and then afterward designated as an backup TX.

Interim Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Broadband or Single Channel? N/A
Feed Line Size N/A
Side Mount Brackets Do you require the separate purchase of side mount brackets for an 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

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 7 3/16 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1650 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

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 Flexible Air
Diameter 4 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 900 feet per run
Justification for New Transmission Line This line will be needed for the temporary or aux TX and antenna which will be installed in the TX building. This TX will be the temporary ch. 32 on air while the existing main TX is removed. The new ch. 19 can then be installed.

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 Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1042698
Coordinates (NAD83) Latitude (NAD83) 37° 11' 31.2" N-
Longitude (NAD83) 088° 58' 53.2" W-
Overall Structure Height 1626.95 feet
Support Structure Height 1550.83 feet
Ground Elevation Above Mean Sea Level (AMSL) 361.87 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner WPSD-TV, LLC
Date Constructed 04/13/2004


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 1000
Explanation Because of the complexity of our TX site and the age of the tower, we will need severe tower modifications in order to comply with the new G type mods. The last analysis was in 2003 for F type mods. Installing an aux TX will be a necessity to stay on air.
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 Yes
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
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 Yes
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
NEPA Section 106 environmental review Yes
Environmental Assessment Yes
ASR Modification Yes
FAA Consultation (including preparation of FAA Form 7460) Yes
Negotiation of Lease and other Matter for Shared Locations No
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 Yes
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

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 Yes
Non-zoning permits Yes
BLM or NFS Coordination Yes
FCC Construction Permit Minor Change Yes
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? No
Does this relocation require Equipment Storage? No
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 $2,461,600.00 $2,220,500.00 N/A $0.00 N/A
Total for all systems $3,869,645.00 $4,026,835.00 N/A $0.00 N/A
Interim Transmitter ULXTE-30 $878,350.00 $736,250.00 $0.00
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW $684,000.00 $650,000.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $15,000.00 N/A N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $1,300.00 $1,250.00 N/A N/A N/A
Other Electrical Service: 200A disconnect and distribution panel $20,000.00 $20,000.00 N/A N/A N/A
UHF inside RF system including switching $147,500.00 $50,000.00 N/A N/A N/A
Primary Transmitter ULXTE 80 $1,583,250.00 $1,484,250.00 $0.00
5 Ton system $20,250.00 $19,250.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,473,000.00 $1,400,000.00 N/A N/A N/A
Transformer 3 phase/480v - 300 KVA $36,800.00 $25,000.00 N/A N/A N/A
Other -- Building Addition Size: 500.0 $15,000.00 $15,000.00 N/A N/A N/A
Switchgear - industrial 800 amp $38,200.00 $25,000.00 N/A 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 $604,760.00 $394,500.00 N/A $0.00 N/A
Total for all systems $3,869,645.00 $4,026,835.00 N/A $0.00 N/A
Interim Antenna TFU-8WB-C160 $296,230.00 $106,400.00 $0.00
UHF – Broadband Panel, Side Mount Auxiliary/Interim, 200 horizontally polarized $100,000.00 $100,000.00 N/A N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
UHF - Lower Power Side Mount, One station - 200-500 kW, horizontally polarized $189,500.00 $0.00 N/A N/A N/A
Primary Antenna TFU-31JTH/VP-R 04 $308,530.00 $288,100.00 $0.00
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $289,500.00 $270,000.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,300.00 $11,700.00 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 $66,600.00 $50,000.00 N/A $0.00 N/A
Total for all systems $3,869,645.00 $4,026,835.00 N/A $0.00 N/A
Interim Transmission Line $66,600.00 $50,000.00 $0.00
Flexible Air Transmission Line - dielectric, 4" $66,600.00 $50,000.00 N/A N/A N/A
Primary Transmission Line $0.00 $0.00 $0.00

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 $381,100.00 $1,257,000.00 N/A $0.00 N/A
Total for all systems $3,869,645.00 $4,026,835.00 N/A $0.00 N/A
Primary Tower TOWER $381,100.00 $1,257,000.00 $0.00
Minor tower reinforcement/modifications $158,000.00 $897,000.00 Severe tower reinforcements from MOD F to Mod G specs are required for the new channel 19 antenna and auxillary 32 antenna. I have attached the tower analysis completed in June 2017. $0.00 N/A
Structural engineering tower load study for well documented tower $12,600.00 $10,000.00 N/A N/A N/A
Tall Tower (greater than 500') $210,500.00 $350,000.00 Estimated cost for installing the auxillary and main antenna. 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 $322,895.00 $83,250.00 N/A $0.00 N/A
Total for all systems $3,869,645.00 $4,026,835.00 N/A $0.00 N/A
Outside Professional Services $322,895.00 $83,250.00 $0.00
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A
Project management of the transition $158,000.00 $20,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $0.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 N/A N/A N/A
NEPA Section 106 environmental review, if needed $6,310.00 $0.00 N/A N/A N/A
ASR modification (prepare FCC Form 854) $2,105.00 $2,000.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A N/A N/A
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, Construction Permit Application $2,105.00 $2,000.00 N/A N/A N/A
Attorney Fees - Aux Antenna, prepare and File Form 2100 Construction Permit or License Application $4,210.00 $4,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A N/A
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet $10,520.00 $5,000.00 N/A N/A N/A
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase $2,105.00 $0.00 N/A N/A N/A
RF Exposure Measurements $21,050.00 $20,000.00 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 $32,690.00 $21,585.00 N/A $0.00 N/A
Total for all systems $3,869,645.00 $4,026,835.00 N/A $0.00 N/A
Other Expenses $32,690.00 $21,585.00 $0.00
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
Local Zoning $2,000.00 $2,000.00 N/A N/A N/A
Non-zoning permits $2,000.00 $2,000.00 N/A N/A N/A
MVPD Notification of Channel Change $500.00 $500.00 N/A N/A N/A
BLM or NFS Coordination $10,000.00 $10,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $0.00 $0.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $500.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $5,000.00 $5,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $3,869,645.00 $4,026,835.00 $0.00

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
Construction of final facilities or all necessary modifications are complete. No
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.

Bill Evans

Vice President of News and Operations


07/10/2017

Attachments

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