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:
70423
Service:
DCA
Call Sign:
WUBX-CD
Channel:
24 (UHF)
File Number:
0000027573
FRN:
0014037857
Date Submitted:
04/30/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

L4 MEDIA GROUP, LLC

Doing Business As: L4 MEDIA GROUP, LLC

PO Box 60606

Suite 2450

Chicago, IL 60606

United States

+1 (612) 202-4980 ssaldana@sktytrading.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

Joseph L. Snelson , Jr .

Technical Consultant

Meintel, Sgrignoli & Wallace

1282 Smallwood Drive, Suite 372

Waldorf, MD 20603

United States

+1 (303) 344-8037 joe.snelson@mswdtv.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. No
Briefly describe transition plan Current transmission system consists of a single transmitter feeding a flexible transmission line which connects to an antenna on the tower. Work includes tower study/rehabilitation to support new antenna, mounting antenna and retuning transmitter.

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Retune Existing
Use Primary (Main)
Ownership Owned
Owner 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 Elettronika
Model TXUD2000
Year 2015
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2.0 kW

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed N/A
New Mask Filter
Power 3 kW
Other Power N/A
New Exciter Is a new exciter needed? No

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
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.

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? No
Existing Antenna Manufacturer and Type Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Other
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 UHF-TV LOG-PERIODIC ANTENNA
ERP: 6.5 kW
Manufacturer
Model CL-1469B
Year 2015

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? Yes
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 Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 1
Lower Limit 470.00 MHz
Upper Limit 860.00 MHz
Design power capacity in use 100.0 %
Other Antenna Type N/A
ERP: 5.52 kW
Manufacturer
Model TUA-C1-01/01M-T
Year 2017
Justification for New Antenna Applicant is proposing to replace the current antenna with one that has a similar pattern and will work on the repack 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? 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? 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 Modify Existing
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) No
Others Types of Users Yes
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1007971
Coordinates (NAD83) Latitude (NAD83) 36° 03' 55.1" N-
Longitude (NAD83) 078° 53' 24.0" W-
Overall Structure Height 320.86 feet
Support Structure Height 299.87 feet
Ground Elevation Above Mean Sea Level (AMSL) 391.07 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Pinnacle Towers LLC
Date Constructed 03/01/1985


Other Types of Users

Users
Cellular

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 undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower 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 200
Explanation Applicant has no internal resources capable of overseeing, identifying, purchasing, installing and commissioning this repack project. It will rely solely on outside services to manage all work required.
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 No
RF Field Engineering Services Comprehensive coverage verification via field study Yes
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

Progress Reporting

Prepare and file 10 required progress reports on FCC Form 2100, Schedule 387 on a quarterly basis with the FCC.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning Yes
Non-zoning permits Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application Yes
FCC Special Temporary Authority Application No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? 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 $109,355.00 $19,340.00 N/A $19,340.00 N/A
Total for all systems $597,180.00 $413,450.75 N/A $112,940.75 N/A
Primary Transmitter TXUD2000 $109,355.00 $19,340.00 $19,340.00
UHF and VHF - minor banding issues $105,200.00 $15,000.00 N/A $15,000.00 N/A
3 kW mask filter $4,155.00 $4,340.00 THE INITIAL ESTIMATE WAS OUTDATED $4,340.00 THE INITIAL ESTIMATE WAS OUT DATED

Components

Actual Information Description File Name
UHF and VHF - minor banding issues

Component Description:
transmitter retune service
Amount:
$15,000.00
3 kW mask filter

Component Description:
DELTA DTV FILTER Part # 1604-8-2N UHF 8 cavities, Power 2.7 KW RMS full service mask filter
Amount:
$4,340.00

