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:
0000024804
FRN:
0015796022
Facility ID:
13993
Repack Channel:
8 (High VHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
12/04/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WSFA LICENSE SUBSIDIARY, LLC

Doing Business As: WSFA LICENSE SUBSIDIARY, LLC

201 MONROE STREET

RSA TOWER, 20TH FLOOR

MONTGOMERY, AL 36104

United States

+1 (334) 206-1400 fcclms@raycommedia.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

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. Yes
Briefly describe transition plan Install TLS-V interim antenna and connect to interim line Remove and replace top mounted antenna and connect to existing transmission line. Install new main and backup transmitters.

Transmitters

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Section Question Response
Transmitter Related Expenses Do you have transmitter related expenses? Yes

Auxiliary Transmitter

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Add Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Auxiliary (Backup)
Description of Use Emergency Backup
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 HTEL
Year 2008
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 1.1 kw
Other Transmitter Type  

Auxiliary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Auxiliary (Backup)
Description of Use Emergency Backup
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model VAXTE-2
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 1.6 kw
Other Transmitter Type  
Justification for New Transmitter Existing Transmitter can not be retuned Manufacturers letter 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) Yes
Transformer (480V) Yes
Power 150 kVA
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  

Auxiliary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

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  
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 Platinum
Year 2008
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 5 kw
Other Transmitter Type  

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Description of Use  
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model VAXTE-8
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 5.9 kw
Other Transmitter Type  
Justification for New Transmitter Exiting transmitter can not be retuned Manufacturers letter attached Headroom analysis attached

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 150 kVA
Rigid Conduit and Wiring No
Size
Length
Other Electrical Service No
Description  
HVAC Service Does the replacement transmitter require HVAC Service? No
Type
Size
Other Size  
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size
Channel 14 Costs Is an RF Consulting Engineer needed?
Is a channel 14 Mask Filer needed?
Is additional field engineering time needed?
Number of Days  

Primary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

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 single
Antenna position in stack Not in Stack
Polarization Horizontal
Type Other Type
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 Traveling Wave
ERP: 31.60 kW
Manufacturer
Model RCA/TW-12A12
Year 1992

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 Type Class Full Power
Mounting Top-mount single
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: 31.60 kW
Manufacturer
Model THV-10A8/VP-R 04
Year 2019
Justification for New Antenna Existing antenna can not be retuned V-pol upgrade not reimbursable

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

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 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: 31.60 kW
Manufacturer
Model TLS-V
Year 2019
Justification for New Antenna Use as transition antenna to allow for removal of existing Ch 12 antenna and installation of new repack Ch 8 antenna.

Interim Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? 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

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 Andrew
Type Rigid
Diameter 6 1/8 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 2050 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 Rigid
Diameter 4 1/16 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 1900 feet per run
Justification for New Transmission Line to feed interim antenna during main antenna change out

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? 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? No
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 31° 58' 29.0" N-
Longitude (NAD83) 086° 09' 44.1" W-
Overall Structure Height 1935.02 feet
Support Structure Height 1853.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 532.15 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner WSFA, LLC
Date Constructed 08/01/1977

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
8649 WZHT FM
73642 WCOV-TV DTV

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 300
Explanation Pattern analysis Antenna Spec Transmitter Spec Building drawings Installation Supervision Accounting Internal Legal
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 No
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements No
Additional Field Engineering Service 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 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? 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 $460,704.74 $385,490.81 N/A $39,643.62 N/A
Total for all systems $1,638,973.14 $1,450,954.11 N/A $95,519.47 N/A
Primary Transmitter VAXTE-8 $250,154.74 $248,704.74 $28,215.71
High VHF - Air Cooled Solid State Transmitter 5.9 kW $188,104.74 $188,104.74 Quote attached Headroom analysis attached $28,215.71 N/A
Switchgear - industrial 800 amp $37,150.00 $36,300.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $24,900.00 $24,300.00 N/A N/A N/A
Auxiliary Transmitter VAXTE-2 $210,550.00 $136,786.07 $11,427.91
High VHF - Air Cooled Solid State Transmitter 1.1 . 4.4 kW $148,500.00 $76,186.07 Quote attached $11,427.91 N/A
Switchgear - industrial 800 amp $37,150.00 $36,300.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $24,900.00 $24,300.00 N/A N/A N/A

