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FCC Form 399: Reimbursement Request

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

(REFERENCE COPY - Not for submission) FCC Form 399: Reimbursement Request

Facility ID:
71329
Service:
DTV
Call Sign:
WDBJ
Channel:
30 (UHF)
File Number:
0000028727
FRN:
0018223693
Date Submitted:
02/04/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GRAY TELEVISION LICENSEE, LLC

Doing Business As: GRAY TELEVISION LICENSEE, LLC

Robert Folliard

4370 Peachtree Road

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 WDBJ will be replacing the existing main transmitter, antenna, and transmission line.

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model Sigma
Year 2000
Type Inductive Output Tube
IOT Power Type Two
Power Capacity 46 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 Parallax U32
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 55 kW
Justification for New Transmitter Harris Sigma series IOT transmitters cannot be retuned, transmitter must be replaced.

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 No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
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? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Construction

Existing building must be modified for new transmitter.

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 605.0 kW
Manufacturer
Model TFU-18GTH-R 04
Year 1999

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? No
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 1000.0 kW
Manufacturer
Model TFU-29JTH/VP-R 04
Year 2017
Justification for New Antenna Repack will move WDBJ to channel 30 so the existing channel 18 antenna needs replaced.

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? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Top Plate Adapter

Adapter for top of tower to match bolts on antenna

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? Yes

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 230 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 7 3/16 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 230 feet per run
Justification for New Transmission Line Utilizing existing antenna during build-out of new transmitter/antenna system. New transmission line needed.

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 1024378
Coordinates (NAD83) Latitude (NAD83) 37° 11' 42.0" N-
Longitude (NAD83) 080° 09' 22.0" W-
Overall Structure Height 148.62 feet
Support Structure Height 77.10 feet
Ground Elevation Above Mean Sea Level (AMSL) 3759.80 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Gray Television Group, Inc.
Date Constructed 06/01/1965


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 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 Yes
Environmental Assessment Yes
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 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)? 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

Name Description

Antenna Structure Registration Announcement

Antenna structure registration announcement in local newspaper

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 $2,179,424.52 $1,775,090.52 N/A $489,955.94 N/A
Total for all systems $3,080,889.00 $2,571,880.85 N/A $541,665.07 N/A
Primary Transmitter Parallax U32 $2,179,424.52 $1,775,090.52 $489,955.94
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW $1,788,000.00 $1,383,666.00 N/A $484,283.10 N/A
Construction $391,424.52 $391,424.52 N/A $5,672.84 N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW

Component Description:
1st Primary Transmitter System
Amount:
$484,283.10
Construction

Component Description:
Transmitter building project.
Amount:
$2,305.98

Component Description:
Transmitter building project: Complete interior and exterior measurements of existing Facility. These docs wil be used for Permits needed for renovations to construct New Transmitter Room.
Amount:
$3,366.86

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 $364,130.00 $303,739.00 N/A $0.00 N/A
Total for all systems $3,080,889.00 $2,571,880.85 N/A $541,665.07 N/A
Primary Antenna TFU-29JTH/VP-R 04 $364,130.00 $303,739.00 $0.00
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $289,500.00 $228,075.00 DTVPros quote JEHQ1247-04 N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 7 3/16. feedline (if needed) $13,900.00 $15,264.00 DTVPros quote JEHQ1247-04 N/A N/A
Top Plate Adapter $54,000.00 $54,000.00 DTVPros quote JEHQ1247-04 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 $66,700.00 $64,734.85 N/A $0.00 N/A
Total for all systems $3,080,889.00 $2,571,880.85 N/A $541,665.07 N/A
Primary Transmission Line $66,700.00 $64,734.85 $0.00
Rigid Transmission Line - copper, 7 3/16" $66,700.00 $64,734.85 DTVPros quote JEHQ1247-04 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 $254,800.00 $242,000.00 N/A $3,000.00 N/A
Total for all systems $3,080,889.00 $2,571,880.85 N/A $541,665.07 N/A
Primary Tower TOWER $254,800.00 $242,000.00 $3,000.00
Structural engineering tower load study for well documented tower $12,600.00 $12,000.00 N/A $3,000.00 N/A
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A N/A N/A
Short Tower (less than 500') $84,200.00 $80,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Structural engineering tower load study for well documented tower

