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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:
64548
Service:
DTV
Call Sign:
KITV
Channel:
20 (UHF)
File Number:
0000028913
FRN:
0024593717
Date Submitted:
01/07/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

KITV, INC.

Doing Business As: KITV, INC.

Wade O'Hagan

999 MONTEREY STREET

SUITE 350

SAN LUIS OBISPO, CA 93401

United States

 +1 (805) 548-0602 sjlwade@aol.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 To relocate from channel 40 to channel 20, KITV will retune its existing primary antenna and install a new transmitter and transmission line at the station's existing tower location.

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)
Description of Use N/A
Ownership Owned
Owner N/A
Site 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
Model DHD30P1 Diamond CD
Year 2004
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 7.5 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 THU9-6 EVO
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 9.8 kW
Justification for New Transmitter The existing transmitter cannot be retuned to operate on channel 20.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
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? Yes
Type Cooling Only
Size 15 tons
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

Name Description

Installation

Move new transmitter to transmitter room on 40th floor

Transmitter Room Ventilation

Transmitter room ventilation services for new transmitter

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 Retune Existing
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 Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 6
Design power capacity in use 100.0 %
Lower Limit 470.00 MHz
Upper Limit 600.00 MHz
Other Antenna Type N/A
ERP: 85.0 kW
Manufacturer RFS
Model PHP6U313
Year 2004

Primary Antenna

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Adjustment to Existing Antenna

Section Question Response
Sweep Test of Existing Antenna Do you need a sweep test of existing antenna? Yes

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

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? 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)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
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 Air
Diameter 3 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 250 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Air
Diameter 3 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 250 feet per run
Justification for New Transmission Line A new transmission line is recommended by antenna manufacturer due to age.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Move Equipment
Tower Use Primary (Main)
Description of Use N/A
Ownership Owned
Is this tower consider Complex? Located on Building
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
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 1019034
Coordinates (NAD83) Latitude (NAD83) 21° 17' 25.0" N-
Longitude (NAD83) 157° 50' 24.0" W-
Overall Structure Height 495.07 feet
Support Structure Height 399.93 feet
Ground Elevation Above Mean Sea Level (AMSL) 4.92 feet
Structure Type BANT - Building with an Antenna
Tower Owner KITV, Inc.
Date Constructed 01/01/1976


Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower Located on Building
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Other Tower Expenses

Demolition and disposal services

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 The station's attorney will manage the reimbursement filings, review engineering applications, and engage in any additional coordination that is needed for KITV to accomplish its repack transition over the three year period.
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 Yes
Quantity 1
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 Yes
Quantity 1
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 No
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

Other Expenses

Engineer Travel Expenses

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 No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
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)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? No
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? Yes

Other Expenses

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Other Expenses Not Listed

Name Description

Other Expenses

Engineer Travel Expenses

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 $393,338.69 $389,838.69 N/A $327,262.12 N/A
Total for all systems $971,578.69 $556,879.69 N/A $374,468.43 N/A
Primary Transmitter THU9-6 EVO $393,338.69 $389,838.69 $327,262.12
UHF - Air Cooled Solid State Transmitter 9.8 kW $313,555.00 $313,555.00 N/A $313,555.00 N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $13,700.00 N/A $4,123.43 N/A
15 Ton system $55,800.00 $53,000.00 N/A N/A N/A
Installation $5,500.00 $5,500.00 N/A $5,500.00 N/A
Transmitter Room Ventilation $4,083.69 $4,083.69 N/A $4,083.69 N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 9.8 kW

Component Description:
Rohde Schwarz 9500086827 - 30% Payment - with Explanatory Statement
Amount:
$94,066.50

Component Description:
Rohde Schwarz 9500097465 - 60% Payment - with Explanatory Statement
Amount:
$188,133.00

Component Description:
Rohde Schwarz 9500097466 - 10% Payment - with Explanatory Statement
Amount:
$31,355.50
Service entrance 3 phase/800 amp/208 volt

Component Description:
Richardson Electric, LLC Invoice #31519
Amount:
$4,123.43
15 Ton system Information not provided.
Installation

Component Description:
Putnam Installation Company Invoice #040219-01
Amount:
$5,500.00
Transmitter Room Ventilation

Component Description:
Blue Chip Builders - Invoice #190501
Amount:
$4,083.69

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 $6,730.00 $8,266.00 N/A $8,266.00 N/A
Total for all systems $971,578.69 $556,879.69 N/A $374,468.43 N/A
Primary Antenna PHP6U313 $6,730.00 $8,266.00 $8,266.00
Sweep test of existing antenna $6,730.00 $8,266.00 The invoice from the vendor for the antenna sweep is $8266.00. $8,266.00 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
RFS Broadcast Systems Invoice #512852
Amount:
$8,266.00

Component Description:
RFS Broadcast Systems Invoice #512852
Amount:
$8,266.00

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 $14,750.00 $14,000.00 N/A $0.00 N/A
Total for all systems $971,578.69 $556,879.69 N/A $374,468.43 N/A
Primary Transmission Line $14,750.00 $14,000.00 $0.00
Flexible Air Transmission Line - dielectric, 3" $14,750.00 $14,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate 		Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $425,000.00 $14,000.00 N/A $3,665.20 N/A
Total for all systems $971,578.69 $556,879.69 N/A $374,468.43 N/A
Primary Tower BANT $425,000.00 $14,000.00 $3,665.20
Other Tower Expenses $4,000.00 $4,000.00 No predetermined cost associated with this item. $3,665.20 N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $421,000.00 $10,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Other Tower Expenses

