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:
22094
Service:
FM
Call Sign:
WINK-FM
File Number:
0000086736
FRN:
0004078598
Eligibility Status:
Eligible
Date Submitted:
12/17/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

FORT MYERS BROADCASTING COMPANY

Doing Business As: FORT MYERS BROADCASTING COMPANY

James L Davis Jr

2824 PALM BEACH BLVD.

FORT MYERS, FL 33916

United States

+1 (239) 479-5504 Jim.Davis@fmbcmail.org 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

Robert Gehman

Consulting Engineer

Kessler and Gehman Associates, Inc.

Robert Gehman

507 NW 60 St, Suite D

Gainesville, FL 32607

United States

+1 (352) 332-3157 bob@kesslerandgehman.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 FM antenna is top of stack mounted on repack station bottom of stack antenna, which will not accommodate the post-transition channel. Tower is in need of significant modifications, which may lead to a lower cost replacement and temporary FM relocation.

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)
Ownership Owned
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model HT-30
Year 1997
Type Other Type
Other Transmitter Type Tube
Power Capacity 30 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 FLX30K
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Model Type Analog
Solid State Power capacity 33 kW
Justification for New Transmitter Interim operation, which must be at adjacent site so the existing tower can be modified or replaced caused by the repack
Does the transmitter require the purchase of a new HD Importer? No
Does the transmitter require the purchase of a new HD Exporter? No

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Other Transmitter Costs Does the transmitter installation require an Additional Exciter? Yes
Does the transmitter installation require any additional transmitter installation costs? Yes
Does the transmitter installation require a Transmitter Building Site Survey/Installation? No
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) Yes
Transformer (480V) No
Rigid Conduit and Wiring Yes
Size 2 inches
Length 100.0 feet
Other Electrical Service No
HVAC Service Does the replacement transmitter require HVAC Service? No
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Other Transmitter-Related Expenses Does the replacement transmitter require a Remote Control? No
Does the replacement transmitter require an RDS Encoder? Yes
Does the replacement transmitter require Audio Processing? Yes
Audio Processing Analog Basic

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)
Ownership Owned
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
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Circular
Type Cross Dipole
ERP: 100.0 kW
Manufacturer
Model DCRC10CHV
Year 2006

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Change Type Purchase New
Ownership Owned
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
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Circular
Type Cross Dipole
ERP: 100.0 kW
Manufacturer
Model SHPX-12AC6-HW
Year 2019
Justification for New Antenna Interim operation, which must be at adjacent site so the existing tower can be modified or replaced caused by the repack

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 3 1/8 inches inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? Yes
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
FM Band Pass Filters Do you require an FM band pass filter? Yes
Notch Filter Do you require a Notch filter? No
De-Icers Do you require De-Icers? No
Radomes Do you require Radomes? No

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Antenna Installation

Antenna Installation

Full Scale Test Range Pattern Measurement

Full Scale Test Range Pattern Measurement

Custom Pole

Custom Pole

Lightning Dissipation Spur

Lightning Dissipation Spur

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)
Ownership Owned
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 Rigid
Diameter 3 1/8 inches
Segment Length 20 inches
Number of parallel runs 1
Length 1350 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Air
Diameter 3 inches
Number of parallel runs 1
Length 1350 feet per run
Justification for New Transmission Line Interim operation, which must be at adjacent site so the existing tower can be modified or replaced caused by the repack
Interior RF Systems Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators? Yes
Does the Installation of the Transmission Line require additional or replacement Inside RF system elbows, fitting, hangers, etc.? Yes

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)
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 1213076
Coordinates (NAD83) Latitude (NAD83) 26° 47' 08.7" N-
Longitude (NAD83) 081° 47' 45.9" W-
Overall Structure Height 1515.07 feet
Support Structure Height 1455.03 feet
Ground Elevation Above Mean Sea Level (AMSL) 28.87 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner American Towers LLC
Date Constructed 02/15/2002

