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:
21149
Service:
DCA
Call Sign:
KAJN-CD
Channel:
19 (UHF)
File Number:
0000028886
FRN:
0003756145
Date Submitted:
02/10/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

AGAPE BROADCASTERS, INC.

Doing Business As: AGAPE BROADCASTERS, INC.

David Thompson

P.O. BOX 1469

CROWLEY, LA 70527

United States

+1 (337) 783-1560 davidt@familyvisiontv.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 THIS AMENDMENT REFLECTS THE STATION DECISION TO INSTALL A SINGLE CHANNEL ANTENNA FOR CH 19 TO REDUCE COST BY $137,610.00 AND CONTROL TPO REQUIREMENT. EXISTING XMTR AND ANTENNA NOT RETUNABLE. STATION FEEDS CABLE HEAD ENDS OFF AIR.

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 AT7800
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1 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 TMU9
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.8 kW
Justification for New Transmitter Current transmitter not supported by manufacturer for parts availability.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

TBD-Transmitter

FIVE DAYS INSTALLING AND TESTING TRANSMITTER. PROOF

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 15.0 kW
Manufacturer
Model SHI2010-32
Year 2000

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Ownership Owned
Owner N/A
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 Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 5.0 kW
Manufacturer
Model PSILPD24OM-19-EP
Year 2018
Justification for New Antenna OLD ANTENNA CAN NOT BE RETUNED.

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 3 1/8 inches inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? No

Tower Equipment And Rigging Costs

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

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Move Equipment
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? 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? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1020854
Coordinates (NAD83) Latitude (NAD83) 30° 02' 55.0" N-
Longitude (NAD83) 091° 59' 49.0" W-
Overall Structure Height 583.98 feet
Support Structure Height 583.98 feet
Ground Elevation Above Mean Sea Level (AMSL) 20.01 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner CALS COMMUNICATIONS SERVICE INC
Date Constructed 10/15/1992


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

Name Description

TOWER RIGGING

EXPENSE TO REMOVE EXISTING SHIVELY 32 SLOT AND INSTALL NEW 24 SLOT

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 695
Explanation STATION HAS CONTRACT ENGINEER WHO WILL REQUIRE ADDITIONAL HOURS TO SUPERVISE CREW AND MANAGE ALL ASPECTS OF PROJECT INCLUDING COORDINATION WITH CABLE COMPANIES. STATION WILL ALSO HIRE AN OUTSIDE FIRM TO FACILITATE TRANSITION TASKS.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 5
Justification TRANSMITTER INSTALLATION, PROOF AND TESTING

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
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 Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application Yes
FCC Special Temporary Authority Application No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

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 $126,000.00 $83,530.65 N/A $79,165.65 N/A
Total for all systems $599,515.00 $344,100.80 N/A $205,777.47 N/A
Primary Transmitter TMU9 $126,000.00 $83,530.65 $79,165.65
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $83,530.65 SJ Ramer Associates Quote. Estimated cost increased to match actual invoices received. Tony Evans Invoice #7341 $79,165.65 N/A
TBD-Transmitter $0.00 $0.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Contract Engineering Services
Amount:
$10,925.00

Component Description:
Installation of transmitter and other equipment for Repack
Amount:
$4,365.00

Component Description:
Repack related invoice for KAJN post transition Channel 19.
Amount:
$30,743.65

Component Description:
FCC Repack Related Invoice, Broadcast Transmitter System TMU9-3, 18ooW UHF transmitter.
Amount:
$37,497.00
TBD-Transmitter 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 $40,630.00 $52,485.15 N/A $38,678.73 N/A
Total for all systems $599,515.00 $344,100.80 N/A $205,777.47 N/A
Primary Antenna PSILPD24OM-19-EP $40,630.00 $52,485.15 $38,678.73
Sweep test of existing antenna $6,730.00 $6,000.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 3 1/8. feedline (if needed) $7,600.00 $3,000.00 N/A $3,000.00 N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $43,485.15 SEE ATTACHED QUOTE. THE EXISTING SHIVELY ANTENNA IS A 32 SLOT. THIS IS A REDUCTION TO A 24 SLOT ANTENNA. LRC Wireless invoice 21185 $35,678.73 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna Information not provided.
Elbow complex, single channel, at antenna input, per 3 1/8. feedline (if needed)

Component Description:
New Primary Antenna, Elbow Complex
Amount:
$3,000.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
24-Bay UHF Digital Slot Antenna for Channel 19
Amount:
$34,650.00

