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:
36717
Service:
DCA
Call Sign:
KSKJ-CD
Channel:
27 (UHF)
File Number:
0000027925
FRN:
0026907345
Date Submitted:
08/14/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

HC2 STATION GROUP, INC.

RENEE ILHARDT

450 PARK AVENUE 30TH FLOOR

NEW YORK, NY 10022

United States

+1 (954) 606-5486 RILHARDT@HC2BROADCASTING.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. No
Briefly describe transition plan Station plans to replace the filters, and re-tune the transmitter if possible.

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 ADT-1000
Year 2007
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity .35 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model TRN-5X-U-18-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 3 kW
Justification for New Transmitter The current transmitter cannot be retuned.

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) Yes
Power 150 kVA
Rigid Conduit and Wiring Yes
Size 1 inches
Length 60.0 feet
Other Electrical Service Yes
Description Provide and install 120/208 3 phase 4 wire 100amp panel board capable of supplying 110 and 108 power
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.

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Circular
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 2
Design power capacity in use 100.0 %
Lower Limit 548.00 MHz
Upper Limit 554.00 MHz
Other Antenna Type N/A
ERP: 1.0 kW
Manufacturer
Model 4DR-8S
Year 2004

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? No
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Circular
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 2
Lower Limit 548.00 MHz
Upper Limit 554.00 MHz
Design power capacity in use 100.0 %
Other Antenna Type N/A
ERP: 1.0 kW
Manufacturer
Model UTVC-01/X
Year 2019
Justification for New Antenna Station's repack was for new location in Mt Harvard. Equipment at original site at Granada Hills CA was not worth salvaging to move due to being discontinued by the manufacturer due to age/supportability.

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? 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? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Air
Diameter 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 150 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? Yes
Type Flexible Foam
Diameter 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 220 feet per run
Justification for New Transmission Line Station's repack was for new location in Mt Harvard. Equipment at original site at Granada Hills CA was not worth salvaging to move due to being discontinued by the manufacturer due to age/supportability.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1013606
Coordinates (NAD83) Latitude (NAD83) 34° 17' 03.0" N-
Longitude (NAD83) 118° 28' 20.0" W-
Overall Structure Height 269.03 feet
Support Structure Height 269.03 feet
Ground Elevation Above Mean Sea Level (AMSL) 1249.98 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Liberman Broadcasting, Inc.
Date Constructed 01/01/1990


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: No reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 260
Explanation Project management fee for the transition of one broadcaster for the tower and transmitter sub-projects. Scheduling and management of the timelines and schedules occurring during the repack.
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

Name Description

Project management expenses

Travel, per diem, lodging for on site visits for project management

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 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)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? No
Does this relocation require Equipment Storage? No
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? No

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 $263,252.00 $204,302.00 N/A $48,702.00 N/A
Total for all systems $482,783.00 $415,164.69 N/A $141,855.15 N/A
Primary Transmitter TRN-5X-U-18-C $263,252.00 $204,302.00 $48,702.00
Other Electrical Service: Provide and install 120/208 3 phase 4 wire 100amp panel board capable of supplying 110 and 108 power $5,000.00 $5,000.00 N/A $5,000.00 N/A
1" Rigid Conduit and Wiring $2,152.00 $2,152.00 N/A $2,152.00 N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $4,000.00 N/A $4,000.00 N/A
Switchgear - industrial 800 amp $38,200.00 $800.00 N/A $800.00 N/A
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW $155,600.00 $155,600.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 3 kW $36,750.00 $36,750.00 ***System Notice: Estimate adjusted and locked because line has been superseded.*** $36,750.00 N/A

Components

Actual Information Description File Name
Other Electrical Service: Provide and install 120/208 3 phase 4 wire 100amp panel board capable of supplying 110 and 108 power

Component Description:
Service entrance and other electrical service. #3441
Amount:
$5,000.00
1" Rigid Conduit and Wiring

Component Description:
Rigid Conduit cost. #3441
Amount:
$2,152.00
Transformer 3 phase/480v - 150 KVA

Component Description:
Transformer cost. #3441
Amount:
$4,000.00
Switchgear - industrial 800 amp

Component Description:
Switchgear cost. #3441
Amount:
$800.00
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW Information not provided.
UHF - Air Cooled Solid State Transmitter 3 kW

Component Description:
Transmitter cost, upgrade excluded. #7122-01
Amount:
$36,750.00

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 $35,550.00 $58,900.45 N/A $49,890.45 N/A
Total for all systems $482,783.00 $415,164.69 N/A $141,855.15 N/A
Primary Antenna UTVC-01/X $35,550.00 $58,900.45 $49,890.45
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $49,890.45 The total amount includes antenna, installation and shipping cost. See attached antenna quote from Kathrein. $49,890.45 N/A
UHF - Lower Power Side Mount, Class A broadband panel (cost per panel) $2,520.00 $2,460.00 N/A N/A N/A
Sweep test of existing antenna $6,730.00 $6,550.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
Antenna cost 50% down. #PO000047-INV
Amount:
$9,540.75

