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:
168638
Service:
LPD
Call Sign:
KGNG-LD
Channel:
26 (UHF)
File Number:
0000089501
FRN:
0000020867
Eligibility Status:
Eligible
Date Submitted:
09/26/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

KING KONG BROADCASTING, INC.

Doing Business As: KING KONG BROADCASTING, INC.

452 E. SILVERADO RANCH BLVD.

#471

LAS VEGAS, NV 89183

United States

+1 (702) 642-8847 larry@kgngtv.com Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

The Preparer is same as the reimbursement contact.

 

 

 

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan Replace the transmitter, antenna and transmission line per the channel relocation project using reasonable and customary engineering and business practices.

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 DTXPRO-1.2KU
Year 2009
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 DTXPRO-1.2KU
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.2 kW
Justification for New Transmitter Replace the transmitter per the channel relocation project using reasonable and customary engineering and business practices.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Other Transmitter Costs
Does the transmitter installation require a Transmitter Building Site Survey/Installation? Yes
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) No
Transformer (480V) No
Rigid Conduit and Wiring Yes
Size 1 inches
Length 20.0 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

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Taxes

Estimated sales tax

Decommission

Estimated costs to decommission old transmitter

Site Prep

Prepare site for installation

Shipping

Estimated Freight

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? 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
Mounting Side Mount
Antenna position in stack Middle
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 9
Design power capacity in use 90.0 %
Lower Limit 470.00 MHz
Upper Limit 860.00 MHz
ERP: 15.0 kW
Manufacturer
Model K72314 Series
Year 2008

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? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Middle
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 9
Lower Limit 470.00 MHz
Upper Limit 860.00 MHz
Design power capacity in use 50.0 %
ERP: 15.0 kW
Manufacturer
Model K72314 Series
Year 2017
Justification for New Antenna Replace the antenna per the channel relocation project using reasonable and customary engineering and business practices.

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? No
Power Dividers Does the panel antenna require power dividers? No
Cable Harness Does the panel antenna require cable harness? No

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Shipping

Estimated freight

Taxes

Estimated freight

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 Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 318 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 Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 162 feet per run
Justification for New Transmission Line Had to move to new tower; could not go off air long enough to move old antenna and replace with new antenna. Required to maintain EAS for Korean, Mexican, and Filipino viewership. Loss of revenue would have been unsustainable for station and programmers
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

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Shipping

Estimated freight

Taxes

Estimated sales tax

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? No
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? No
Coordinates (NAD83) Latitude (NAD83) 35° 56' 43.9" N-
Longitude (NAD83) 115° 02' 35.9" W-
Overall Structure Height 100.00 feet
Support Structure Height 100.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 1311.00 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Unknown
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: No study needed
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 200
Explanation Required to assist in the turnkey management of the channel relocation project in order that the existing internal personnel can maintain and operate the stations daily operational requirements and plans.
Outside RF consulting Engineering Services Perform engineering study for displacement application 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
Prepare Form 601 Yes
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
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 5
Justification Estimated field engineering services during transition activities. Actual costs to be determined.

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
Permit and Filing Costs FCC Construction Permit Major Change Yes
FCC Construction Permit Minor Change Yes
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)? No
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 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 $110,980.00 $41,577.06 N/A $41,577.06 N/A
Total for all systems $292,007.40 $99,546.05 N/A $89,906.05 N/A
Primary Transmitter DTXPRO-1.2KU $110,980.00 $41,577.06 $41,577.06
Service entrance 3 phase/800 amp/208 volt $14,400.00 $0.00 N/A $0.00 N/A
Decommission $0.00 $0.00 Estimated costs to de-install, disconnect and decommission old transmitter. N/A N/A
Site Prep $0.00 $0.00 4/1/2020- Working to obtain quote which may be delayed due to coronavirus pandemic. N/A N/A
Transmitter Building Site Survey/Installation $10,000.00 $0.00 Estimated costs for site survey and transmitter installation. Revised upon Site Survey. 4/2/2020- Working to obtain quote which may be delayed due to coronavirus pandemic. N/A N/A
Taxes $0.00 $0.00 Estimated sales tax. Actual costs to be determined. N/A N/A
Shipping $2,580.00 $2,580.00 Per attached Pineapple Distribution invoice #KINGKONG26 dated 10/20/17 $2,580.00 Actual invoice submitted.
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $38,997.06 Cost determined per invoice #KINGKONG26 $38,997.06 Actual invoices uploaded.
1" Rigid Conduit and Wiring $0.00 $0.00 Estimated costs to replace conduit and wiring. Actual costs to be determined. N/A N/A

Components

Actual Information Description File Name
Service entrance 3 phase/800 amp/208 volt Information not provided.
Decommission Information not provided.
Site Prep Information not provided.
Transmitter Building Site Survey/Installation Information not provided.
Taxes Information not provided.
Shipping

Component Description:
Shipping fees for transmitter.
Amount:
$2,580.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Transmitter from Pineapple Distribution. No quote provided, and company has since gone out of business so no EIN provided.
Amount:
$38,997.06
1" Rigid Conduit and Wiring 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 $15,750.00 $16,778.75 N/A $16,778.75 N/A
Total for all systems $292,007.40 $99,546.05 N/A $89,906.05 N/A
Primary Antenna K72314 Series $15,750.00 $16,778.75 $16,778.75
Taxes $0.00 $0.00 Estimated sales tax. Actual costs to be determined. 4/13/2020 - Working to obtain more information which may be delayed due to coronavirus pandemic. N/A N/A
Shipping $0.00 $0.00 Estimate of shipping fees for new antenna. Actual costs to be determined. 4/13/2020 - Working to obtain more information which may be delayed due to coronavirus pandemic. N/A N/A
UHF Broadband panel antenna (per panel), horizontally-polarized $15,750.00 $16,778.75 Actual invoice $16,778.75 N/A

