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:
0000028732
FRN:
0018223693
Facility ID:
10976
Repack Channel:
13 (High VHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
12/03/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GRAY TELEVISION LICENSEE, LLC

Robert Folliard

PO Box 30319

Atlanta, GA 30319

United States

+1 (202) 750-1585 Robert.Folliard@gray.tv 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

Samuel Hariton

Widelity

Samuel Hariton

4031 University Dr

Suite 100

Fairfax, VA 22030

United States

+1 (339) 222-8107 sam.hariton@widelity.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 WVFX will be replacing the existing main transmitter, antenna, and transmission line. The station will also be installing a full interim system.

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  
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 TXU-300D
Year 2007
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 3 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
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 4.8 kw
Other Transmitter Type  
Justification for New Transmitter Existing Transmitter is Out of Band For ch13 and Mosfets are no longer made.

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 Yes
Description The new transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size 5 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  

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Tagline Clearance

Tree/Brush Removal for tag line

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 Broadband Panel
Number of Stations Supported 1
Number of Panels 8
Design power capacity in use 100.0 %
Lower Limit 174.00 MHz
Upper Limit 216.00 MHz
Other Antenna Type N/A
ERP: 30.00 kW
Manufacturer
Model SWDDP3-1-3-1/10
Year 2008

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 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: 30.00 kW
Manufacturer
Model THV-5A 13-R P220 SM
Year 2017
Justification for New Antenna Lacking documentation for retune viability

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 3 1/8 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? 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

Sweep Existing Transmission Line

Sweep test of existing antenna and transmission line

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 3 1/8 inches
Segment Length 19 ½ '
Other Segment Length
Number of parallel runs 1
Length 640 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 3 1/8 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 650 feet per run
Justification for New Transmission Line Existing Line is in 20' sections Ch13 requires 19 1/2' sections.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1034466
Coordinates (NAD83) Latitude (NAD83) 39° 18' 02.0" N-
Longitude (NAD83) 080° 20' 36.0" W-
Overall Structure Height 632.21 feet
Support Structure Height 600.06 feet
Ground Elevation Above Mean Sea Level (AMSL) 1359.89 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Gray Television Group, Inc.
Date Constructed 10/26/1992


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: 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 900
Explanation Strategic Support
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 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 Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification Yes
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 Yes
RF Field Engineering Services Comprehensive coverage verification via field study No
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 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? No
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

Security

Site security during transition

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 $184,008.94 $184,008.94 N/A $8,560.00 N/A
Total for all systems $1,321,871.94 $1,282,562.94 N/A $60,293.65 N/A
Primary Transmitter VAXTE $184,008.94 $184,008.94 $8,560.00
High VHF - Air Cooled Solid State Transmitter 4.8 kW $157,873.94 $157,873.94 N/A N/A N/A
Other Electrical Service: The new transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors. $10,600.00 $10,600.00 N/A N/A N/A
Other -- HVAC Service Type: H Size:5 (Other) $6,975.00 $6,975.00 See Jackson Heating & Air quote N/A N/A
Tagline Clearance $8,560.00 $8,560.00 See attached Dogwood Tree Service Tagline Clearance Invoice #5620 $8,560.00 N/A

Components

Actual Information Description File Name
High VHF - Air Cooled Solid State Transmitter 4.8 kW Information not provided.
Other Electrical Service: The new transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors. Information not provided.
Other -- HVAC Service Type: H Size:5 (Other) Information not provided.
Tagline Clearance

Component Description:
Professional Services
Amount:
$8,560.00

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 $196,495.00 $186,839.00 N/A $3,009.00 N/A
Total for all systems $1,321,871.94 $1,282,562.94 N/A $60,293.65 N/A
Primary Antenna THV-5A 13-R P220 SM $196,495.00 $186,839.00 $3,009.00
Sweep Existing Transmission Line $3,009.00 $3,009.00 See attached invoice for sweep test of existing antenna and transmission line $3,009.00 N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $22,550.00 $13,600.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 3 1/8. feedline (if needed) $7,580.00 $7,024.00 N/A N/A N/A
High VHF - High Power Side Mount One Station horizontally polarized $156,806.00 $156,806.00 DTVPros quote JEHQ1264-01 N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A