Component Description:
AST to perform analysis on (1) 60' SS Tower utilizing VA PE
Amount:
$3,000.00
Minor tower reinforcement/modifications Information not provided.
Short Tower (less than 500') 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 $184,010.00 $161,750.00 N/A $48,374.65 N/A
Total for all systems $3,080,889.00 $2,571,880.85 N/A $541,665.07 N/A
Outside Professional Services $184,010.00 $161,750.00 $48,374.65
Project management of the transition $142,200.00 $135,000.00 N/A $41,429.65 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A 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
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $3,900.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,062.50 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $982.50 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A N/A
NEPA Section 106 environmental review, if needed $6,310.00 $1,000.00 N/A N/A N/A
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet $10,520.00 $2,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$1,895.60

Component Description:
Project Management
Amount:
$2,314.90

Component Description:
Project Management
Amount:
$1,931.30

Component Description:
Project Management
Amount:
$2,076.05

Component Description:
Project Management
Amount:
$2,152.35

Component Description:
Project management
Amount:
$2,116.05

Component Description:
Project management
Amount:
$2,397.65

Component Description:
Project Management
Amount:
$913.95

Component Description:
Project Management
Amount:
$2,157.60

Component Description:
Project Management
Amount:
$28.20

Component Description:
Project Management
Amount:
$2,536.05

Component Description:
Project Management
Amount:
$1,616.50

Component Description:
Project Management
Amount:
$733.30

Component Description:
Project Management
Amount:
$802.25

Component Description:
Transition Related Project Management Costs
Amount:
$3,300.00

Component Description:
Project Management
Amount:
$1,630.60

Component Description:
Project Management
Amount:
$2,019.15

Component Description:
Project Management
Amount:
$1,668.75

Component Description:
Project Management
Amount:
$2,373.10

Component Description:
Project Management
Amount:
$1,863.20

Component Description:
Project management
Amount:
$2,831.90

Component Description:
Project Management
Amount:
$2,071.20
Prepare and or review reimbursement form Information not provided.
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
Regarding repack Ch-30, review planned antenna specifications, provie comments and inquiry regarding tower height under construction.
Amount:
$175.00

Component Description:
Conduct review of repacked channel assignment and implementation with prospective antenna, discuss results.
Amount:
$1,875.00

Component Description:
Perform engineering study for new channel assignment
Amount:
$475.00

Component Description:
Conduct channel study of post-auction CH 30 for expansion created by increased ERP. Prep of engineering portions of FCC CP-MOD application.
Amount:
$1,375.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Prepared engineering section for CP application
Amount:
$2,062.50
Prepare engineering section of 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:
Complete and file first priority window construction permit filing for pop loss
Amount:
$196.50

Component Description:
Repack CP application
Amount:
$786.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
NEPA Section 106 environmental review, if needed Information not provided.
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet 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 $31,824.48 $24,566.48 N/A $334.48 N/A
Total for all systems $3,080,889.00 $2,571,880.85 N/A $541,665.07 N/A
Other Expenses $31,824.48 $24,566.48 $334.48
Antenna Structure Registration Announcement $334.48 $334.48 Antenna structure registration announcement in local paper. $334.48 N/A
MVPD Notification of Channel Change $1,500.00 $1,500.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $5,000.00 $5,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $6,800.00 $6,800.00 N/A N/A N/A
Non-zoning permits $5,000.00 $5,000.00 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 $335.00 $325.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $4,347.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A

Components

Actual Information Description File Name
Antenna Structure Registration Announcement

Component Description:
Antenna structure registration. Gives notice that on 09/13/2017, it filed an application with the FCC
Amount:
$334.48
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.
Non-zoning permits Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
DTV Medical Facility Notification Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $3,080,889.00 $2,571,880.85 $541,665.07

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.

Robert Folliard

Assistant Secretary


02/04/2019

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).

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

  2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

  3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

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

  5. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .

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

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

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

  9. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Robert Folliard

Assistant Secretary


02/04/2019

Attachments

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