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:
0000028383
FRN:
0003593860
Facility ID:
49330
Repack Channel:
24 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
10/25/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

STATION VENTURE OPERATIONS, LP

Margaret L. Tobey

C/O NBCUNIVERSAL

300 NEW JERSEY AVENUE, N.W., SUITE 700

WASHINGTON, DC 20001

United States

+1 (202) 524-6401 MARGARET.TOBEY@NBCUNI.COM Limited Partnership

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

Margaret L Tobey

NBCUniversal, LLC

300 New Jersey Ave. NW

Suite 700

Washington, DC 20001

United States

+1 (202) 524-6401 Margaret.Tobey@nbcuni.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. Yes
Briefly describe transition plan Switch to aux transmitter and antenna. Retune main combiner filters and transmitter. After retuning remain on aux transmitter and antenna until operation can start on the new channel with the retuned main facility.

Question Response
Sharee Station Facility ID 35994
Call Sign KXTX-TV
Type Commercial
Licensee Name NBC TELEMUNDO LICENSE LLC
Status LICENSED
DTS No
Community of License DALLAS, TX
Pre-auction RF Channel 40
Post-auction RF Channel 36
Neilsen DMA Dallas-Ft. Worth
Network Affiliation

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 Rohde & Schwarz
Model THU9-72
Year 2017
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 78 kw
Other Transmitter Type  

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed  
New Mask Filter Power Other kw
Other Power 0
New Exciter Is a new exciter needed? No
Exciter Type

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

Name Description

Re channel Combiner

Rechannel Mask Filter/Combiner System (KXAS Portion)

Auxiliary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Auxiliary (Backup)
Description of Use Used to maintain coverage when main transmitter or antenna are unavailable
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
Model CTT-U-DCX
Year 1999
Type Inductive Output Tube
IOT Power Type Two
Description  
Power capacity 40 kw
Solid State Cooling  
Solid State Power Capacity  
Other Transmitter Type  

Auxiliary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Auxiliary (Backup)
Description of Use used to maintain coverage when main antenna or transmitter is unavailable
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model THU9-24
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 55 kw
Other Transmitter Type  
Justification for New Transmitter New transmitter required because the existing transmitter is End of Life (see attachment). Additionally, we have chosen a Solid State to replace this IOT as it is less expensive then a new IOT transmitter (details attached)

Auxiliary 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 Yes
Description Lighting Reconfiguration
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? 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  

Auxiliary Transmitter

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Other Transmitter Cost Not Listed

Name Description

50 kW filter

50 kW filter

Transmitter Installation

includes electrical, xmtr install with required RF modifications, commissioning and proof, and removal of existing Comark xmtr

Dehydrator

Dehydrator and gassing kit

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Auxiliary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Retune Existing
Antenna Use Auxiliary (Backup)
Description of Use Used to maintain coverage when main transmitter or antenna are unavailable
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? Yes
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 Broadband Panel
Number of Stations Supported 2
Number of Panels 18
Design power capacity in use 50.0 %
Lower Limit 470.00 MHz
Upper Limit 698.00 MHz
Other Antenna Type N/A
ERP: 353.00 kW
Manufacturer Dielectric
Model TUA-C3-6/18U-1-R DC SM
Year 2009

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID Call Sign
35994 KXTX-TV

Auxiliary Antenna

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Adjustment to Existing Antenna

Section Question Response
Sweep Test of Existing Antenna Do you need a sweep test of existing antenna? Yes

Auxiliary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? Yes
Type New
Number of channels supported 2
Frequencies of channels supported upper and lower frequency
Frequency 470.0 MHz - 698.0 MHz

Auxiliary 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

Auxiliary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Auxiliary (Backup)
Description of Use used to maintain coverage when primary antenna or transmitter is unavailavble
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? Yes
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Waveguide
Diameter
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 1530 feet per run

Facility ID's and Call Signs of all stations with whom the transmission line is shared.

