Go to the Federal Communications Commission homepage at www.fcc.gov

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:
6837
Service:
DCA
Call Sign:
WJYL-CD
Channel:
29 (UHF)
File Number:
0000025705
FRN:
0026483859
Date Submitted:
05/31/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WJYL, LLC

Doing Business As: WJYL, LLC

John W. Smith Jr.

5555 Arnie Loop

Lakewood Ranch, FL 34211

United States

+1 (502) 693-3146 jwschampion@mac.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

Greg Best

Consulting Engineer

Greg Best Consulting, Inc.

Greg Best

16100 Outlook Avenue

Stilwell, KS 66085

United States

+1 (816) 792-2913 gbconsulting54@gmail.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 See attached transition plan document. Tower owner will not make modifications to meet upgraded standard. Station must relocate to new tower.

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 SC500UB
Year 2005
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.2 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? No
Manufacturer
Model ULXTE-6
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 4.3 kW
Justification for New Transmitter Existing Screen Service transmitter manufacturer no longer in business.

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) Yes
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring Yes
Size 2 inches
Length 75.0 feet
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

Information not provided.

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use N/A
Change Type Purchase
Manufacturer
Model ULXTE-2
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 1.4 kW
Justification for New Transmitter This transmitter replaces an existing backup transmitter. Existing backup transmitter supplier is no longer in business.

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) Yes
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring Yes
Size 2 inches
Length 75.0 feet
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
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

Information not provided.

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: 9.55 kW
Manufacturer
Model PSILPOI16
Year 2005

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 Types 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: 15.0 kW
Manufacturer
Model AL12O-29-PM
Year 2019
Justification for New Antenna Existing slot antenna will not operate on repacked channel.

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

Name Description

Scattering Analysis

Scattering analysis for new WJYL slot 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 Flexible Air
Diameter 3 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 325 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 Flexible Air
Diameter 3 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 825 feet per run
Justification for New Transmission Line Station is moving to a new tower and it is more economical to install new t-line than to try to move existing T-Line, add another length to it, and install on the the new tower.

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 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? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1052448
Coordinates (NAD83) Latitude (NAD83) 38° 22' 10.1" N-
Longitude (NAD83) 085° 49' 45.5" W-
Overall Structure Height 517.71 feet
Support Structure Height 517.71 feet
Ground Elevation Above Mean Sea Level (AMSL) 989.82 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner P & B TOWERS, LLC
Date Constructed 04/01/2002

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
6838 WWJS-CD 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

Name Description

Tower Structure Analysis

Structure Analysis for new tower.

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 180
Explanation Supervision of Antenna and Transmitter installation and commissioning, and coordination of electrical contractor, tower rigging, and other normal site-related expenses.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification 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 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? No
Does this relocation require Equipment Storage? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

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 $443,820.36 $440,795.36 N/A $0.00 N/A
Total for all systems $813,725.36 $813,826.36 N/A $21,934.85 N/A
Interim Transmitter ULXTE-2 $178,943.00 $177,893.00 $0.00
UHF - Liquid Cooled Solid State Transmitter 1.4 kW $138,793.00 $138,793.00 See quote attachment for backup transmitter to replace existing backup transmitter that is no longer supported. N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $1,950.00 $1,950.00 N/A N/A N/A
Switchgear - industrial 800 amp $38,200.00 $37,150.00 N/A N/A N/A
Primary Transmitter ULXTE-6 $264,877.36 $262,902.36 $0.00
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $1,950.00 $1,875.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 4.3 kW $224,727.36 $224,727.36 Please see attached quote Q-78272 from GatesAir $0.00 z

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 $37,830.00 $23,631.00 N/A $0.00 N/A
Total for all systems $813,725.36 $813,826.36 N/A $21,934.85 N/A
Primary Antenna AL12O-29-PM $37,830.00 $23,631.00 $0.00
Scattering Analysis $4,800.00 $4,800.00 See quote attachment for WJYL Scattering Analysis. N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $12,431.00 See quote attachment for primary antenna from ERI. Antenna is Hpol only. $0.00 N/A