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
41376 WLZE-LD LPD
61504 WXCW DTV
71580 WRXY-TV DTV
70649 WFTX-TV DTV

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 need for guyed or free-standing tower
Tower Reinforcements Please select whether tower reinforcements are needed: Major 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 40
Explanation Station requires outside assistance to handle the extra work caused by the repack-related activities
Outside RF consulting Engineering Services 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
Prepare Form 601 No
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 2
Negotiation of Lease and other Matter for Shared Locations Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Form 399 assistance or other program management costs Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 7
Justification Station requires on-site assistance to handle the extra work caused by the repack-related activities

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Other Engineering Services

Engineering services not specifically listed in the 399 Form

Other Legal Services

Legal services not specifically listed in the 399 Form

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Permit and Filing Costs FCC Construction Permit Major Change No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
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? No
Point to Point Microwave (STL/ICR) Frequency Coordination for Unidirection System No
Frequency Coordination for Bi-Direction System No
New Point to Point Microwave System Yes
Type 950 MHz Licensed Part 74 Systems
1 pair IP-only Codecs for fiber, internet or IP microwave systems 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 $316,550.00 $316,550.00 N/A $0.00 N/A
Total for all systems $1,073,922.00 $1,139,601.50 N/A $171,620.75 N/A
Primary Transmitter FLX30K $316,550.00 $316,550.00 $0.00
Other Transmitter-Related Expenses RDS Encoder $1,750.00 $1,750.00 N/A N/A N/A
Liquid Cooled Solid State Transmitter 33 kW Analog $188,000.00 $188,000.00 Interpolated between upper level of 30 and 40 kW air-cooled analog transmitters to estimate cost of 33 kW liquid cooled transmitter N/A N/A
Switchgear - industrial 800 amp $38,200.00 $38,200.00 N/A N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $2,600.00 $2,600.00 N/A N/A N/A
Additional exciter $12,000.00 $12,000.00 N/A N/A N/A
Transmitter Installation $70,500.00 $70,500.00 N/A N/A N/A
Audio Processing - Analog basic $3,500.00 $3,500.00 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 $335,149.50 $379,329.00 N/A $171,620.75 N/A
Total for all systems $1,073,922.00 $1,139,601.50 N/A $171,620.75 N/A
Primary Antenna SHPX-12AC6-HW $335,149.50 $379,329.00 $171,620.75
Lightning Dissipation Spur $600.00 $600.00 See attached / uploaded PDF file titled "ERI WINK-FM-1000 v191217jgv1.pdf" $300.00 N/A
Antenna Installation $212,994.00 $212,994.00 See attached / uploaded PDF file titled "ERI WINK-FM-1000 v191217jgv1.pdf" $106,497.00 N/A
Custom Pole $65,840.00 $65,840.00 See attached / uploaded PDF file titled "ERI WINK-FM-1000 v191217jgv1.pdf" $32,920.00 N/A
Full Scale Test Range Pattern Measurement $10,028.00 $10,028.00 See attached / uploaded PDF file titled "ERI WINK-FM-1000 v191217jgv1.pdf" $5,014.00 N/A
Pattern scatter analysis for side mount (if not included in antenna base cost) $0.00 $0.00 N/A N/A N/A
Side Mount antenna brackets $7,000.00 $7,000.00 Translators catalog reference N/A N/A
Elbow complex, 3 1/8 $7,600.00 $7,600.00 Translators catalog reference N/A N/A
Sweep test of existing antenna $5,730.00 $5,730.00 N/A N/A N/A
FM Band pass filter (depends on power input and number of sections) $15,757.50 $15,757.50 N/A N/A N/A
High Power 51 - 100 kW Circularly-polarized $9,600.00 $53,779.50 See attached / uploaded PDF file titled "ERI WINK-FM-1000 v191217jgv1.pdf" $26,889.75 N/A