Facility ID Call Sign
35994 KXTX-TV

Auxiliary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Auxiliary (Backup)
Description of Use used to maintain coverage when primary transmitter or antenna is unavalable
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Rigid
Diameter 6 1/8 inches
Segment Length Broadband
Other Segment Length
Number of parallel runs 1
Length 1530 feet per run
Justification for New Transmission Line New transmission line required to support new channels for KXAS (ch 24) & KXTX (ch 36). The final cost will be split between both stations

Auxiliary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Move Equipment
Tower Use Primary (Main)
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 No
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 1054150
Coordinates (NAD83) Latitude (NAD83) 32° 35' 07.0" N-
Longitude (NAD83) 096° 58' 07.0" W-
Overall Structure Height 1504.90 feet
Support Structure Height 1400.90 feet
Ground Elevation Above Mean Sea Level (AMSL) 813.97 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner Telemundo of Texas LLC
Date Constructed 02/06/2017

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
35994 KXTX-TV DTV

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 320
Explanation Project oversight of transmitter install, electrical connectivity, tower work, and antenna installation. Additional time will be spent tracking financial and legal process and coordinating with other broadcasters
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development No
Prepare engineering section of Form FCC Construction Permit Application No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare engineering section of Form FCC License to Cover Application No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare request for Special Temporary Authority No
Quantity N/A
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 No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare request for Special Temporary Authority No
Quantity N/A
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 Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 20
Justification Ground level RF system design

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)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
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 $2,094,558.32 $826,038.12 N/A $751,154.28 N/A
Total for all systems $2,917,118.32 $1,271,677.12 N/A $948,719.60 N/A
Primary Transmitter THU9-72 $118,310.80 $39,464.80 $0.00
UHF and VHF - minor banding issues $102,400.00 $23,554.00 N/A N/A N/A
Other 0 kW mask filter $0.00 $0.00 Mask filtering is done the combiner with a tunable filter. A separate filter is not required. N/A N/A
Re channel Combiner $15,910.80 $15,910.80 N/A N/A N/A
Auxiliary Transmitter THU9-24 $1,976,247.52 $786,573.32 $751,154.28
Transmitter Installation $160,764.80 $160,764.80 see attached auxiliary installation proposal. $160,764.80 N/A
50 kW filter $30,387.65 $30,387.65 N/A $0.00 N/A
10 Ton system $37,900.00 $4,353.27 Cost split 50/50 between KXAS and KXTX $4,353.27 Filler
Other Electrical Service: Lighting Reconfiguration $1,163.69 $1,163.69 Costs split 50/50 between KXAS and KXTX $1,163.68 N/A
Dehydrator $5,031.38 $5,031.38 Cost split 50/50 between KXAS and KXTX for shared system N/A N/A
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW $1,741,000.00 $584,872.53 N/A $584,872.53 N/A

Components

Actual Information Description File Name
UHF and VHF - minor banding issues Information not provided.
Other 0 kW mask filter Information not provided.
Re channel Combiner Information not provided.
Transmitter Installation

Component Description:
Aux transmitter installation
Amount:
$80,382.40

Component Description:
Aux transmitter installation
Amount:
$80,382.40
50 kW filter Information not provided.
10 Ton system

Component Description:
Costs are split 50/50 between KXAS and KXTX. This is for half of the attached invoice.
Amount:
$4,353.27
Other Electrical Service: Lighting Reconfiguration

Component Description:
Costs split 50/50 between KXAS and KXTX
Amount:
$1,163.68
Dehydrator Information not provided.
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW

Component Description:
Transmitter and components. See invoice with supporting documentation attached.
Amount:
$584,872.53

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 $91,670.00 $86,750.00 N/A $875.00 N/A
Total for all systems $2,917,118.32 $1,271,677.12 N/A $948,719.60 N/A
Auxiliary Antenna TUA-C3-6/18U-1-R DC SM $91,670.00 $86,750.00 $875.00
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
New combiner, cost per channel (without antenna) $80,000.00 $80,000.00 N/A N/A N/A
Sweep test of existing antenna $6,550.00 $1,750.00 See line on attached quote $875.00 N/A
UHF – Broadband Panel, Side Mount Auxiliary/Interim, 353 horizontally polarized $0.00 $0.00 Re-use existing antenna after replacing waveguide with broadband coax. N/A N/A

