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:
66781-18-54680
Service:
DRT
Call Sign:
KIRO-TV
Channel:
18 (UHF)
File Number:
0000086807
FRN:
0014361620
Eligibility Status:
Eligible
Date Submitted:
01/19/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

KIRO-TV, Inc.

Doing Business As: KIRO-TV, Inc.

Chief Engineer

2807 Third Avenue

Seattle, WA 98121

United States

+1 (206) 728-7777 knealey@kiro7.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

Keith Nealey

Director of Engineering

KIRO-TV, Inc.

Chief Engineer

2807 THIRD AVENUE

SEATTLE, WA 98121

United States

+1 (206) 728-7777 knealey@kiro7.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 We powered down the old transmitter, took down the old antenna and removed the old transmitter. We then installed the new transmitter and antenna in place of the old ones using existing wave guide. This occurred in a three hour period in Nov. of 2018.

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 TTHDU-250
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 180 W

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 UAXTE-3P-C-600W
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 600 W
Justification for New Transmitter Location within the predicted noiselimited contour of and predicted interference greater than 0.5 percent to Post-Incentive-Auction Spectrum Repack facilities of Full-Service station KWDK on Channel 34, which itself is being repacked from Channel 42.

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) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Rigid Conduit and Wiring No
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

Mask Filter

Mask Filter 625W UHF Part FLUA-0062506AT

Assembly Parts

UAXT Kit 10FT Flex Assembly

Translator Receiver

Sencore MRD26 Receiver

Tax

Tax on all GatesAir transmitter parts

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 Bottom
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 4
Design power capacity in use 33.0 %
Lower Limit 692.00 MHz
Upper Limit 698.00 MHz
ERP: 0.95 kW
Manufacturer
Model ALP4L1-HSP-51
Year 2009

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? Yes
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Bottom
Polarization Horizontal
Type Slotted Coaxial
ERP: 0.95 kW
Manufacturer
Model AL4P-18M
Year 2018
Justification for New Antenna Antenna cannot be retuned to Channel 18 from 51

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

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)
Ownership Leased
Is this tower consider Complex? Candelabra
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1056094
Coordinates (NAD83) Latitude (NAD83) 47° 30' 16.3" N-
Longitude (NAD83) 121° 58' 10.0" W-
Overall Structure Height 310.04 feet
Support Structure Height 270.01 feet
Ground Elevation Above Mean Sea Level (AMSL) 2838.88 feet
Structure Type LTOWER - Lattice Tower
Tower Owner American Towers LLC
Date Constructed 12/01/1998

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID Call Sign Service
20357 KZOK-FM FM
4630 KQMV FM
35419 KWDK DTV
20356 KSWD FM
1091 KJAQ FM
57843 KNUC FM
56852 KWPX-TV DTV

Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: 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 Candelabra
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Tower Climbers

Rigged tower, removed old antenna, attached new antenna

Tower Climbers

Moved translator receive antenna to lower position on tower

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 100
Explanation KIRO-TV does not have sufficient resource capacity and expertise in house to handle all activities necessary for completion of the station's build by the construction deadline. KIRO-TV will hire an outside firm to facilitate a timely transition.
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 No
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 2
Negotiation of Lease and other Matter for Shared Locations Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Form 399 assistance or other program management costs No
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements Yes
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 No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
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? 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 $37,830.94 $26,837.19 N/A $26,837.19 N/A
Total for all systems $155,415.25 $70,819.09 N/A $67,410.59 N/A
Primary Transmitter UAXTE-3P-C-600W $37,830.94 $26,837.19 $26,837.19
Mask Filter $3,692.97 $3,692.97 N/A $3,692.97 N/A
Assembly Parts $867.26 $867.26 N/A $867.26 N/A
Tax $2,461.91 $2,461.91 N/A $2,461.91 N/A
Translator Receiver $2,708.80 $2,708.80 N/A $2,708.80 N/A
UHF - Air Cooled Solid State Transmitter 320 - 700 Watts $28,100.00 $17,106.25 N/A $17,106.25 See attached quote "IAASAQUAH Q-76154 KIRO DRT UAXTE-3P-C 600w.pdf" for type, cooling and power information.

Components

Actual Information Description File Name
Mask Filter

Component Description:
Mask filter portion of GatesAir, Inc. translator invoice
Amount:
$3,692.97
Assembly Parts

Component Description:
Includes lines 3 and 4 of invoice.
Amount:
$867.26
Tax

Component Description:
Tax on invoice
Amount:
$2,461.91
Translator Receiver

Component Description:
Translator receiver portion of invoice
Amount:
$2,708.80
UHF - Air Cooled Solid State Transmitter 320 - 700 Watts

Component Description:
Full amount of Transmitter plus tax. See quote "Cox Media- ISSAQUAH KIRO Q-76153 Quote.pdf" for power and cooling details.
Amount:
$17,106.25

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 $13,242.50 $13,242.50 N/A $13,242.50 N/A
Total for all systems $155,415.25 $70,819.09 N/A $67,410.59 N/A
Primary Antenna AL4P-18M $13,242.50 $13,242.50 $13,242.50
UHF-Low Power, Side Mount, Slotted Coaxial, 0.95kW input, Horizontal $13,242.50 $13,242.50 N/A $13,242.50 Please see "ERI Antenna Preliminary Specification 20180509-995 ISSAQUAH.pdf" and "ERI Antenna Quote 20180509-995 - Issaquah Translator.pdf" for antenna mounting and polarization details.