Components

Actual Information Description File Name
Scattering Analysis Information not provided.
Sweep test of existing antenna Information not provided.
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
Please deny this invoice
Amount:
N/A

Component Description:
Please deny this invoice
Amount:
N/A

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 $48,675.00 $0.00 N/A $0.00 N/A
Total for all systems $813,725.36 $813,826.36 N/A $21,934.85 N/A
Primary Transmission Line $48,675.00 $0.00 $0.00
Flexible Air Transmission Line - dielectric, 3" $48,675.00 N/A N/A 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 $211,900.00 $201,400.00 N/A $1,400.00 N/A
Total for all systems $813,725.36 $813,826.36 N/A $21,934.85 N/A
Primary Tower GTOWER $0.00 $0.00 $0.00
Primary Tower TOWER $211,900.00 $201,400.00 $1,400.00
Tower Structure Analysis $1,400.00 $1,400.00 N/A $1,400.00 N/A
Tall Tower (greater than 500') $210,500.00 $200,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Tower Structure Analysis

Component Description:
Old Wave Tower Structure Analysis for WJYL-CD Change to channel 29 repack
Amount:
$1,400.00
Tall Tower (greater 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 $53,420.00 $135,485.00 N/A $20,534.85 N/A
Total for all systems $813,725.36 $813,826.36 N/A $21,934.85 N/A
Outside Professional Services $53,420.00 $135,485.00 $20,534.85
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
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $1,122.00 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
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $1,750.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $1,662.50 N/A
Project management of the transition $28,440.00 $111,675.00 Widelity Strategic Support Quote $16,000.35 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 $2,560.00 N/A N/A N/A

Components

Actual Information Description File Name
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:
Legal services for filing repack application for WJYL-CD and review of original form 399.
Amount:
$1,122.00

Component Description:
WJYL CD itemized legal fees invoice. Showing hours and rate per FCC request.
Amount:
$1,122.00

Component Description:
HARDY CAREY CHAUTIN BALKIN LLP LEGAL FEES REVISED 3/23/18. SHOWING HOURLY RATE, TOTAL AND FACILITY ID NUMBER. ORIGINAL FORM PREPARATIONS AND CP
Amount:
$1,122.00
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:
Preparation of form 399 and preparation of original CP application.
Amount:
$1,750.00

Component Description:
Engineering services for repack for WJYL-CD application CP and original form 399.
Amount:
$1,312.50

Component Description:
Revised Engineering invoice for all initial preparation of CP and Form 399 for WJYL CD per FCC request.
Amount:
$1,750.00
Perform engineering study for new channel assignment and antenna development

Component Description:
Engineering Repack Services
Amount:
$1,225.00

Component Description:
Review system design, transmitter and antenna quotes.
Amount:
$437.50

Component Description:
Engineering Repack Services
Amount:
$437.50
Project management of the transition

Component Description:
Project Management
Amount:
$3,451.55

Component Description:
Project Management
Amount:
$2,827.85

Component Description:
Project Management
Amount:
$3,241.10

Component Description:
Project Management
Amount:
$4,359.45

Component Description:
Project Management
Amount:
$2,120.40
Prepare and or review reimbursement form Information not provided.
Address transition timing and coordination issues w/ other stations and wireless 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 $18,080.00 $12,515.00 N/A $0.00 N/A
Total for all systems $813,725.36 $813,826.36 N/A $21,934.85 N/A
Other Expenses $18,080.00 $12,515.00 $0.00
MVPD Notification of Channel Change $3,000.00 $3,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $1,500.00 $1,500.00 N/A N/A N/A
Equipment Storage N/A N/A N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $1,500.00 $1,500.00 N/A N/A N/A
Non-zoning permits N/A N/A 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 $6,000.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $813,725.36 $813,826.36 $21,934.85

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.

DAVID B. SMITH , SR .

GM/REPACK MANAGER


05/31/2019

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.

DAVID B. SMITH , SR .

GM/REPACK MANAGER


05/31/2019

Attachments

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