Components

Actual Information Description File Name
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) Information not provided.
New combiner, cost per channel (without antenna) Information not provided.
Sweep test of existing antenna

Component Description:
See "antenna & transmission line sweep" on invoice
Amount:
$875.00
UHF – Broadband Panel, Side Mount Auxiliary/Interim, 353 horizontally polarized 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 $345,780.00 $108,661.00 N/A $97,794.90 N/A
Total for all systems $2,917,118.32 $1,271,677.12 N/A $948,719.60 N/A
Auxiliary Transmission Line $345,780.00 $108,661.00 $97,794.90
Rigid Transmission Line - copper, 6 1/8" broadband $345,780.00 $108,661.00 50% of total cost of $217,322, split with KXTX $97,794.90 N/A

Components

Actual Information Description File Name
Rigid Transmission Line - copper, 6 1/8" broadband

Component Description:
Half of lines 2-19
Amount:
$48,897.45

Component Description:
Half of lines 2-19
Amount:
$48,897.45

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 $205,000.00 $85,100.00 N/A $42,550.00 N/A
Total for all systems $2,917,118.32 $1,271,677.12 N/A $948,719.60 N/A
Primary Tower GTOWER $205,000.00 $85,100.00 $42,550.00
Tall Tower (greater than 500') $205,000.00 $85,100.00 See attached quote, first 2 lines plus "misc items" $42,550.00 N/A

Components

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

Component Description:
See all lines on invoice except sweep
Amount:
$42,550.00

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 $158,860.00 $150,878.00 N/A $52,095.42 N/A
Total for all systems $2,917,118.32 $1,271,677.12 N/A $948,719.60 N/A
Outside Professional Services $158,860.00 $150,878.00 $52,095.42
Project management of the transition $49,280.00 $48,000.00 N/A $44,326.46 N/A
Comprehensive coverage verification via field study, if needed $81,900.00 $80,000.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $378.00 N/A $378.00 N/A
Additional Field Engineering Service, 20 Days $20,000.00 $20,000.00 ground level RF engineering $6,955.00 N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A $435.96 N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
July 2018 Project Management Services
Amount:
$1,015.00

Component Description:
Project Management
Amount:
$4,650.00

Component Description:
June 2018 Project Management Services & Travel Expenses
Amount:
$11,394.10

Component Description:
Project management and travel expenses
Amount:
$12,810.91

Component Description:
Project Management Services
Amount:
$1,365.00

Component Description:
Project Management Services
Amount:
$975.00

Component Description:
Project Management Services
Amount:
$2,145.00

Component Description:
Project management
Amount:
$3,900.00

Component Description:
Project Management Services
Amount:
$348.95

Component Description:
Project Management Services
Amount:
$1,072.50

Component Description:
Project management
Amount:
$4,650.00
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
See lines 1 & 2 of invoice, less 10% vendor discount.
Amount:
$189.00

Component Description:
Preparation of minor change application
Amount:
$189.00
Additional Field Engineering Service, 20 Days

Component Description:
RFS Field Services to assist in combiner/filter retune
Amount:
$6,955.00
Prepare and or review reimbursement form

Component Description:
Review of Form 399
Amount:
$43.65

Component Description:
See lines 3-5 of invoice, less 10% vendor discount.
Amount:
$348.66

Component Description:
Review of Form 399
Amount:
$43.65

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 $21,250.00 $14,250.00 N/A $4,250.00 N/A
Total for all systems $2,917,118.32 $1,271,677.12 N/A $948,719.60 N/A
Other Expenses $21,250.00 $14,250.00 $4,250.00
MVPD Notification of Channel Change $0.00 $0.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $0.00 $0.00 N/A N/A N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $4,250.00 N/A $4,250.00 N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Delivery and Handling Charges Information not provided.
DTV Medical Facility Notification

Component Description:
Medical Notification Mailing
Amount:
$4,250.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $2,917,118.32 $1,271,677.12 $948,719.60

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.

Margaret L Tobey

Assistant Secretary


10/25/2018

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

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

  1. The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material.

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

  3. The above-named entity certifies that 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).

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

  5. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

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

  7. 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.

Margaret L Tobey

Assistant Secretary


10/25/2018

Attachments

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