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:
0000028546
FRN:
0024413338
Facility ID:
68395
Repack Channel:
30 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
02/21/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

FIFTH STREET ENTERPRISES, LLC

Doing Business As: FIFTH STREET ENTERPRISES, LLC

RON BRUNO

975 Greentree Rd.

Pittsburgh, PA 15220

United States

+1 (412) 921-7577 dawn@thevideohouse.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 The plan is to replace the existing channel 39 system with a retuned transmitter, a new channel 30 antenna, new 3" flex air line, and new filter.

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Retune Existing
Use Primary (Main)
Description of Use  
Ownership Owned
Owner  
Site  
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer Rohde & Schwarz
Model NV8605
Year 2012
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 3.5 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 4
New Exciter Is a new exciter needed? No
Exciter Type

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power
Rigid Conduit and Wiring No
Size
Length
Other Electrical Service No
Description  
HVAC Service Does the replacement transmitter require HVAC Service? No
Type
Size
Other Size  
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size
Channel 14 Costs Is an RF Consulting Engineer needed?
Is a channel 14 Mask Filer needed?
Is additional field engineering time needed?
Number of Days  

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Transmitter Retuning Cost

Retune existing 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? Yes
Is the existing antenna directional? No
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 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 Omni-directional
ERP: 15.00 kW
Manufacturer
Model KAT 750-10068
Year 2014

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

Facility ID Call Sign
272 WPTG-CD
68411 WIIC-LD

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 Class A
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization Circular
Type Broadband Slot
Number of Stations Supported 1
Number of Panels/Bays 1
Lower Limit 560.00 MHz
Upper Limit 626.00 MHz
Design power capacity in use 47.0 %
Other Antenna Type N/A
ERP: 12.50 kW
Manufacturer
Model TLP-12B BB C/P
Year 2017
Justification for New Antenna The existing antenna and combiner are used by station on channel 31, that is first adjacent to our newly assigned channel 30. The existing antenna and combiner will not work with first adjacent channels.

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? Yes
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.

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? Yes
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Air
Diameter 3 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 400 feet per run

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

Facility ID Call Sign
272 WPTG-CD
68411 WIIC-LD

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 Flexible Air
Diameter 3 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 400 feet per run
Justification for New Transmission Line A new transmission line will be necessary to support the new antenna, as the existing transmission line will continue to remain in use by the existing other stations on the existing antenna.

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 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) Yes
Others Types of Users Yes
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1022324
Coordinates (NAD83) Latitude (NAD83) 40° 26' 46.2" N-
Longitude (NAD83) 079° 57' 50.2" W-
Overall Structure Height 594.15 feet
Support Structure Height 516.07 feet
Ground Elevation Above Mean Sea Level (AMSL) 1164.68 feet
Structure Type LTOWER - Lattice Tower
Tower Owner WQED MULTIMEDIA
Date Constructed 08/01/1972

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
272 WPTG-CD DTV
41314 WINP-TV DTV
41315 WQED DTV
54002 WQED-FM FM
65681 WTAE-TV DTV
66636 WOSC-CD DTV
7622 WNNB-CD DTV
68405 WEPA-CD DTV

Other Types of Users

Users
WQMA386
KA2208
W244CU 139106
W271CW 158245
WQGN429
WIIC-LD 68411
WPDN-LD 68062
WPPQ574
WQBT460

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 tower with candelabra
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

Structural Analysis

Once the mapping is complete, a Structural analysis will need to be completed.

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 2000
Explanation WBYD does not have sufficient resource capacity and expertise in house to handle all of the Project Management related tasks necessary to facility on-time completion of the station's build by the Construction Deadline
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 No
For Auxiliary Facility N/A
For Main Facility N/A
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 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 Yes
RF exposure measurements Yes
Additional Field Engineering Service Yes
Number of Days 8
Justification RF Project management of tower and transmitter installs

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 Yes
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 No
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? 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

Name Description

Vehicle Rentals

Required for equipment delivery.

