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:
21476
Service:
LPA
Call Sign:
WPNM-LD
Channel:
27 (UHF)
File Number:
0000089754
FRN:
0018282269
Eligibility Status:
Eligible
Date Submitted:
10/20/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WEST CENTRAL OHIO BROADCASTING, INC.

Keith Wilkowski

405 Madison Avenue,

Suite 2100

Toledo, OH 43604

United States

+1 (419) 724-7276 kwilkowski@blockcommunications.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

Samuel Hariton

Widelity

Samuel Hariton

4031 University Dr

Suite 100

Fairfax, VA 22030

United States

+1 (339) 222-8107 sam.hariton@widelity.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 WPNM-LP is planning to upgrade its transmitter, upgrade its antenna, purchase new transmission line and move to a different tower.

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
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 830-A
Year 1999
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.0 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 ULXT-6
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 5.4 kW
Justification for New Transmitter Re-tuning the existing main transmitter is not an option because the existing transmitter's power output is insufficient to provide the necessary ERP from the new antenna due in part to the longer run of transmission line

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? No
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) Yes
Transformer (480V) Yes
Power 150 kVA
Rigid Conduit and Wiring Yes
Size 1.25 inches
Length 125.0 feet
Other Electrical Service Yes
Description Install service cut-off, breaker box, and attach transmitter to service upon completion by Gates. Renting building and tower space.
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? Yes
Size 96.0 square feet

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Primary Transmitter Remote Control System

Remote Control System

Primary Transmitter - Other Parts

Parts necessary for transmitter functionality

Transmitter-Demodulator

Transmitter-Demodulator

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? Yes
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 Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 2
Number of Panels 4
Design power capacity in use 50.0 %
Lower Limit 470.00 MHz
Upper Limit 862.00 MHz
ERP: 7.7 kW
Manufacturer
Model 4X1KBBU
Year 2004

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID Call Sign
70612 WAMS-LD

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 Elliptical
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model ATC-BCE512O-V0-27
Year 2018
Justification for New Antenna This antenna is required because the pre-displacement antenna could not be retuned to the new channel.

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? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Primary Antenna - Antenna Mounts

Primary Antenna - Antenna Mounts

Fabricate and install ice bridge, heat exchanger protection on pad

Fabricate and install ice bridge, heat exchanger protection on pad.

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 Utilize Existing
Use Primary (Main)
Ownership Owned
Is the existing transmission line shared with another station or stations? Yes
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Andrew
Type Flexible Foam
Diameter 7/8 inches
Number of parallel runs 1
Length 250 feet per run

Facility ID's and Call Signs of all stations with whom the transmission line is shared.

Facility ID Call Sign
70612 WAMS-LD

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Primary Transmission Line - Additional Installation Pieces

Additional pieces required for installation

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 Owned
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? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1016071
Coordinates (NAD83) Latitude (NAD83) 41° 08' 12.0" N-
Longitude (NAD83) 083° 54' 24.0" W-
Overall Structure Height 1089.55 feet
Support Structure Height 1030.83 feet
Ground Elevation Above Mean Sea Level (AMSL) 727.03 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner BOWLING GREEN STATE UNIVERSITY
Date Constructed 08/13/2004


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 254
Explanation WPNM-LD does not have sufficient resource capacity and expertise in house to handle all of the reimbursement filing, tracking, progress reporting, monitoring and all other activities necessary to facilitate on-time completion of the station's build
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 No
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 No
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service No

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 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
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

Name Description

Receive Antenna

Receive Antenna needed due to repack channel change

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 $371,766.79 $263,371.63 N/A $69,766.68 N/A
Total for all systems $612,272.51 $532,190.51 N/A $152,409.65 N/A
Primary Transmitter ULXT-6 $371,766.79 $263,371.63 $69,766.68
Primary Transmitter - Other Parts $5,051.90 $5,051.90 Please see Estimated Cost Justification WPNM-LP-110-Primary Transmitter - Other Parts v1 $1,246.25 N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $5,222.93 see Justifying Quote WPNM-LP GatesAir Q-77810 Transformer. Transformer will be 75kVA but was entered as 150kVA due to limitation of LMS system $0.00 N/A
Switchgear - industrial 800 amp $38,200.00 $38,200.00 N/A N/A N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $14,400.00 N/A N/A N/A
Transmitter-Demodulator $918.67 $918.67 Please see Heartland Video Systems quote WISQ63261 $918.67 N/A
Primary Transmitter Remote Control System $8,138.62 $8,138.62 Please see WPNM-LP Remote Control System Budget Revision Justification Letter $4,338.57 N/A
Other Electrical Service: Install service cut-off, breaker box, and attach transmitter to service upon completion by Gates. Renting building and tower space. $8,655.82 $8,655.82 see Estimated Cost Justification WPNM-LD-110-Primary Transmitter - Other Electrical Service v0 $8,655.82 N/A
UHF - Liquid Cooled Solid State Transmitter 4.9 - 6.5 kW $255,000.00 $166,931.91 Please see GatesAir quote Q-73520 and Q-88762 for the like for like. $54,447.10 N/A
Other -- Building Addition Size: 96.0 $3,851.78 $3,851.78 see Estimated Cost Justification WPNM-LP-110-Primary Transmitter - Building Addition, 96 sq ft v0 $160.27 N/A
1.25" Rigid Conduit and Wiring $12,000.00 $12,000.00 Station renting from another company/tower. Cost reflect installation of step down transformer, & transmitter electrical needs. N/A N/A