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 $34,290.00 $30,700.00 N/A $4,500.00 N/A
Total for all systems $597,180.00 $413,450.75 N/A $112,940.75 N/A
Primary Antenna TUA-C1-01/01M-T $34,290.00 $30,700.00 $4,500.00
Sweep test of existing antenna $6,730.00 $4,500.00 N/A $4,500.00 N/A
UHF - Lower Power Side Mount, Class A broadband panel (cost per panel) $1,260.00 $1,200.00 N/A N/A N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $25,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
SWEEP TEST
Amount:
$4,500.00
UHF - Lower Power Side Mount, Class A broadband panel (cost per panel) Information not provided.
UHF - Lower Power Side Mount, Class A One Station antenna -- basic 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 $268,500.00 $238,000.00 N/A $5,700.00 N/A
Total for all systems $597,180.00 $413,450.75 N/A $112,940.75 N/A
Primary Tower TOWER $268,500.00 $238,000.00 $5,700.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $25,000.00 N/A $5,700.00 N/A
Short Tower (less than 500') $84,200.00 $63,000.00 N/A N/A N/A
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study

Component Description:
PERMIT APPLICATION AND CONSTRUCTION DOCS
Amount:
$5,700.00

Component Description:
ATC application fee
Amount:
$4,920.00

Component Description:
Structural engineering, prorated portion
Amount:
$1,500.00
Short Tower (less than 500') Information not provided.
Minor tower reinforcement/modifications 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 $158,150.00 $103,903.75 N/A $76,893.75 N/A
Total for all systems $597,180.00 $413,450.75 N/A $112,940.75 N/A
Outside Professional Services $158,150.00 $103,903.75 $76,893.75
Progress Reporting $20,000.00 $20,000.00 Prepare and file 10 required progress reports on FCC Form 2100, Schedule 387 on a quarterly basis with the FCC. $1,192.50 N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $30,000.00 See attached QUOTE 598, WUBX L4, 030120 REPACK FIELD TESTING $30,000.00 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 $3,047.50 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $9,473.75 Due to tower loading and congestion concerns we had to consider alternative antennas and mounting heights which necessitated additional studies. $9,473.75 Conduct Study for Alternative Antenna, also, due to tower congestion and loading concerns Conduct Study, Prepare and File FCC CP Modification of Construction Permit form 2100 for change in antenna height on tower for WUBX-CD
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A 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 $3,180.00 ACTUAL SERVICES EXCEEDED ESTIMATE $3,180.00 The original estimate was based on the FCC menu, and missed the actual labor required to complete the task by $180
Project management of the transition $31,600.00 $30,000.00 N/A $30,000.00 N/A

Components

Actual Information Description File Name
Progress Reporting

Component Description:
Prepare FCC Form 387 Repack Progress Report Filing. WUBX-CD
Amount:
$1,192.50
Comprehensive coverage verification via field study, if needed

Component Description:
FIELD TESTING
Amount:
$30,000.00
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:
WUBX-CD Durham, NC Prepare initial budgets, equipment list, and determine equipment replacements for new repack channel; Prepare FCC Form 2100 Schedule 399 Budget and Narrative for filing in initial CP Filing Window. 11.5 hours
Amount:
$3,047.50
Perform engineering study for new channel assignment and antenna development

Component Description:
Conduct Study for Alternative Antenna; Prepare and File FCC Modification of Construction Permit form 2100; Prepare TPO & Tech Summary Calculations for WUBX-CD Durham, NC
Amount:
$1,192.50

Component Description:
Conduct Study, Prepare and File FCC CP Modification of Construction Permit form 2100 for change in antenna height on tower for WUBX-CD
Amount:
$1,258.75

Component Description:
- Analyze potential early transition for WUBX-CD
Amount:
$662.50

Component Description:
WUBX-CD Durham, NC Conduct TVStudy analysis of initial channel assignment and analyze interference issues with new repack channel assignment. 17.25 hours
Amount:
$6,360.00

Component Description:
WUBX-CD Durham, NC Develop azimuth antenna pattern and determine antenna required for FCC Form 2100 Construction Permit Application for initial Repack Channel CP filing. 6.75 hours
Amount:
$1.00
Prepare and or review reimbursement form 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:
WUBX-CD Durham, NC Prepare technical portions of FCC Form 2100 Construction Permit Application and Engineering Exhibits required to be filed with initial repack Construction Permit Application - filing window. 12.0 hours
Amount:
$3,180.00
Project management of the transition