Components

Actual Information Description File Name
High VHF - Air Cooled Solid State Transmitter 5.9 kW

Component Description:
Transmitter, Mask Filter Saystem, RF Accessories, Electrical, Installation & Proof
Amount:
$28,215.71
Switchgear - industrial 800 amp Information not provided.
Transformer 3 phase/480v - 150 KVA Information not provided.
High VHF - Air Cooled Solid State Transmitter 1.1 . 4.4 kW

Component Description:
Transmitter, Mask Filter Saystem, Electrical, Installation & Proof
Amount:
$11,427.91
Switchgear - industrial 800 amp Information not provided.
Transformer 3 phase/480v - 150 KVA 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 $342,718.40 $342,418.40 N/A $0.00 N/A
Total for all systems $1,638,973.14 $1,450,954.11 N/A $95,519.47 N/A
Interim Antenna TLS-V $58,473.40 $58,323.40 $0.00
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A
High VHF - High Power Side Mount One Station horizontally polarized $51,923.40 $51,923.40 Quote attached N/A N/A
Primary Antenna THV-10A8/VP-R 04 $284,245.00 $284,095.00 $0.00
High VHF - High Power Top Mount One Station elliptically or circularly polarized $277,695.00 $277,695.00 Quote attached E-Pol premium not included in cost N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 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 $262,200.00 $174,724.90 N/A $0.00 N/A
Total for all systems $1,638,973.14 $1,450,954.11 N/A $95,519.47 N/A
Interim Transmission Line $262,200.00 $174,724.90 $0.00
Rigid Transmission Line - copper, 4 1/16" $262,200.00 $174,724.90 Quote attached (see main antenna quote) 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 $370,800.00 $357,800.00 N/A $51,550.00 N/A
Total for all systems $1,638,973.14 $1,450,954.11 N/A $95,519.47 N/A
Primary Tower TOWER $370,800.00 $357,800.00 $51,550.00
Minor tower reinforcement/modifications $153,500.00 $150,000.00 N/A $51,550.00 N/A
Tall Tower (greater than 500') $205,000.00 $200,000.00 N/A N/A N/A
Structural engineering tower load study for well documented tower $12,300.00 $7,800.00 N/A N/A N/A

Components

Actual Information Description File Name
Minor tower reinforcement/modifications

Component Description:
Engineering, materials and project management services
Amount:
$51,550.00
Tall Tower (greater than 500') Information not provided.
Structural engineering tower load study for well documented tower 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 $154,980.00 $151,250.00 N/A $4,325.85 N/A
Total for all systems $1,638,973.14 $1,450,954.11 N/A $95,519.47 N/A
Outside Professional Services $154,980.00 $151,250.00 $4,325.85
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,535.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $1,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,560.00 $2,500.00 N/A N/A N/A
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 request for Special Temporary Authorization $3,585.00 $3,500.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,305.00 $2,250.00 N/A N/A N/A
Project management of the transition $46,200.00 $45,000.00 N/A $4,325.85 N/A

Components

Actual Information Description File Name
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), Construction Permit Application Information not provided.
Perform engineering study for new channel assignment and antenna development Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
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.
Project management of the transition

Component Description:
Project Management
Amount:
$2,002.45

Component Description:
Project Management
Amount:
$2,323.40

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 $47,570.00 $39,270.00 N/A $0.00 N/A
Total for all systems $1,638,973.14 $1,450,954.11 N/A $95,519.47 N/A
Other Expenses $47,570.00 $39,270.00 $0.00
Equipment Delivery and Handling Charges $2,970.00 $2,970.00 On site forklift rental estimate Representative quote attached N/A N/A
Equipment Storage $30,500.00 $30,500.00 Estimate for Dielectric on site antenna storage Dielectric letter attached N/A N/A
Develop and air announcement of upcoming channel change $2,850.00 $2,850.00 estimate for on air rescan announcement production Quote attached N/A N/A
MVPD Notification of Channel Change $0.00 $0.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $2,950.00 Group quote attached 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 $1,638,973.14 $1,450,954.11 $95,519.47

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.

Robert Thurber

VP, Engineering


12/04/2018

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.

Robert Thurber

VP, Engineering


12/04/2018

Attachments

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