Components

Actual Information Description File Name
Primary Transmitter - Other Parts

Component Description:
Parts
Amount:
$72.62

Component Description:
Invoice moved to correct budget category
Amount:
N/A

Component Description:
2" Aluminum Filter Special
Amount:
$380.62

Component Description:
Zinc Yellow-Chromate Plated Grade 8 Steel Washer
Amount:
$87.29

Component Description:
Other Parts
Amount:
$705.72

Component Description:
Invoice moved to correct budget category.
Amount:
N/A
Transformer 3 phase/480v - 150 KVA Information not provided.
Switchgear - industrial 800 amp Information not provided.
Service entrance 3 phase/800 amp/208 volt Information not provided.
Transmitter-Demodulator

Component Description:
Senecore Modular Receiver
Amount:
$918.67
Primary Transmitter Remote Control System

Component Description:
Invoice moved to correct budget category
Amount:
N/A

Component Description:
Remote Control System
Amount:
$4,338.57
Other Electrical Service: Install service cut-off, breaker box, and attach transmitter to service upon completion by Gates. Renting building and tower space.

Component Description:
COMPONENTS
Amount:
$8,655.82
UHF - Liquid Cooled Solid State Transmitter 4.9 - 6.5 kW

Component Description:
ULXT-6 Transmitter and Line Items
Amount:
$54,447.10

Component Description:
Freight
Amount:
$290.88

Component Description:
FREIGHT
Amount:
$5,764.50

Component Description:
Invoice moved to the correct budget category.
Amount:
N/A

Component Description:
Invoice moved to correct budget category.
Amount:
N/A

Component Description:
Invoice moved to correct budget category per NMI message
Amount:
N/A
Other -- Building Addition Size: 96.0

Component Description:
Credit Memo - This invoice is for upgraded materials because the concrete pad would not have been necessary if the station had not upgraded their transmitter.
Amount:
($3,691.50)

Component Description:
RF Switch, dehydrator mount
Amount:
$160.27

Component Description:
Cement Pad for Heat Exchanger
Amount:
$3,691.50
1.25" 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 $32,096.69 $32,096.69 N/A $26,366.69 N/A
Total for all systems $612,272.51 $532,190.51 N/A $152,409.65 N/A
Primary Antenna ATC-BCE512O-V0-27 $32,096.69 $32,096.69 $26,366.69
Fabricate and install ice bridge, heat exchanger protection on pad $6,938.75 $6,938.75 See narrative and WPNM-LP Ice Bridge Estimated Cost Justification $6,938.75 N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical $18,888.99 $18,888.99 Please see attached Alive Telecom quote ATC-BCE512O-V0-27 $18,888.99 N/A
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A
Primary Antenna - Antenna Mounts $538.95 $538.95 Please see WPNM-LP Primary Antenna - Antenna Mounts Budget Revision Justification Letter $538.95 N/A

Components

Actual Information Description File Name
Fabricate and install ice bridge, heat exchanger protection on pad

Component Description:
Fabricate and Install Ice Bridge/Heat Exchanger
Amount:
$6,938.75
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical

Component Description:
304 Stainless Steel U-bolts,316 Stainless Steel Washers, Super Corrosion-resistant Stainless Steel Hex Nuts
Amount:
$228.33

Component Description:
Invoice moved to correct budget category.
Amount:
N/A

Component Description:
Ch27 E-POL Coaxial Slot Antenna
Amount:
$8,967.00

Component Description:
Invoice moved to correct budget category.
Amount:
N/A

Component Description:
Invoice moved to correct budget category.
Amount:
N/A

Component Description:
ATC-BCE512O-V0-27 CH 27 E-POL Coaxial Slot Antenna Full Radome Azimuth Side Mount
Amount:
$8,966.99

Component Description:
Shipping of Antenna
Amount:
$955.00
Sweep test of transmission line and antenna Information not provided.
Primary Antenna - Antenna Mounts