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 $116,686.00 $14,286.00 N/A $0.00 N/A
Total for all systems $1,316,314.00 $1,188,278.92 N/A $28,467.05 N/A
Primary Transmitter NV8605 $116,686.00 $14,286.00 $0.00
Transmitter Retuning Cost $8,596.00 $8,596.00 N/A N/A N/A
Other 4 kW mask filter $5,690.00 $5,690.00 N/A N/A N/A
UHF and VHF - minor banding issues $102,400.00 $0.00 N/A 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 $32,150.00 $30,843.00 N/A $0.00 N/A
Total for all systems $1,316,314.00 $1,188,278.92 N/A $28,467.05 N/A
Primary Antenna TLP-12B BB C/P $32,150.00 $30,843.00 $0.00
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $25,600.00 $24,443.00 Cost for H-pole and mounting equipment. See attached Dielectric quote. 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 $22,800.00 $23,504.92 N/A $0.00 N/A
Total for all systems $1,316,314.00 $1,188,278.92 N/A $28,467.05 N/A
Primary Transmission Line $22,800.00 $23,504.92 $0.00
Flexible Air Transmission Line - dielectric, 3" $22,800.00 $23,504.92 See attached Rohde & Schwarz quote. 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 $601,450.00 $588,000.00 N/A $0.00 N/A
Total for all systems $1,316,314.00 $1,188,278.92 N/A $28,467.05 N/A
Primary Tower LTOWER $601,450.00 $588,000.00 $0.00
Structural Analysis $19,000.00 $19,000.00 N/A N/A N/A
Minor tower reinforcement/modifications $153,500.00 $150,000.00 N/A N/A N/A
Structural engineering tower load study for a documented tower with candelabra $19,450.00 $19,000.00 N/A N/A N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $409,500.00 $400,000.00 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 $466,075.00 $454,750.00 N/A $28,467.05 N/A
Total for all systems $1,316,314.00 $1,188,278.92 N/A $28,467.05 N/A
Outside Professional Services $466,075.00 $454,750.00 $28,467.05
RF Exposure Measurements $20,500.00 $20,000.00 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
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet $10,240.00 $10,000.00 N/A N/A N/A
NEPA Section 106 environmental review, if needed $6,140.00 $6,000.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,095.00 $4,000.00 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
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $1,500.00 N/A $0.00 N/A
Project management of the transition $308,000.00 $300,000.00 N/A $24,317.05 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 $2,400.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A $1,750.00 N/A
Additional Field Engineering Service, 8 Days $16,000.00 $16,000.00 N/A N/A N/A

Components

Actual Information Description File Name
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet Information not provided.
NEPA Section 106 environmental review, if needed Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Project management of the transition

Component Description:
Project Management
Amount:
$2,723.45

Component Description:
Project Management
Amount:
$1,450.85

Component Description:
Technical , Consultation and Planning Services
Amount:
$75.00

Component Description:
Project Management
Amount:
$2,457.65

Component Description:
Re-pack consulting and updating
Amount:
$75.00

Component Description:
Project Management
Amount:
$1,733.70

Component Description:
Project Management
Amount:
$1,724.85

Component Description:
Technical , Consultation and Planning Services
Amount:
$75.00

Component Description:
Project Management
Amount:
$1,109.85

Component Description:
Project Management
Amount:
$2,204.70

Component Description:
Project Management
Amount:
$1,582.05

Component Description:
Project Management
Amount:
$1,414.15

Component Description:
Technical , Consultation and Planning Services. Attended a Conference at Rohde and Schwartz on 3/6/2017 concerning the 399 re-pack documentation.
Amount:
$75.00

Component Description:
Technical , Consultation and Planning Services. Review and answering technical questions through a telephone conference call for the follow up report for the Re-pack
Amount:
$75.00

Component Description:
Project Management
Amount:
$4,287.60

Component Description:
Project Management
Amount:
$1,397.30

Component Description:
Project Management
Amount:
$1,855.90
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:
Interference study of repack Ch 30
Amount:
$2,400.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Preparation of engineering portion of initial FCC Application for Construction Permit for repack facility; e-filing
Amount:
$1,750.00
Additional Field Engineering Service, 8 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 $77,153.00 $76,895.00 N/A $0.00 N/A
Total for all systems $1,316,314.00 $1,188,278.92 N/A $28,467.05 N/A
Other Expenses $77,153.00 $76,895.00 $0.00
Vehicle Rentals $5,000.00 $5,000.00 N/A N/A N/A
MVPD Notification of Channel Change $2,000.00 $2,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $15,000.00 $15,000.00 N/A N/A N/A
Equipment Storage $10,000.00 $10,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $15,000.00 $15,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $10,000.00 $10,000.00 N/A N/A N/A
Non-zoning permits $2,500.00 $2,500.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,070.00 $1,070.00 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
Local Zoning $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 $1,316,314.00 $1,188,278.92 $28,467.05

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.

Dawn Azua

production manager


02/21/2019

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.

Dawn Azua

Production Manager


02/21/2019

Attachments

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