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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:
18780
Service:
DTV
Call Sign:
WHLA-TV
Channel:
15 (UHF)
File Number:
0000026938
FRN:
0002711455
Date Submitted:
04/17/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

STATE OF WISCONSIN - EDUCATIONAL COMMUNICATIONS BOARD

Doing Business As: STATE OF WISCONSIN - EDUCATIONAL COMMUNICATIONS BOARD

Stephen Bauder

3319 W. BELTLINE HWY.

MADISON, WI 53713

United States

 +1 (608) 264-9746 steve.bauder@wi.gov 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

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 Install temporary mask filter, antenna and line to facilitate continued operation on existing channel during transition. Replace transmitter and main antenna/line.

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 Diamond DHD60P2
Year 2002
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 15.0 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 TMU9
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 16.5 kW
Justification for New Transmitter The existing Harris Diamond transmitter, which currently operates on channel 30, cannot be modified to perform correctly on channel 15.

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 N/A
Rigid Conduit and Wiring Yes
Size 2.5 inches
Length 100.0 feet
Other Electrical Service Yes
Description Re-locate and re-wire existing 100kVA UPS to feed new transmitter. Install temporary service to feed existing transmitter to facilitate use of existing service to feed new transmitter.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 25 tons
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

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Temporary Mask Filter

Facilitates removal of existing floor-mounted filter/N-1 combiner to make room for the new transmitter

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: 307.5 kW
Manufacturer
Model ATW25H3-HTOU-31-H
Year 2002

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? Yes
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: 218.0 kW
Manufacturer
Model ATW20H3-ETO-15H
Year 2018
Justification for New Antenna Existing antenna will not function on new channel. Incremental cost associated with 15%elliptical polarization of new antenna to be borne entirely by licensee.

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? 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 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

Name Description

Temporary Antenna

Required for continued operation between the time the main antenna is removed/replaced and commencement of operations on the new channel/antenna.

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)
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
Type Rigid
Diameter 8 3/16 inches
Other Diameter N/A
Segment Length Other
Other Segment Length 19.333 feet
Number of parallel runs 0
Length 875 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 875 feet per run
Justification for New Transmission Line Existing line length will not support operation on new channel.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Temporary line

Feeds temporary antenna.

Transmissionline adapters

Required to connect interim antenna system to transmitter

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? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users Yes
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1024862
Coordinates (NAD83) Latitude (NAD83) 43° 48' 18.3" N-
Longitude (NAD83) 091° 22' 05.1" W-
Overall Structure Height 824.14 feet
Support Structure Height 772.63 feet
Ground Elevation Above Mean Sea Level (AMSL) 1215.86 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner State of Wisconsin - Educational Communications Board
Date Constructed 10/01/2002

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
63055 WHLA FM
4327 WLSU FM

Other Types of Users

Users
WI State Patrol
WI DNR
NOAA WX Radio
MN State Patrol
Ambulance Fire

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: 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? No
Number of Hours N/A
Explanation N/A
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 No
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers No
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 2
Justification Consulting services related to the design, coordination and planning of tower and in-building RF work.

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 No
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 $833,160.67 $535,044.29 N/A $507,630.36 N/A
Total for all systems $1,725,128.67 $1,329,052.29 N/A $859,646.78 N/A
Primary Transmitter TMU9 $833,160.67 $535,044.29 $507,630.36
Temporary Mask Filter $20,166.67 $20,166.67 N/A $20,166.67 N/A
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW $684,000.00 $471,803.55 N/A $471,803.55 N/A
Other Electrical Service: Re-locate and re-wire existing 100kVA UPS to feed new transmitter. Install temporary service to feed existing transmitter to facilitate use of existing service to feed new transmitter. $29,994.00 $29,994.00 Re-locate and re-wire existing 100kVA UPS to feed new transmitter. Install temporary service to feed existing transmitter to facilitate use of existing service to feed new transmitter. N/A N/A
25 Ton system $91,500.00 $5,580.07 Heat load was reduced sufficiently to eliminate the need to replace air conditioning. All that was needed was removal of one air conditioner to open outdoor pad space for a heat exchanger, and blocking the return/supply openings $11,160.14 original component could not be edited, duplicate components
2.5" Rigid Conduit and Wiring $7,500.00 $7,500.00 N/A $4,500.00 N/A

