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:
39664
Service:
DTV
Call Sign:
WCSH
Channel:
31 (UHF)
File Number:
0000028041
FRN:
0024376113
Date Submitted:
05/10/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

PACIFIC AND SOUTHERN, LLC

Doing Business As: PACIFIC AND SOUTHERN, LLC

Law Department

TEGNA, Inc.

7950 Jones Branch Drive

McLean, VA 22107

United States

+1 (703) 873-6600 LAWDEPT@TEGNA.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

Jeffrey Johnson , Johnson .

Vice President Projects

TEGNA

Jeffrey Johnson

7950 Jones Branch Drive

McLean, VA 22102

United States

+1 (703) 873-6736 jsjohnson@tegna.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan WCSH will construct it's new assigned facility. this will require a new transmitter, antenna and interim antenna and line during the primary facility construction.

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 CDP3200 P2
Year 2001
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? Yes
Manufacturer
Model ULXTE 72
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 47.2 kW
Justification for New Transmitter Station has in excess of 10% TPO headroom and is eligible for a 1-Step-Up Allowance. Reimbursable TPO is 36.6 kW based on initial 90-day filing CP. This would require a ULXTE-60. A 1-Step-Up is the ULXTE-72 and is therefore reimbursable.

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 3 inches
Length 100.0 feet
Other Electrical Service Yes
Description Additional electrical services required for transmitter installation, including heat exchangers, transformers, cooling pumps, etc.
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? Yes
Size 100.0 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.

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? No
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: 1000.0 kW
Manufacturer
Model TFU-28DSC-R 4C150
Year 2001

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? No
New Antenna Manufacturer and Types 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: 775.0 kW
Manufacturer
Model TFU-26DSC-R 4C150
Year 2018
Justification for New Antenna Station's licensed horizontally polarized, side-mount, main antenna cannot be re-tuned and must be replaced for new channel assignment.

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 7 3/16 inches 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

Name Description

Shipping

$6,800

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? No
New Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Slot
Number of Stations Supported 1
Number of Panels/Bays 24
Lower Limit 650.00 MHz
Upper Limit 656.00 MHz
Design power capacity in use 100.0 %
Other Antenna Type N/A
ERP: 1000.0 kW
Manufacturer
Model TFU-24WB-R C160
Year 2018
Justification for New Antenna An interim antenna is necessary to keep station on air during primary antenna replacement & for duration of assigned phase. TFU-24WB cost is equivalent to a single-channel slot interim antenna. A TFU-24WB is required to replicate existing coverage.

Interim Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? B
Feed Line Size 6 1/8 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for an 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

Name Description

Shipping

$5,400

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 1400 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

TX Line Sweep

Sweep required to verify post-transition channel measures well on existing line.

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 Broadband
Other Segment Length
Number of parallel runs 1
Length 1250 feet per run
Justification for New Transmission Line Interim transmission line is necessary to keep station on air during primary antenna replacement & for duration of assigned phase. 6-1/8" rigid line is required to provide required power rating for replication ERP.

Interim Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

TX Line Sweep

Sweep required to verify new TX line measures well

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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Add 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? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1055705
Coordinates (NAD83) Latitude (NAD83) 43° 51' 30.0" N-
Longitude (NAD83) 070° 42' 39.0" W-
Overall Structure Height 1304.77 feet
Support Structure Height 1304.77 feet
Ground Elevation Above Mean Sea Level (AMSL) 1228.33 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Pacific and Southern, LLC
Date Constructed 01/01/1984


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 undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Major 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 It will be necessary to schedule and coordinate multiple vendors, complete progress reports, and update Schedule 399s. Station does not have available personnel or personnel trained in project management for such complex projects.
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 2
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 2
NEPA Section 106 environmental review No
Environmental Assessment No
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 Yes
Number of Days 20
Justification It will be necessary to survey the site, plan the equipment, develop specifications for purchasing, & oversee multiple vendor RF projects. Station does not have available personnel or personnel trained in such services.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Pre filing site review

outside engineering firm to review all sites

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 No
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? 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