Component Description:
Project Management services, research and coordination w/rf engineering, equipment vendors and site owners
Amount:
$2,250.00

Component Description:
Project Management services, planning and coordination
Amount:
$1,500.00

Component Description:
REPACK PROJECT MANAGEMENT SERVICES. RESEARCH AND COORDINATION W/RF ENGINEERING, ATTORNEY, EQUIPMENT VENDORS AND SITE OWNER
Amount:
$1,500.00

Component Description:
PROJECT MANAGEMENT SERVICES
Amount:
$3,750.00

Component Description:
PROJECT MANAGEMENT
Amount:
$2,250.00

Component Description:
PROJECT MANAGEMENT SERVICES
Amount:
$3,000.00

Component Description:
PROJECT MANAGEMENT
Amount:
$3,000.00

Component Description:
PROJECT MANAGEMENT
Amount:
$3,750.00

Component Description:
Project Management services, research and coordination w/rf engineering, equipment vendors and site owners
Amount:
$2,250.00

Component Description:
Project Management services, research and coordination w/rf engineering, equipment vendors and site owners
Amount:
$1,500.00

Component Description:
Project management, lease modification and installation planning
Amount:
$750.00

Component Description:
PROJECT MANAGEMENT SERVICES
Amount:
$3,000.00

Component Description:
Project Management services, research and coordination w/rf engineering, equipment vendors and site owners
Amount:
$1,500.00

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 $26,885.00 $21,507.00 N/A $6,507.00 N/A
Total for all systems $597,180.00 $413,450.75 N/A $112,940.75 N/A
Other Expenses $26,885.00 $21,507.00 $6,507.00
Disposal Costs (for equipment and other waste, net of any salvage value) $1,000.00 $1,000.00 Applicant will be required to dispose of the current pre-repack antenna and parts that were replaced for transmitter retuning. The exact costs are not known at this time. N/A N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 It is possible other unknown expenses may arise that are not identified on this budget submission. The amount proposed is less than 3% of the total project cost to cover such contingencies. N/A N/A
Equipment Storage $2,500.00 $2,500.00 Applicant may receive antenna and transmitter parts prior to set installation dates. There is no on-site storage available and applicant may be forced to use outside temporary storage facilities. N/A N/A
Develop and air announcement of upcoming channel change $2,500.00 $2,500.00 It is required that the applicant give notification to viewers of the repack channel change. Applicant has limited internal resources to create and produce such notifications and will most likely have to obtain the services from an outside vendor. N/A N/A
Non-zoning permits $2,000.00 $2,000.00 It is currently unknown what the city or county may levy on applicant in terms of a building permit to perform the tower work required. It is felt this estimate should cover the associated costs for any required permits. N/A N/A
Local Zoning $2,000.00 $2,000.00 It is currently unknown what the local zoning authority or city/county may levy on applicant to perform the tower work required. It is felt this estimate should cover the associated costs for any required permits. N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 FCC APPARENTLY INCREASED THE PRICE $335.00 N/A
DTV Medical Facility Notification $11,550.00 $6,172.00 The original estimate was outdated $6,172.00 The initial estimated was outdated.

Components

Actual Information Description File Name
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Equipment Storage Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Non-zoning permits Information not provided.
Local Zoning Information not provided.
FCC Filing Fees - Form 2100 license to cover application

Component Description:
license fee
Amount:
$335.00
DTV Medical Facility Notification

Component Description:
DTV Notification Service: Notification of Medical Facilities Transmitter Medical Facility Notification per proposal
Amount:
$6,172.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $597,180.00 $413,450.75 $112,940.75

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. Yes
Construction of final facilities or all necessary modifications are complete. Yes
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.

Robert Wayne Jordan

ENGINEER


04/30/2020

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.

Robert Wayne Jordan

ENGINEER


04/30/2020

Certification

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Section Question Response
Submission of Final Allocation or Accounting Information 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 representations.

  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 all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates.

  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 acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  6. 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.

Robert Wayne Jordan

ENGINEER


04/30/2020

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