Component Description:
Antenna Mounts
Amount:
$44.96

Component Description:
Antenna Mounts
Amount:
$228.33

Component Description:
Antenna Mounts
Amount:
$195.71

Component Description:
Antenna Mounts
Amount:
$69.95

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 $1,179.75 $1,179.75 N/A $1,179.74 N/A
Total for all systems $612,272.51 $532,190.51 N/A $152,409.65 N/A
Primary Transmission Line $1,179.75 $1,179.75 $1,179.74
Primary Transmission Line - Additional Installation Pieces $1,179.75 $1,179.75 Please see Electronics Research, Inc. proposal 201962-909, proposal 20190612-818, and change request 35819T, plus actual sales and freight tax on invoices 53611 and 53683 $1,179.74 N/A

Components

Actual Information Description File Name
Primary Transmission Line - Additional Installation Pieces

Component Description:
4" BOOT ASSEMBLY FOR 3/8" & 7/8" CABLE
Amount:
$606.05

Component Description:
Displaced Translator Parts
Amount:
$251.35

Component Description:
DISPLACED TRANSLATOR PARTS
Amount:
$211.24

Component Description:
OHIO SALES TAX
Amount:
$111.10

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 $157,750.00 $157,750.00 N/A $4,280.00 N/A
Total for all systems $612,272.51 $532,190.51 N/A $152,409.65 N/A
Primary Tower TOWER $157,750.00 $157,750.00 $4,280.00
Tower Rigging Tall Tower (greater than 500') $157,750.00 $157,750.00 N/A $4,280.00 N/A

Components

Actual Information Description File Name
Tower Rigging Tall Tower (greater than 500')

Component Description:
Labor
Amount:
$856.00

Component Description:
Labor to change out existing LPtv antenna
Amount:
$3,424.00

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 $42,082.00 $70,395.16 N/A $49,824.26 N/A
Total for all systems $612,272.51 $532,190.51 N/A $152,409.65 N/A
Outside Professional Services $42,082.00 $70,395.16 $49,824.26
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A $985.50 N/A
Perform engineering study for displacement application $1,800.00 $18,025.83 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $18,025.83 N/A
Project management of the transition $26,797.00 $41,910.00 see Justifying Quote WPNM-LD Widelity strategic support quote $30,576.10 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $236.83 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $236.83 Please see submitted invoices.
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 Form 601 $755.00 $755.00 N/A N/A N/A

Components

Actual Information Description File Name
Prepare/ Review 399 reimbursement form

Component Description:
Fees
Amount:
$985.50
Perform engineering study for displacement application

Component Description:
Consulting Engineering Services
Amount:
$4,997.33

Component Description:
Consulting Engineering Services
Amount:
$307.90

Component Description:
Consulting engineering Services
Amount:
$1,270.35

Component Description:
Consulting Engineering Services
Amount:
$3,175.15

Component Description:
Consulting Engineerings Services
Amount:
$637.50

Component Description:
Consulting engineering services
Amount:
$7,637.60
Project management of the transition

Component Description:
Project management
Amount:
$6,750.80

Component Description:
Project Management
Amount:
$3,687.80

Component Description:
Project Management
Amount:
$465.25

Component Description:
Project Management
Amount:
$8,240.90

Component Description:
Project Management
Amount:
$4,412.65

Component Description:
Project Management
Amount:
$1,535.95

Component Description:
Project Management
Amount:
$438.00

Component Description:
Project Management
Amount:
$254.80

Component Description:
Project Management
Amount:
$2,933.10

Component Description:
Project Management
Amount:
$369.10

Component Description:
Project Management
Amount:
$593.95

Component Description:
Project Management
Amount:
$893.80
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
Review status of repack reimbursements
Amount:
$236.83
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 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 Information not provided.
Prepare Form 601 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 $7,397.28 $7,397.28 N/A $992.28 N/A
Total for all systems $612,272.51 $532,190.51 N/A $152,409.65 N/A
Other Expenses $7,397.28 $7,397.28 $992.28
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,110.00 N/A N/A N/A
Receive Antenna $992.28 $992.28 Please see Heartland Video Systems quote WISQ64813, plus actual shipping and tax on invoice 72302 $992.28 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A
FCC Filing Fees - Form 2100 Major change CP application $4,960.00 $4,960.00 N/A N/A N/A

Components

Actual Information Description File Name
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
Receive Antenna

Component Description:
4' Parabolic UHF Broadband
Amount:
$992.28
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Form 2100 Major 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 $612,272.51 $532,190.51 $152,409.65

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. 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.

Keith Wilkowski

VP, Legal & Governmental Affairs


10/20/2020

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.

Keith Wilkowski

VP, Legal & Governmental Affairs


10/20/2020

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