Components

Actual Information Description File Name
Temporary Mask Filter

Component Description:
First payment for temporary mask filter
Amount:
$9,085.00

Component Description:
Final payment including shipping for temporary mask filter
Amount:
$11,081.67
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW

Component Description:
Transmitter final payment
Amount:
$353,852.66

Component Description:
Transmitter initial payment, fifth attempt.
Amount:
$117,950.89
Other Electrical Service: Re-locate and re-wire existing 100kVA UPS to feed new transmitter. Install temporary service to feed existing transmitter to facilitate use of existing service to feed new transmitter. Information not provided.
25 Ton system

Component Description:
Remove air conditioner, cover openings.
Amount:
$5,580.07

Component Description:
remove HVAC unit, block opening. This should be the only HVAC-related expenditure
Amount:
$5,580.07
2.5" Rigid Conduit and Wiring

Component Description:
First phase of electrical service installation for new transmitter
Amount:
$4,500.00

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 $356,230.00 $285,000.00 N/A $166,725.00 N/A
Total for all systems $1,725,128.67 $1,329,052.29 N/A $859,646.78 N/A
Primary Antenna ATW20H3-ETO-15H $356,230.00 $285,000.00 $166,725.00
Temporary Antenna $60,000.00 $60,000.00 N/A $44,925.00 N/A
Sweep test of existing antenna $6,730.00 $0.00 N/A N/A N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $289,500.00 $225,000.00 incremental costs associated with the addition of elliptical polarization will be borne entirely by licensee. $121,800.00 N/A

Components

Actual Information Description File Name
Temporary Antenna

Component Description:
Antenna cost is $44,925.00 Previously reimbursed $20,216.25 This claim is remaining balance for antenna $21,828.75
Amount:
$21,828.75

Component Description:
As invoiced, 45% of antenna and initial sweep costs, line costs claimed separately
Amount:
$23,096.25
Sweep test of existing antenna Information not provided.
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized

Component Description:
30% deposit with antenna order per terms
Amount:
$60,900.00

Component Description:
30% of WHLA ANTENNA SYSTEM costs as invoiced. Line is on same invoice but reimbursement will be requested separately. See ERI quote 20171106-241
Amount:
$60,900.00

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 $245,008.00 $236,258.00 N/A $132,590.38 N/A
Total for all systems $1,725,128.67 $1,329,052.29 N/A $859,646.78 N/A
Primary Transmission Line $245,008.00 $236,258.00 $132,590.38
Transmissionline adapters $17,258.00 $17,258.00 Required for various configurations of existing/new transmitter, main/temporary antenna, and temporary/new mask filter. $13,156.11 N/A
Temporary line $51,000.00 $51,000.00 N/A $45,633.13 N/A
Rigid Transmission Line - copper, 6 1/8" $176,750.00 $168,000.00 Existing 8 3/16" line length will not work on new channel. Line must be replaced, electing to reduce line size to 6 1/8" to preserver tower loading. $73,801.14 N/A

Components

Actual Information Description File Name
Transmissionline adapters

Component Description:
RF Line parts for temporary and permanent antennas
Amount:
$13,156.11
Temporary line

Component Description:
line cost is $38,410.63, shipping cost is $7,222.50 (attributing all shipping costs to line), for a total line cost of $45,633.13, of which $17,284.78 has been reimbursed. This component is for reimbursement of total line cost - previous reimbursement.
Amount:
$28,348.35

Component Description:
As invoiced, 45% of line costs
Amount:
$17,284.78
Rigid Transmission Line - copper, 6 1/8"