Name Description

Internal labor

Local and Corporate Labor

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 $1,528,200.00 $1,454,900.00 N/A $0.00 N/A
Total for all systems $3,503,402.00 $3,361,917.00 N/A $0.00 N/A
Primary Transmitter ULXTE 72 $1,528,200.00 $1,454,900.00 $0.00
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,473,000.00 $1,400,000.00 N/A N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $5,200.00 $4,900.00 N/A N/A N/A
Other Electrical Service: Additional electrical services required for transmitter installation, including heat exchangers, transformers, cooling pumps, etc. $25,000.00 $25,000.00 Additional electrical services required for transmitter installation, including heat exchangers, transformers, cooling pumps, etc. N/A N/A
Other -- Building Addition Size: 100.0 $25,000.00 $25,000.00 New pad required for heat exchangers, transformers, pumps, etc. Equipment must also be shielded. 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 $497,560.00 $492,680.00 N/A $0.00 N/A
Total for all systems $3,503,402.00 $3,361,917.00 N/A $0.00 N/A
Interim Antenna TFU-24WB-R C160 $214,720.00 $212,280.00 $0.00
Shipping $5,400.00 $5,400.00 N/A N/A N/A
UHF - High Power, Side Mount, basic slot antenna, 24 bay,, 1000 kW input, directional,, horizontally polarized $160,480.00 $160,480.00 N/A N/A N/A
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed) $13,700.00 $13,000.00 N/A N/A N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,260.00 $5,000.00 Per Widelity estimate N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $22,000.00 Per Widelity estimate N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 Per Dielectric quotes N/A N/A
Primary Antenna TFU-26DSC-R 4C150 $282,840.00 $280,400.00 $0.00
Shipping $6,800.00 $6,800.00 N/A N/A N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,260.00 $5,000.00 Per Widelity estimate N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $22,000.00 Per Widelity estimate N/A N/A
Elbow complex, single channel, at antenna input, per 7 3/16. feedline (if needed) $13,900.00 $13,200.00 Per Widelity estimate N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 per Widelity estimate N/A N/A
UHF - High Power, Side Mount, basic slot antenna, 775 kW input, directional,, horizontally polarized $227,000.00 $227,000.00 Per Widelity estimate. 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 $302,800.00 $289,050.00 N/A $0.00 N/A
Total for all systems $3,503,402.00 $3,361,917.00 N/A $0.00 N/A
Interim Transmission Line $296,400.00 $282,650.00 $0.00
Rigid Transmission Line - copper, 6 1/8" broadband $290,000.00 $276,250.00 N/A N/A N/A
TX Line Sweep $6,400.00 $6,400.00 N/A N/A N/A
Primary Transmission Line $6,400.00 $6,400.00 $0.00
TX Line Sweep $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 $657,800.00 $625,000.00 N/A $0.00 N/A
Total for all systems $3,503,402.00 $3,361,917.00 N/A $0.00 N/A
Primary Tower TOWER $657,800.00 $625,000.00 $0.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $25,000.00 N/A N/A N/A
Major tower reinforcement/modifications $421,000.00 $400,000.00 N/A N/A N/A
Tall Tower (greater than 500') $210,500.00 $200,000.00 Per Widelity estimate 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 $376,900.00 $360,750.00 N/A $0.00 N/A
Total for all systems $3,503,402.00 $3,361,917.00 N/A $0.00 N/A
Outside Professional Services $376,900.00 $360,750.00 $0.00
Project management of the transition $158,000.00 $150,000.00 It will be necessary to schedule and coordinate multiple vendors, complete progress reports, and update Schedule 399s. Station does not have available personnel or personnel trained in project management for such complex projects. N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 Per Widelity estimate 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
ASR modification (prepare FCC Form 854) $2,105.00 $2,000.00 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 $2,000.00 N/A N/A N/A
Additional Field Engineering Service, 20 Days $50,000.00 $50,000.00 $2,500 per site visit including expenses x 20 days. It is necessary to survey the site, plan the equipment, develop specifications for purchasing, & oversee multiple vendor RF projects. Station does not have available personnel trained in such services. N/A N/A
Pre filing site review $23,000.00 $23,000.00 N/A N/A N/A
RF Exposure Measurements $21,050.00 $20,000.00 Per Widelity estimate N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 Per Widelity estimate N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $7,360.00 $7,000.00 Per Widelity estimate N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 Per Widelity estimate N/A N/A
Prepare request for Special Temporary Authorization $4,100.00 $3,000.00 Per Widelity estimate N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 per Widelity estimate N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 Per Widelity estimate N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 Per Widelity estimate N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 Per Widelity estimate 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 $140,142.00 $139,537.00 N/A $0.00 N/A
Total for all systems $3,503,402.00 $3,361,917.00 N/A $0.00 N/A
Other Expenses $140,142.00 $139,537.00 $0.00
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
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
Non-zoning permits $25,000.00 $25,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $25,000.00 $25,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $25,000.00 $25,000.00 N/A N/A N/A
Internal labor $24,052.00 $24,052.00 N/A N/A N/A
MVPD Notification of Channel Change $6,000.00 $6,000.00 Execute communication plan to the MVPD's about the up coming changes and testing dates. N/A N/A
Develop and air announcement of upcoming channel change $6,000.00 $6,000.00 40 hours at $150 per hour to shoot, edit, and post spot for audience awareness. N/A N/A
Equipment Storage $15,000.00 $15,000.00 Six months of storage per Dielectric rate card for 2 flatbeds of equipment. N/A N/A
Local Zoning $900.00 $900.00 3 cents per hundred for construction permit. N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 Per Widelity estimate 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 $3,503,402.00 $3,361,917.00 $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.

William T. Godfrey , Jr. .

Consulting Engineers


05/10/2018

Attachments

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