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:
0000025939
FRN:
0001590330
Facility ID:
51207
Repack Channel:
33 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
04/10/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GULF-CALIFORNIA BROADCAST COMPANY

Doing Business As: GULF-CALIFORNIA BROADCAST COMPANY

PO Box 97701

ST. JOSEPH, MO 64501

United States

+1 (816) 271-8405 TIM.HANNAN@NPGCO.COM Corporation

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 Please see the attached narrative for KDFX-CD's transition plan.

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 ACT-5XU-560-A-C
Year 2014
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 0.56 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? Yes
Manufacturer
Model UAXTE-4R37
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 2.4 kw
Other Transmitter Type  
Justification for New Transmitter Current transmitter will be re-purpose for a different station/frequency due to technical capabilities. New transmitter is required to comply with the repack for this station.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
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

RF parts

Spare RF parts required for the transmitter deployment

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 Lease 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 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 Parapanel
ERP: 4.80 kW
Manufacturer SCA
Model 4DR-8S
Year 2014

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 Lease New
Is this a request for upgraded equipment? Yes
Ownership Leased
Owner KESQ-TV
Is antenna shared? Yes
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Type Class Full Power
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Broadband Panel
Number of Stations Supported 4
Number of Panels/Bays 8
Lower Limit 470.00 MHz
Upper Limit 700.00 MHz
Design power capacity in use 13.3 %
Other Antenna Type N/A
ERP: 15.00 kW
Manufacturer
Model SBB-E-8C170
Year 2018
Justification for New Antenna Existing Primary antenna cannot be re-tuned to the new transition frequency.

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? Yes
Type New
Number of channels supported 4
Frequencies of channels supported RF channel
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? No
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

Enter a list of RF channel numbers.

RF Channel Number
33
18
20
28

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Interim Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Interim
Description of Use N/A
Change Type Purchase New
Ownership Leased
Owner KESQ-TV
Is antenna shared? Yes
Is antenna directional? Yes
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 Broadband Panel
Number of Stations Supported 2
Number of Panels/Bays 8
Lower Limit 470.00 MHz
Upper Limit 872.00 MHz
Design power capacity in use 50.0 %
Other Antenna Type N/A
ERP: 20.80 kW
Manufacturer
Model 750 10402
Year 2018
Justification for New Antenna INTERIM ANTENNA IS REQUIRED TO FACILITATE ONGOING OPERATIONS AS TOWER WORK, NEW FEED LINE AND NEW ANTENNA IS INSTALLED.

Interim Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? Yes
Type New
Number of channels supported 2
Frequencies of channels supported RF channel
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? No
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

Enter a list of RF channel numbers.

RF Channel Number
42
39

Interim Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? No

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 Move Equipment
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1220472
Coordinates (NAD83) Latitude (NAD83) 33° 51' 58.1" N-
Longitude (NAD83) 116° 26' 05.0" W-
Overall Structure Height 88.91 feet
Support Structure Height 60.04 feet
Ground Elevation Above Mean Sea Level (AMSL) 1555.10 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Gulf-California Broadcast Co
Date Constructed 09/23/1968

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
25577 KESQ-TV DTV

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 595
Explanation Please see attached Widelity quote.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations No
Prepare or Review FCC Form 399 for Reimbursement 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 Yes
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

Name Description

Additional Repack Legal Services Not Otherwise Specified in Form 399

Non-Catalog Legal Services such as review of quarterly transition status reports and other miscellaneous non-catalog legal fees.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application 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? 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 $139,536.47 $57,919.03 N/A $29,637.39 N/A
Total for all systems $553,374.47 $286,038.60 N/A $63,737.55 N/A
Primary Transmitter UAXTE-4R37 $139,536.47 $57,919.03 $29,637.39
Service entrance 3 phase/800 amp/208 volt $14,050.00 $14,050.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $123,000.00 $41,382.56 Please see the attached GatesAir quote Q-76805 $27,957.56 N/A
RF parts $2,486.47 $2,486.47 Please see the attached Gatesair quote Q-76805 GatesAir invoice US0318631 $1,679.83 N/A

Components

Actual Information Description File Name
Service entrance 3 phase/800 amp/208 volt Information not provided.
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
UAXTE-4R37 High Efficiency TRA
Amount:
$1,107.56

Component Description:
UAXTE-4 Transmitter
Amount:
$13,425.00

Component Description:
UAXTE-4 Transmitter
Amount:
$13,425.00
RF parts

Component Description:
KDFX-CD-110-1st Primary Transmitter - New Gatesair transmitter - additional RF Parts
Amount:
$806.64

Component Description:
KDFX-CD-110-1st Primary Transmitter - New Gatesair transmitter - additional RF Parts
Amount:
$806.64

Component Description:
KDFX-CD-110-1st Primary Transmitter - New Gatesair transmitter - additional RF Parts
Amount:
$66.55