Component Description:
30% of transmission line system. See ERI quote 20171106-241
Amount:
$36,900.57

Component Description:
30% payment with order for transmission line per terms
Amount:
$36,900.57

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 $223,100.00 $212,000.00 N/A $44,467.50 N/A
Total for all systems $1,725,128.67 $1,329,052.29 N/A $859,646.78 N/A
Primary Tower GTOWER $223,100.00 $212,000.00 $44,467.50
Tall Tower (greater than 500') $210,500.00 $200,000.00 N/A $39,967.50 N/A
Structural engineering tower load study for well documented tower $12,600.00 $12,000.00 N/A $4,500.00 N/A

Components

Actual Information Description File Name
Tall Tower (greater than 500')

Component Description:
Initial payment for tower work, including main antenna and line replacement, and interim antenna and line installation.
Amount:
$39,967.50
Structural engineering tower load study for well documented tower

Component Description:
Structural Analysis of WHLA tower
Amount:
$4,500.00

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 $31,080.00 $24,750.00 N/A $5,012.50 N/A
Total for all systems $1,725,128.67 $1,329,052.29 N/A $859,646.78 N/A
Outside Professional Services $31,080.00 $24,750.00 $5,012.50
Additional Field Engineering Service, 2 Days $3,000.00 $3,000.00 2 days x $1500/day $337.50 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 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
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 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 $3,000.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $2,500.00 N/A $750.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $925.00 N/A

Components

Actual Information Description File Name
Additional Field Engineering Service, 2 Days

Component Description:
Portion of invoice related to WHLA RF consulting
Amount:
$337.50
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.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization 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:
portion of invoice related to prep of engineering section of CP application for new channel
Amount:
$3,000.00
Perform engineering study for new channel assignment and antenna development

Component Description:
portion of invoice related to engineering study of new channel assignment
Amount:
$750.00
Prepare and or review reimbursement form

Component Description:
Review of Form 1876
Amount:
$150.00

Component Description:
Repack channel change mod work; review form 399
Amount:
$300.00

Component Description:
Review form 387 and reimbursement allocations
Amount:
$100.00

Component Description:
Review form 399; review expense justifications
Amount:
$375.00

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 $36,550.00 $36,000.00 N/A $3,221.04 N/A
Total for all systems $1,725,128.67 $1,329,052.29 N/A $859,646.78 N/A
Other Expenses $36,550.00 $36,000.00 $3,221.04
Disposal Costs (for equipment and other waste, net of any salvage value) $8,000.00 $8,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 N/A $2,780.54 N/A
Develop and air announcement of upcoming channel change $2,500.00 $2,500.00 N/A N/A N/A
MVPD Notification of Channel Change $2,000.00 $2,000.00 N/A N/A N/A
Equipment Storage $2,500.00 $2,500.00 N/A $440.50 N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Equipment Delivery and Handling Charges

Component Description:
Forklift rental to off-load new equipment. Tax should not have been charged and is not being claimed for reimbursement
Amount:
$1,390.27

Component Description:
Per FCC Request, cover letter provided explaining why expense is covered under repack guidelines and why requested amount is less than invoiced amount
Amount:
$1,390.27
Develop and air announcement of upcoming channel change Information not provided.
MVPD Notification of Channel Change Information not provided.
Equipment Storage

Component Description:
Transmitter system storage. Added PO per RFAS26938. Existing component could not be edited.
Amount:
$100.50

Component Description:
transmitter system storage, added PO per RFAS 26938, existing component could not be edited
Amount:
$119.75

Component Description:
Misc storage charges, added cover per FCC request
Amount:
$119.75

Component Description:
Misc. storage charges, Added cover letter per FCC request
Amount:
$100.50
DTV Medical Facility Notification Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $1,725,128.67 $1,329,052.29 $859,646.78

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.

Gene Purcell

Executive Director


04/17/2018

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.

Gene Purcell

Executive Director


04/17/2018

Attachments

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