Components

Actual Information Description File Name
Lightning Dissipation Spur

Component Description:
ERI WINK-FM-1000 Lightning spur v191217jgv1
Amount:
$300.00
Antenna Installation

Component Description:
ERI WINK-FM-1000 Antenna install v191217jgv1
Amount:
$106,497.00
Custom Pole

Component Description:
ERI WINK-FM-1000 Custom pole v191217jgv1
Amount:
$32,920.00
Full Scale Test Range Pattern Measurement

Component Description:
ERI WINK-FM-1000 Pattern meas v191217jgv1
Amount:
$5,014.00
Pattern scatter analysis for side mount (if not included in antenna base cost) Information not provided.
Side Mount antenna brackets Information not provided.
Elbow complex, 3 1/8 Information not provided.
Sweep test of existing antenna Information not provided.
FM Band pass filter (depends on power input and number of sections) Information not provided.
High Power 51 - 100 kW Circularly-polarized

Component Description:
ERI WINK-FM-1000 FM antenna v191217jgv1
Amount:
$26,889.75

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 $99,650.00 $99,650.00 N/A $0.00 N/A
Total for all systems $1,073,922.00 $1,139,601.50 N/A $171,620.75 N/A
Primary Transmission Line $99,650.00 $99,650.00 $0.00
Flexible Air Transmission Line - dielectric, 3" $79,650.00 $79,650.00 N/A N/A N/A
Interior RF Systems: Inside RF system including switching, patch panels and dehydrators $10,000.00 $10,000.00 N/A N/A N/A
Interior RF Systems: Elbows, fitting, hangers, etc. $10,000.00 $10,000.00 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 $171,450.00 $192,950.00 N/A $0.00 N/A
Total for all systems $1,073,922.00 $1,139,601.50 N/A $171,620.75 N/A
Primary Tower GTOWER $171,450.00 $192,950.00 $0.00
Tower Rigging Tall Tower (greater than 500') $157,750.00 $179,250.00 Interpolated catalog values above 1,000' to obtain cost for 1,250' antenna installation N/A N/A
Major tower reinforcement/modifications $5,000.00 $5,000.00 AMT Capital Contribution N/A N/A
Study needed for guyed or free-standing tower $8,700.00 $8,700.00 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 $112,317.50 $112,317.50 N/A $0.00 N/A
Total for all systems $1,073,922.00 $1,139,601.50 N/A $171,620.75 N/A
Outside Professional Services $112,317.50 $112,317.50 $0.00
Other Legal Services $10,000.00 $10,000.00 N/A N/A N/A
Other Engineering Services $10,000.00 $10,000.00 N/A N/A N/A
Additional Field Engineering Service, 7 Days $14,000.00 $14,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $52,600.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $4,470.00 $4,470.00 N/A N/A N/A
Attorney Fees - Negotiation of Lease and other matters for Shared Locations $1,280.00 $1,280.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,280.00 $1,280.00 N/A N/A N/A
Form 399 assistance or other Program Management costs $5,000.00 $5,000.00 N/A N/A N/A
Project management of the transition $4,220.00 $4,220.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A

Components

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 $38,805.00 $38,805.00 N/A $0.00 N/A
Total for all systems $1,073,922.00 $1,139,601.50 N/A $171,620.75 N/A
Other Expenses $38,805.00 $38,805.00 $0.00
FCC Filing Fees - Special Temporary Authorization request $305.00 $305.00 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
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 N/A N/A N/A
New Point to Point Microwave System: 950 MHz Licensed Part 74 Systems(price includes 6-foot antennas. Single link and redundant systems are included in this price range) $18,500.00 $18,500.00 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 $1,073,922.00 $1,139,601.50 $171,620.75

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.

Jeffrey C Gehman

Engineering Associate


12/17/2019

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.

Jeffrey C Gehman

Engineering Associate


12/17/2019

Attachments

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