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 $169,840.00 $14,396.57 N/A $0.00 N/A
Total for all systems $553,374.47 $286,038.60 N/A $63,737.55 N/A
Interim Antenna 750 10402 $89,840.00 $0.00 $0.00
UHF - Lower Power Side Mount, Class A broadband panel (cost per panel) $9,840.00 $0.00 N/A N/A N/A
UHF – Broadband Panel, Side Mount Auxiliary/Interim, 21 horizontally polarized $0.00 $0.00 PHANTOM ANTENNA N/A N/A
New combiner, cost per channel (without antenna) $80,000.00 $0.00 Interim combiner cost being paid by KESQ-TV. Please see attached narrative for details. N/A N/A
Primary Antenna SBB-E-8C170 $80,000.00 $14,396.57 $0.00
UHF - High Power, Side Mount, broadband panel, 8 bay,, 15 kW input, directional,, elliptically or circularly polarized $0.00 $0.00 Leasing antenna from KESQ-TV at zero cost. Please see attached narrative for details. N/A N/A
New combiner, cost per channel (without antenna) $80,000.00 $14,396.57 22.5% of the cost of the combiner. Please see attached narrative and RFS quote 20067492 for details. N/A N/A

Components

Information not provided.

Cost Information

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Transmission Line

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 $81,900.00 $81,900.00 N/A $0.00 N/A
Total for all systems $553,374.47 $286,038.60 N/A $63,737.55 N/A
Primary Tower TOWER $81,900.00 $81,900.00 $0.00
Short Tower (less than 500') $81,900.00 $81,900.00 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 $146,570.00 $125,545.00 N/A $34,100.16 N/A
Total for all systems $553,374.47 $286,038.60 N/A $63,737.55 N/A
Outside Professional Services $146,570.00 $125,545.00 $34,100.16
Additional Repack Legal Services Not Otherwise Specified in Form 399 $5,000.00 $5,000.00 N/A $4,232.20 N/A
RF Exposure Measurements $20,500.00 $0.00 All RF Exposure Measurement costs will be apportioned to sister station KESQ-TV. Please see attached cover letter N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,585.00 $3,585.00 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 $3,179.36 N/A
Prepare request for Special Temporary Authorization $1,535.00 $1,535.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $1,000.00 N/A $1,000.00 N/A
Project management of the transition $91,630.00 $99,675.00 Please see attached quote from Widelity $23,922.50 N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A $1,078.60 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 $2,000.00 N/A $687.50 N/A

Components

Actual Information Description File Name
Additional Repack Legal Services Not Otherwise Specified in Form 399

Component Description:
Repack Legal Services for KDFX-CD
Amount:
$924.60

Component Description:
Repack Legal Services for KDFX-CD
Amount:
$907.00

Component Description:
Repack legal services
Amount:
$46.40

Component Description:
KDFX-CD-550-Attorney - Additional Repack Legal Services
Amount:
$721.40

Component Description:
Repack legal services
Amount:
$151.90

Component Description:
Non-Catalog Legal Services such as review of quarterly transition status reports and other miscellaneous non-catalog legal fees.
Amount:
$37.12

Component Description:
Repack Legal Services
Amount:
$27.84

Component Description:
Repack legal services
Amount:
$324.80

Component Description:
Repack legal services
Amount:
$46.40

Component Description:
Repack Legal Services
Amount:
$27.84

Component Description:
KDFX-CD-550-Attorney - Additional Repack Legal Services
Amount:
$403.60

Component Description:
Repack legal services
Amount:
$613.30
RF Exposure Measurements Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Filing legal services on KDFX C.P. year 2017.
Amount:
$888.00

Component Description:
General repack filing and follow up. See "Repack Invoice Cover Memo."
Amount:
$2,291.36
Prepare request for Special Temporary Authorization Information not provided.
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:
Engineering study work for new channel assignment and antenna development.
Amount:
$1,000.00
Project management of the transition

Component Description:
Project Management
Amount:
$3,887.15

Component Description:
Cost Reconciliation
Amount:
$5,344.95

Component Description:
Project Management
Amount:
$5,946.75

Component Description:
Project Management
Amount:
$1,250.80

Component Description:
Project Management
Amount:
$2,298.50

Component Description:
Project Managment
Amount:
$1,579.80

Component Description:
Project Management
Amount:
$1,037.80

Component Description:
Project Management
Amount:
$2,576.75
Prepare and or review reimbursement form

Component Description:
Repack Legal Services for KDFX-CD
Amount:
$218.00

Component Description:
Repack Legal Services for KDFX-CD
Amount:
$489.40

Component Description:
KDFX-CD-590-Prepare and/or Review Reimbursement Form
Amount:
$371.20
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:
"Calculation of replication transmitter power output requirement based on FCC issued replication facility effective radiated power."
Amount:
$250.00

Component Description:
Engineering study work for new channel assignment and antenna development.
Amount:
$375.00

Component Description:
Engineering study work for new channel assignment and antenna development.
Amount:
$62.50

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 $15,528.00 $6,278.00 N/A $0.00 N/A
Total for all systems $553,374.47 $286,038.60 N/A $63,737.55 N/A
Other Expenses $15,528.00 $6,278.00 $0.00
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 $750.00 $750.00 N/A N/A N/A
Equipment Storage $500.00 $500.00 N/A N/A N/A
Equipment Delivery and Handling Charges $500.00 $500.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $500.00 $500.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $2,000.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $333.00 $333.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $195.00 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 $553,374.47 $286,038.60 $63,737.55

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.

James W. DeChant

VP of Technology


04/10/2019

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.

James W. DeChant

VP of Technology


04/10/2019

Attachments

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