Component Description:
Antenna cost 50% balance. #185462
Amount:
$9,827.40

Component Description:
Antenna shipping cost. #35508747256
Amount:
$1,762.30

Component Description:
Installation 50% down. #46430
Amount:
$14,380.00

Component Description:
Installation 50% balance. #46485
Amount:
$14,380.00
UHF - Lower Power Side Mount, Class A broadband panel (cost per panel) Information not provided.
Sweep test of existing antenna 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 $5,280.00 $3,864.00 N/A $3,864.00 N/A
Total for all systems $482,783.00 $415,164.69 N/A $141,855.15 N/A
Primary Transmission Line $5,280.00 $3,864.00 $3,864.00
Flexible Foam Transmission Line - dielectric, 1 5/8" $5,280.00 $3,864.00 N/A $3,864.00 N/A

Components

Actual Information Description File Name
Flexible Foam Transmission Line - dielectric, 1 5/8"

Component Description:
Transmission line cost. #185327
Amount:
$3,864.00

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 $96,800.00 $83,100.00 N/A $1,200.00 N/A
Total for all systems $482,783.00 $415,164.69 N/A $141,855.15 N/A
Primary Tower TOWER $96,800.00 $83,100.00 $1,200.00
Short Tower (less than 500') $84,200.00 $81,900.00 N/A N/A N/A
Structural engineering tower load study for well documented tower $12,600.00 $1,200.00 N/A $1,200.00 N/A

Components

Actual Information Description File Name
Short Tower (less than 500') Information not provided.
Structural engineering tower load study for well documented tower

Component Description:
Tower analysis. #160125694
Amount:
$1,200.00

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 $67,460.00 $52,227.24 N/A $34,974.93 N/A
Total for all systems $482,783.00 $415,164.69 N/A $141,855.15 N/A
Outside Professional Services $67,460.00 $52,227.24 $34,974.93
Project management expenses $1,400.00 $1,400.00 On-site expenses for project management $372.69 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $125.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $0.00 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 $650.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $2,500.00 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A $2,500.00 N/A
Project management of the transition $41,080.00 $27,077.24 N/A $27,077.24 N/A

Components

Actual Information Description File Name
Project management expenses

Component Description:
Trip Expenses Dallas to LA to gather info for repack project planning and 399 estimate preparation.
Amount:
$372.69
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:
Review of initial post-auction baseline construction permit application
Amount:
$125.00
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:
Prepare engineering section of initial post-auction baseline construction permit application
Amount:
$1,750.00
Perform engineering study for new channel assignment and antenna development

Component Description:
Perform engineering study for new channel assignment. Line item was $850, but reducing reimb. request to $650 to match fixed fee quote from vendor. We're absorbing the extra $200 out of pocket.
Amount:
$650.00
Prepare and or review reimbursement form

Component Description:
Fee for preparation of 399 Reimbursement Cost Estimates
Amount:
$2,500.00
Address transition timing and coordination issues w/ other stations and wireless

Component Description:
Transition and coordination related cost. #160125695
Amount:
$2,500.00
Project management of the transition

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 10 stations. #1140
Amount:
$1,503.60

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 20 stations. #1144
Amount:
$796.10

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #472568
Amount:
$985.76

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #1096
Amount:
$714.93

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #1112
Amount:
$521.40

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #1118
Amount:
$1,609.03

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #1116
Amount:
$1,254.03

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 10 stations. #1134
Amount:
$1,678.60

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 10 stations. #473121
Amount:
$2,044.14

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 10 stations. $1122
Amount:
$1,979.10

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #472232
Amount:
$901.10

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #471659
Amount:
$1,206.00

Component Description:
Project management ATC. #347965
Amount:
$9,480.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 10 stations. #1129
Amount:
$1,758.65

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 15 stations. #1104
Amount:
$644.80

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 $14,441.00 $12,771.00 N/A $3,223.77 N/A
Total for all systems $482,783.00 $415,164.69 N/A $141,855.15 N/A
Other Expenses $14,441.00 $12,771.00 $3,223.77
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $1,777.77 N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $0.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $1,446.00 $1,446.00 N/A $1,446.00 N/A

Components

Actual Information Description File Name
DTV Medical Facility Notification

Component Description:
Medical notification service. #INV-001857
Amount:
$1,777.77
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
Develop and air announcement of upcoming channel change

Component Description:
Announcement cost. #6113848997
Amount:
$504.00

Component Description:
Announcement cost. #6113921584
Amount:
$942.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $482,783.00 $415,164.69 $141,855.15

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.

Henry Turner

Chief Operating Officer


08/14/2019

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.

Henry Turner

Chief Operating Officer


08/14/2019

Attachments

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