Component Description:
Koko Head Plaza - Invoice 312
Amount:
$3,665.20
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) 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 $59,680.00 $59,250.00 N/A $22,035.15 N/A
Total for all systems $971,578.69 $556,879.69 N/A $374,468.43 N/A
Outside Professional Services $59,680.00 $59,250.00 $22,035.15
Prepare and or review reimbursement form $2,630.00 $5,500.00 The actual costs were greater than the estimated costs. Estimated costs increased to reflect. $5,351.25 N/A
Project management of the transition $31,600.00 $30,000.00 N/A $15,528.90 N/A
Other Expenses $0.00 $0.00 N/A $0.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 N/A N/A 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 N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 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 $75.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $1,080.00 N/A

Components

Actual Information Description File Name
Prepare and or review reimbursement form

Component Description:
LS Invoice #483111 - October 2020
Amount:
$1,210.00

Component Description:
LS Invoice #482077 - August 2020
Amount:
$550.00

Component Description:
Lerman Senter - April 2019 Invoice # 474391
Amount:
$363.75

Component Description:
LS Invoice #481595 - July 2020
Amount:
$220.00

Component Description:
LS Invoice #484245 - December 2020
Amount:
$440.00

Component Description:
Lerman Senter -- November 2019 -- Invoice #478100
Amount:
$220.00

Component Description:
LS Invoice - March 2018
Amount:
$335.00

Component Description:
LS Invoice - Feb 2018
Amount:
$235.00

Component Description:
LS Invoice #483716 -- November 2020
Amount:
$660.00

Component Description:
LS Invoice #482610 - Sept 2020
Amount:
$330.00

Component Description:
LS Invoice - July 2018
Amount:
$247.50

Component Description:
LS Invoice - April 2018
Amount:
$540.00
Project management of the transition

Component Description:
Repack legal project management services - November 2017.
Amount:
$105.40

Component Description:
Lerman Senter -- October 2019 -- Invoice #477618
Amount:
$110.00

Component Description:
LS -- Jan 2019 -- Invoice #472829
Amount:
$525.00

Component Description:
LS - Nov 2018 - Invoice #471738
Amount:
$105.00

Component Description:
Repack legal project management services - May 2017.
Amount:
$727.50

Component Description:
Lerman Senter - August 2019 Invoice #476019
Amount:
$330.00

Component Description:
LS Invoice #481002 - June 2020
Amount:
$770.00

Component Description:
LS Invoice #480287 - April 2020
Amount:
$330.00

Component Description:
Lerman Senter - March 2019 Invoice # 473834
Amount:
$420.00

Component Description:
LS Invoice - Aug 2018
Amount:
$71.25

Component Description:
Repack legal project management services - September 2017.
Amount:
$113.20

Component Description:
LS Invoice - May 2018
Amount:
$67.50

Component Description:
Repack legal project management services - July 2017.
Amount:
$1,158.75

Component Description:
Repack legal project management services - March 2017.
Amount:
$342.50

Component Description:
Repack legal project management services - December 2017.
Amount:
$100.00

Component Description:
LS - Dec 2018 - Invoice #472553
Amount:
$105.00

Component Description:
Lerman Senter - Feb 2019 Invoice # 473409
Amount:
$1,260.00

Component Description:
Lerman Senter - Sept 2019 - Invoice #477086
Amount:
$1,650.00

Component Description:
Lerman Senter - June 2019 Invoice #475144 - Project Management
Amount:
$1,282.50

Component Description:
LS - Sept 2018 - Invoice #470555
Amount:
$315.00

Component Description:
Lerman Senter - July 2019 Invoice #475569
Amount:
$440.00

Component Description:
Lerman Senter - May 2019 Invoice #474670
Amount:
$1,442.50

Component Description:
Repack legal project management services - August 2017.
Amount:
$3,022.80

Component Description:
LS - Oct 2018 - Invoice #471149
Amount:
$735.00
Other Expenses

Component Description:
Hilton Hawaiian Village Invoice #7068954 A
Amount:
N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
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.
Perform engineering study for new channel assignment and antenna development Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Mid-State Consultants - Invoice 1903-5005 - April 2019
Amount:
$75.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Mid-State 8-17 Invoice for KITV CP.
Amount:
$1,080.00

Component Description:
Mid-State Consultants - Invoice 1707-5012 - Aug 2017
Amount:
$1,080.00

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 $72,080.00 $71,525.00 N/A $13,239.96 N/A
Total for all systems $971,578.69 $556,879.69 N/A $374,468.43 N/A
Other Expenses $72,080.00 $71,525.00 $13,239.96
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A $335.00 N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $3,245.00 N/A
Other Expenses $10,000.00 $10,000.00 No predetermined cost associated with this item. $8,024.96 N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 Estimate based on prior experience and site's remote location. $1,635.00 N/A
Develop and air announcement of upcoming channel change $10,000.00 $10,000.00 Estimate based on prior experience. N/A N/A
Equipment Delivery and Handling Charges $25,000.00 $25,000.00 Estimate based on prior experience. N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $10,000.00 $10,000.00 Estimate based on prior experience. N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A

Components

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

Component Description:
Lerman Senter - June 2019 Invoice #475144 - License to Cover
Amount:
$335.00
DTV Medical Facility Notification

Component Description:
DTVNotification.com Invoice #INV-001988 - Medical Notifications
Amount:
$3,245.00
Other Expenses

Component Description:
Hilton Hawaiian Village Invoice #7068954 A
Amount:
$8,024.96
MVPD Notification of Channel Change

Component Description:
DTVNotification.com Invoice #INV-001987 - MVPD Notifications
Amount:
$1,635.00
Develop and air announcement of upcoming channel change Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $971,578.69 $556,879.69 $374,468.43

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.

Wade O'Hagan

Vice President


01/07/2021

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.

Wade O'Hagan

Vice President


01/07/2021

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.

Wade O'Hagan

Vice President


01/07/2021

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