Components

Actual Information Description File Name
Sweep Existing Transmission Line

Component Description:
transmission line and antenna inspection
Amount:
$3,009.00
Side mount brackets for high power antennas (if not included in antenna base cost) Information not provided.
Elbow complex, single channel, at antenna input, per 3 1/8. feedline (if needed) Information not provided.
High VHF - High Power Side Mount One Station horizontally polarized Information not provided.
Sweep test of existing antenna 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 $65,650.00 $64,000.00 N/A $0.00 N/A
Total for all systems $1,321,871.94 $1,282,562.94 N/A $60,293.65 N/A
Primary Transmission Line $65,650.00 $64,000.00 $0.00
Rigid Transmission Line - copper, 3 1/8" $65,650.00 $64,000.00 Catalog Cost 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 $626,800.00 $612,000.00 N/A $6,850.00 N/A
Total for all systems $1,321,871.94 $1,282,562.94 N/A $60,293.65 N/A
Primary Tower TOWER $626,800.00 $612,000.00 $6,850.00
Major tower reinforcement/modifications $409,500.00 $400,000.00 N/A $0.00 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 $12,000.00 N/A $6,850.00 N/A

Components

Actual Information Description File Name
Major tower reinforcement/modifications Information not provided.
Tall Tower (greater than 500') Information not provided.
Structural engineering tower load study for well documented tower

Component Description:
Tower Mapping
Amount:
$6,850.00

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 $164,970.00 $160,750.00 N/A $41,874.65 N/A
Total for all systems $1,321,871.94 $1,282,562.94 N/A $60,293.65 N/A
Outside Professional Services $164,970.00 $160,750.00 $41,874.65
ASR modification (prepare FCC Form 854) $2,050.00 $2,000.00 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
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A $196.50 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
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A $1,425.00 N/A
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A $1,150.00 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
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A N/A N/A
Project management of the transition $138,600.00 $135,000.00 N/A $39,103.15 N/A

Components

Actual Information Description File Name
ASR modification (prepare FCC Form 854) 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

Component Description:
Professional Services
Amount:
$196.50
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:
Prepare engineering section of FCC Form 2100 Construction Permit Application
Amount:
$1,425.00
Perform engineering study for new channel assignment and antenna development

Component Description:
Perform engineering study for new channel assignment
Amount:
$1,150.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Prepare and or review reimbursement form Information not provided.
Project management of the transition

Component Description:
Cost Reconciliation
Amount:
$2,226.45

Component Description:
Project Management
Amount:
$2,019.35

Component Description:
Project Management
Amount:
$1,974.15

Component Description:
Project Management
Amount:
$2,223.75

Component Description:
Project Mgt
Amount:
$802.25

Component Description:
Project Mgt
Amount:
$1,968.80

Component Description:
Project Mgt
Amount:
$2,481.05

Component Description:
Project Management
Amount:
$2,190.25

Component Description:
Project Management
Amount:
$1,745.10

Component Description:
Project Management
Amount:
$1,970.00

Component Description:
Project Management
Amount:
$2,031.85

Component Description:
Transition Related Project Management Costs
Amount:
$3,000.00

Component Description:
Project Management
Amount:
$2,314.90

Component Description:
Project Mgt
Amount:
$28.20

Component Description:
Project Management
Amount:
$1,795.60

Component Description:
Project Management
Amount:
$2,231.90

Component Description:
Project Mgt
Amount:
$733.30

Component Description:
Project management
Amount:
$2,667.65

Component Description:
Project Mgt
Amount:
$801.45

Component Description:
Project management
Amount:
$1,966.05

Component Description:
Project Management
Amount:
$1,931.10

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 $83,948.00 $74,965.00 N/A $0.00 N/A
Total for all systems $1,321,871.94 $1,282,562.94 N/A $60,293.65 N/A
Other Expenses $83,948.00 $74,965.00 $0.00
Security $15,000.00 $15,000.00 N/A N/A N/A
MVPD Notification of Channel Change $1,000.00 $1,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $10,600.00 $10,600.00 N/A N/A N/A
Equipment Storage $19,500.00 $19,500.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $15,000.00 $15,000.00 See attached Disposal Quote N/A N/A
Non-zoning permits $10,000.00 $10,000.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $333.00 $325.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,070.00 $1,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $2,350.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,321,871.94 $1,282,562.94 $60,293.65

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 Folliard

Assistant Secretary


12/01/2018

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 Folliard

Assistant Secretary


12/01/2018

Attachments

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