Components

Actual Information Description File Name
UHF-Low Power, Side Mount, Slotted Coaxial, 0.95kW input, Horizontal

Component Description:
1st part of Issaquah antenna invoice.
Amount:
$5,444.00

Component Description:
2nd part of Issaquah antenna invoice. Includes Tax and Freight charges. See cover letter "ISSAQUAH TRANSLATOR COVER LETTER FOR INVOICE COMBINATION.pdf" for details
Amount:
$7,798.50

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 $9,200.00 $9,200.00 N/A $8,808.00 N/A
Total for all systems $155,415.25 $70,819.09 N/A $67,410.59 N/A
Primary Tower LTOWER $9,200.00 $9,200.00 $8,808.00
Tower Climbers $1,200.00 $1,200.00 N/A $1,101.00 N/A
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas) $8,000.00 $8,000.00 N/A $7,707.00 N/A

Components

Actual Information Description File Name
Tower Climbers

Component Description:
Lower receive antenna so as not to get RF interference from transmitter
Amount:
$1,101.00
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas)

Component Description:
Rig tower, remove existing antenna and hang new antenna in its place. Waveguide rerouting.
Amount:
$7,707.00

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 $94,250.00 $20,647.59 N/A $17,631.09 N/A
Total for all systems $155,415.25 $70,819.09 N/A $67,410.59 N/A
Outside Professional Services $94,250.00 $20,647.59 $17,631.09
RF Exposure Measurements $12,100.00 $500.00 N/A $150.00 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $47.10 Please see KIRO-TV1 Attorney Fees - Negotiation of Lease and Other Matters budget justification letter $47.10 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,740.40 FCC filing fees are included in the legal costs $1,740.40 x
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $1,881.34 N/A $1,881.34 x
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $500.00 N/A $300.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $1,200.00 N/A $1,017.86 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $284.50 N/A $284.50 x
Project management of the transition $10,550.00 $2,806.25 Please see KIRO-TV1 Project Management Budget Revision Justification Letter $2,806.25 N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $5,000.00 N/A $4,312.15 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $4,470.00 $5,188.00 Staggered RF power increases required multiple changes to the STA request during a period of 3 months. $3,661.10 N/A
Perform engineering study for displacement application $1,800.00 $1,500.00 N/A $1,430.39 N/A

Components

Actual Information Description File Name
RF Exposure Measurements

Component Description:
RF measurement portion of Issaquah translator - See Merrill Weiss 399 costs worksheet - Issaquah.pdf & Merrill Weiss KIRO Translator Breakdown.pdf
Amount:
$150.00
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
Other Matters
Amount:
$47.10
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
License to cover
Amount:
$439.50

Component Description:
License to cover
Amount:
$1,213.00

Component Description:
License to Cover
Amount:
$87.90

Component Description:
Legal LTC application portion of Issaquah Translator - see Cooley 399 costs worksheet - Issaquah.pdf
Amount:
$1,632.97
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
C.P.A
Amount:
$242.36

Component Description:
C.P.A
Amount:
$298.30

Component Description:
C.P.A
Amount:
$5.86

Component Description:
C.P.A
Amount:
$194.26

Component Description:
C.P.A
Amount:
$78.50

Component Description:
C.P.A
Amount:
$810.86

Component Description:
C.P.A
Amount:
$251.20

Component Description:
Legal CP application portion of Issaquah Translator - see Cooley 399 costs worksheet - Issaquah.pdf
Amount:
$964.85
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
RF LTC application portion of Issaquah translator - See Merrill Weiss 399 costs worksheet - Issaquah.pdf & Merrill Weiss KIRO Translator Breakdown.pdf
Amount:
$300.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
RF CP application portion of Issaquah translator - See Merrill Weiss 399 costs worksheet - Issaquah.pdf & Merrill Weiss KIRO Translator Breakdown.pdf
Amount:
$1,017.86
Prepare/ Review 399 reimbursement form

Component Description:
Professional Services
Amount:
$255.20

Component Description:
Prepare 399
Amount:
$29.30
Project management of the transition

Component Description:
Project Management
Amount:
$2,806.25
Comprehensive coverage verification via field study, if needed

Component Description:
RF study portion of Issaquah translator - See Merrill Weiss 399 costs worksheet - Issaquah.pdf & Merrill Weiss KIRO Translator Breakdown.pdf
Amount:
$4,312.15
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
S.T.A
Amount:
$121.40

Component Description:
S.T.A
Amount:
$229.30

Component Description:
S.T.A
Amount:
$2,507.70

Component Description:
S.T.A
Amount:
$263.70

Component Description:
S.T.A
Amount:
$274.20

Component Description:
S.T.A
Amount:
$29.30

Component Description:
S.T.A
Amount:
$235.50

Component Description:
Legal STA application portion of Issaquah Translator - see Cooley 399 costs worksheet - Issaquah.pdf
Amount:
$5,188.00
Perform engineering study for displacement application

Component Description:
RF displacement study portion of Issaquah translator - See Merrill Weiss 399 costs worksheet - Issaquah.pdf & Merrill Weiss KIRO Translator Breakdown.pdf
Amount:
$1,430.39

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 $891.81 $891.81 N/A $891.81 N/A
Total for all systems $155,415.25 $70,819.09 N/A $67,410.59 N/A
Other Expenses $891.81 $891.81 $891.81
Equipment Delivery and Handling Charges $891.81 $891.81 N/A $891.81 N/A

Components

Actual Information Description File Name
Equipment Delivery and Handling Charges

Component Description:
Freight for Issaquah Translator transmitter
Amount:
$891.81

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $155,415.25 $70,819.09 $67,410.59

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.

Keith Nealey

Director of Engineering


01/19/2021

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 Nealey

Director of Engineering


01/19/2021

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.

Keith Nealey

Director of Engineering


01/19/2021

Attachments

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