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:
0000028691
FRN:
0018223693
Facility ID:
190915
Repack Channel:
36 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
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

50 NORTH MAIN STREET

HARRISONBURG, VA 22802

United States

+1 (540) 433-9191 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. Yes
Briefly describe transition plan The station will be replacing the main antenna and transmission line, retuning the main transmitter, and installing an interim transmitter while the main transmitter is being retuned.

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 Harris
Model UAX2000
Year 2013
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 2.2 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 2.5
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

Information not provided.

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use  
Change Type Lease New
Manufacturer
Model UAXT-3R37
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 1.5 kw
Other Transmitter Type  
Justification for New Transmitter Renting transmitter while main is being retuned.

Interim 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? 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  
Inside RF System Is an additional interior RF system required to support this interim transmitter? No

Interim Transmitter

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Other Transmitter Cost Not Listed

Name Description

HVAC

Additional HVAC for interim 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? 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 Class A
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 13.00 kW
Manufacturer
Model AL80-43 (Single Channel with Broadband Nulling System)
Year 2013

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? No
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Type Class Class A
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: 13.00 kW
Manufacturer
Model AL80-36
Year 2012
Justification for New Antenna Current Antenna cannot be retuned.

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? No

Primary 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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Add 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 this transmission currently shared with any other stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Andrew
Type Flexible Foam
Diameter 7/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 164 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

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 Flexible Foam
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 164 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 Flexible Foam
Diameter 1 5/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 2
Length 164 feet per run
Justification for New Transmission Line Required for the new channel 36 antenna while the channel 43 antenna is broadcasting.

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 Leased
Is this tower consider Complex? Candelabra
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) No
Others Types of Users Yes
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) 38° 23' 34.4" N-
Longitude (NAD83) 078° 46' 12.0" W-
Overall Structure Height 80.00 feet
Support Structure Height 80.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 2921.20 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Rockingham County, VA
Date Constructed 01/01/1979


Other Types of Users

Users
misc unlicensed
Emergency Radio
WVIR TV Trans

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 Candelabra
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Moving Equipment

Removing main antenna, installing a new antenna

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 712
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 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 Yes
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 Yes
Number of Days 5
Justification Yes. NRAO Compliance

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 No
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? 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 $240,756.70 $75,220.60 N/A $0.00 N/A
Total for all systems $1,056,249.70 $515,584.60 N/A $41,858.25 N/A
Interim Transmitter UAXT-3R37 $133,000.00 $57,664.00 $0.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $123,000.00 $47,664.00 Rental while the transmitter is being retuned 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. $5,000.00 $5,000.00 N/A N/A N/A
HVAC $5,000.00 $5,000.00 N/A N/A N/A
Primary Transmitter UAX2000 $107,756.70 $17,556.60 $0.00
UHF and VHF - minor banding issues $102,400.00 $12,199.90 N/A N/A N/A
Other 2.5 kW mask filter $5,356.70 $5,356.70 See attached GatesAir quote GA-00022587 N/A N/A

Components

Information not provided.

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $25,600.00 $3,840.00 N/A $0.00 N/A
Total for all systems $1,056,249.70 $515,584.60 N/A $41,858.25 N/A
Primary Antenna AL80-36 $25,600.00 $3,840.00 $0.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $25,600.00 $3,840.00 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 $7,872.00 $7,544.00 N/A $0.00 N/A
Total for all systems $1,056,249.70 $515,584.60 N/A $41,858.25 N/A
Interim Transmission Line $7,872.00 $7,544.00 $0.00
Flexible Foam Transmission Line - dielectric, 1 5/8" $7,872.00 $7,544.00 N/A N/A N/A
Primary Transmission Line $0.00 $0.00 $0.00
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 $601,860.00 $262,960.00 N/A $0.00 N/A
Total for all systems $1,056,249.70 $515,584.60 N/A $41,858.25 N/A
Primary Tower TOWER $601,860.00 $262,960.00 $0.00
Moving Equipment $26,560.00 $26,560.00 See attached Shenandoah Tower quote B17-1358 N/A N/A
Structural engineering tower load study for well documented tower $12,300.00 $6,400.00 N/A N/A N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $409,500.00 $80,000.00 Short tower with candelabra on top N/A N/A
Minor tower reinforcement/modifications $153,500.00 $150,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $148,183.00 $142,550.00 N/A $41,858.25 N/A
Total for all systems $1,056,249.70 $515,584.60 N/A $41,858.25 N/A
Outside Professional Services $148,183.00 $142,550.00 $41,858.25
Project management of the transition $109,648.00 $106,800.00 N/A $36,824.25 N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 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
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A $3,812.50 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A $1,025.00 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 request for Special Temporary Authorization $1,535.00 $1,500.00 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
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 - Negotiation of lease and other matters for shared locations $4,095.00 $2,000.00 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
Additional Field Engineering Service, 5 Days $5,000.00 $5,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$1,907.30

Component Description:
Project Management
Amount:
$2,067.45

Component Description:
Project Management
Amount:
$1,938.10

Component Description:
Project management
Amount:
$2,592.65

Component Description:
Project Management
Amount:
$2,406.05

Component Description:
Project Management
Amount:
$2,176.30

Component Description:
Project Management
Amount:
$28.20

Component Description:
Project Management
Amount:
$2,498.65

Component Description:
Project management
Amount:
$2,614.40

Component Description:
Project Management
Amount:
$1,743.75

Component Description:
Project Management
Amount:
$1,328.55

Component Description:
Project Management
Amount:
$802.25

Component Description:
Project Management
Amount:
$733.30

Component Description:
Project Management
Amount:
$988.95

Component Description:
Project Management
Amount:
$2,017.75

Component Description:
Project Management
Amount:
$1,698.10

Component Description:
Project Management
Amount:
$1,958.85

Component Description:
Project Management
Amount:
$2,262.90

Component Description:
Project Management
Amount:
$1,697.55

Component Description:
Transition Related Project Management Costs
Amount:
$1,500.00

Component Description:
Project Management
Amount:
$1,863.20
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:
Respond to query from NRAO Quiet Zone interference office for add'l detail of 11.4 kW 90 day facility. On receipt from NRAO, prepare amendment to pending 90 day FCC CP application.
Amount:
$437.50

Component Description:
Provide NRAO Quiet Zone interference office with specifications of substitute directional antenna
Amount:
$550.00

Component Description:
Perform engineering study for new channel assignment
Amount:
$250.00

Component Description:
Engineering for statement of consent application/new channel study
Amount:
$1,562.50

Component Description:
Review correspondence re: predicted interference to 11 GHz microwave system from Rural Broadband application, facilitate interference analysis, discuss with counsel, assist with prep of objections.
Amount:
$687.50

Component Description:
Perform engineering study for new channel assignment
Amount:
$325.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Perform engineering and develop exhibits for CP application
Amount:
$1,025.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Professional services: complete and file Repack Application for WSVF-CD
Amount:
$196.50
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Additional Field Engineering Service, 5 Days 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 $31,978.00 $23,470.00 N/A $0.00 N/A
Total for all systems $1,056,249.70 $515,584.60 N/A $41,858.25 N/A
Other Expenses $31,978.00 $23,470.00 $0.00
MVPD Notification of Channel Change $1,200.00 $1,200.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $3,000.00 $3,000.00 N/A N/A N/A
Equipment Storage $5,000.00 $5,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $2,755.00 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 - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
Non-zoning permits $6,000.00 $6,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 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 $1,056,249.70 $515,584.60 $41,858.25

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


02/04/2019

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


02/04/2019

Attachments

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