Components

Actual Information Description File Name
Taxes Information not provided.
Shipping Information not provided.
UHF Broadband panel antenna (per panel), horizontally-polarized

Component Description:
Kathrein Panels
Amount:
$16,778.75

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 $3,888.00 $11,405.84 N/A $11,405.84 N/A
Total for all systems $292,007.40 $99,546.05 N/A $89,906.05 N/A
Primary Transmission Line $3,888.00 $11,405.84 $11,405.84
Taxes $0.00 $0.00 N/A N/A N/A
Shipping $0.00 $0.00 N/A N/A N/A
Interior RF Systems: Inside RF system including switching, patch panels and dehydrators $0.00 $0.00 N/A N/A N/A
Flexible Foam Transmission Line - dielectric, 1 5/8" $3,888.00 $11,405.84 Per Invoice #KGNG26 from Wholesale Electric Supply dated 12/21/17. Includes freight and tax $11,405.84 N/A

Components

Actual Information Description File Name
Taxes Information not provided.
Shipping Information not provided.
Interior RF Systems: Inside RF system including switching, patch panels and dehydrators Information not provided.
Flexible Foam Transmission Line - dielectric, 1 5/8"

Component Description:
1 5/8 transmission line
Amount:
$11,405.84

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 $56,190.00 $8,900.00 N/A $8,900.00 N/A
Total for all systems $292,007.40 $99,546.05 N/A $89,906.05 N/A
Primary Tower TOWER $56,190.00 $8,900.00 $8,900.00
Tower Rigging Short Tower (less than 500') $56,190.00 $8,900.00 Cost determined from JT3 Telecom invoice uploaded on 4.9.20 $8,900.00 N/A

Components

Actual Information Description File Name
Tower Rigging Short Tower (less than 500')

Component Description:
Antenna installation
Amount:
$8,900.00

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 $98,489.40 $20,719.40 N/A $11,079.40 N/A
Total for all systems $292,007.40 $99,546.05 N/A $89,906.05 N/A
Outside Professional Services $98,489.40 $20,719.40 $11,079.40
Project management of the transition $21,100.00 $0.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $900.00 Actual Cost for Engineering Displacement Work done by BWS $900.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $50.00 N/A $50.00 N/A
Form 399 assistance or other Program Management costs $7,269.40 $7,269.40 ***System Notice: Estimate adjusted and locked because line has been superseded.***Cost determined from submitted invoices. $7,629.40 The Sub-total is not greater than the estimated cost. They are both identical. It seems to be an an error in LMS.
Perform engineering study for displacement application $1,800.00 $0.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $10,000.00 N/A N/A N/A
Additional Field Engineering Service, 5 Days $0.00 $0.00 Estimated field engineering services during transition activities. Actual costs to be determined. N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $0.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $0.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $0.00 N/A N/A N/A
Prepare Form 601 $755.00 $0.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $0.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $2,500.00 ***System Notice: Estimate adjusted and locked because line has been superseded.***Per attached quote from QCommunications #QC-KGNG-1 dated 10/30/2019 $2,500.00 N/A

Components

Actual Information Description File Name
Project management of the transition Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Displacement Engineering BWS
Amount:
$900.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
License to Cover Filing
Amount:
$50.00
Form 399 assistance or other Program Management costs

Component Description:
399 Assistance Sept2020
Amount:
$800.00

Component Description:
Form 399 Assistance and PM Costs
Amount:
$1,493.80

Component Description:
Project Management for Repack transition.
Amount:
$1,139.60

Component Description:
Project management
Amount:
$754.60

Component Description:
Prepare and Process Form 399
Amount:
$500.00

Component Description:
Project Management
Amount:
$1,940.40

Component Description:
Project management for 399 Repack
Amount:
$1,001.00
Perform engineering study for displacement application Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Additional Field Engineering Service, 5 Days Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare Form 601 Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare/ Review 399 reimbursement form

Component Description:
Form 399 Submission
Amount:
$2,500.00

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 $6,710.00 $165.00 N/A $165.00 N/A
Total for all systems $292,007.40 $99,546.05 N/A $89,906.05 N/A
Other Expenses $6,710.00 $165.00 $165.00
FCC Filing Fees - Form 2100 license to cover application $335.00 $165.00 N/A $165.00 N/A
FCC Filing Fees - Form 2100 Major change CP application $4,960.00 $0.00 4/2/2020- Working to obtain quote which may be delayed due to coronavirus pandemic. N/A N/A
Equipment Delivery and Handling Charges $0.00 $0.00 Transport, forklift rental and handling fees from staging area to transmitter site. N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $0.00 4/2/2020- Working to obtain quote which may be delayed due to coronavirus pandemic. N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $0.00 N/A N/A N/A

Components

Actual Information Description File Name
FCC Filing Fees - Form 2100 license to cover application

Component Description:
Fee paid FCC
Amount:
$165.00
FCC Filing Fees - Form 2100 Major change CP application Information not provided.
Equipment Delivery and Handling Charges Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $292,007.40 $99,546.05 $89,906.05

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.

Susan Hansen

Consultant


09/26/2020

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.

Susan Hansen

Consultant


09/26/2020

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.

Larry Hunt

President


09/26/2020

Attachments

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