Component Description:
Please Deny this component
Amount:
N/A

Component Description:
MYAT 301-064 Reducer MYAT 301-010 Bullet
Amount:
$1,028.73

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 $235,500.00 $25,000.00 N/A $7,806.37 N/A
Total for all systems $599,515.00 $344,100.80 N/A $205,777.47 N/A
Primary Tower TOWER $235,500.00 $25,000.00 $7,806.37
TOWER RIGGING $25,000.00 $25,000.00 N/A $7,806.37 N/A
Tall Tower (greater than 500') $210,500.00 $0.00 RIGGING N/A N/A

Components

Actual Information Description File Name
TOWER RIGGING

Component Description:
Tower Rigging
Amount:
$7,806.37
Tall Tower (greater than 500') 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 $146,500.00 $134,750.00 N/A $73,349.27 N/A
Total for all systems $599,515.00 $344,100.80 N/A $205,777.47 N/A
Outside Professional Services $146,500.00 $134,750.00 $73,349.27
Project management of the transition $109,810.00 $105,750.00 N/A $70,648.70 N/A
Additional Field Engineering Service, 5 Days $7,500.00 $7,500.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 N/A $765.07 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A $435.50 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
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $1,500.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $1,750.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $2,500.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$1,372.55

Component Description:
Project Management
Amount:
$2,190.40

Component Description:
Project Management
Amount:
$3,341.80

Component Description:
Project Management
Amount:
$298.80

Component Description:
Project Management
Amount:
$516.40

Component Description:
Project management
Amount:
$2,941.40

Component Description:
Project Management
Amount:
$2,588.90

Component Description:
Project Management
Amount:
$4,292.00

Component Description:
Project Management
Amount:
$362.35

Component Description:
Project Management
Amount:
$407.90

Component Description:
Project Management
Amount:
$2,366.95

Component Description:
Project Management
Amount:
$592.35

Component Description:
Project Management
Amount:
$336.20

Component Description:
Cost Reconciliation
Amount:
$1,666.65

Component Description:
Project Management
Amount:
$2,314.75

Component Description:
Project Management
Amount:
$1,470.00

Component Description:
Project management
Amount:
$1,063.75

Component Description:
Project Management
Amount:
$3,095.85

Component Description:
Project Management
Amount:
$2,057.60

Component Description:
Project Management
Amount:
$7,500.00

Component Description:
Project Management
Amount:
$1,966.00

Component Description:
Project Management
Amount:
$1,944.60

Component Description:
Project Management
Amount:
$2,080.50

Component Description:
Project Management
Amount:
$2,157.10

Component Description:
Project Management
Amount:
$4,232.90

Component Description:
Project Management
Amount:
$2,911.70

Component Description:
Project Management
Amount:
$3,518.95

Component Description:
Invoice resubmitted after denial
Amount:
N/A

Component Description:
Project Management
Amount:
$1,100.85

Component Description:
Project Management
Amount:
$1,757.45

Component Description:
Project Management
Amount:
$790.30

Component Description:
Project Management
Amount:
$182.50

Component Description:
Project Management
Amount:
$2,328.70

Component Description:
Project Management
Amount:
$2,072.25

Component Description:
Project Management
Amount:
$379.45

Component Description:
Project Management
Amount:
$2,448.85
Additional Field Engineering Service, 5 Days Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
KAJN-CD FCC Reimbursement of Repack Expense
Amount:
$765.07
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
KAJN-550-Attorney - License to Cover Application (Main)
Amount:
$435.50
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

Component Description:
Coordination with client, Antenna manufacture, Local engineer, Transmitter installation engineer
Amount:
$1,500.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for new channel assignment and antenna development Information not provided.
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Prepare and or review reimbursement form 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 $50,885.00 $48,335.00 N/A $6,777.45 N/A
Total for all systems $599,515.00 $344,100.80 N/A $205,777.47 N/A
Other Expenses $50,885.00 $48,335.00 $6,777.45
Equipment Storage $3,500.00 $3,500.00 N/A N/A N/A
Equipment Delivery and Handling Charges $12,000.00 $12,000.00 N/A $1,094.45 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $7,500.00 $7,500.00 N/A N/A N/A
Non-zoning permits $3,500.00 $3,500.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 Pillsbury Invoice #8246904 $335.00 N/A
DTV Medical Facility Notification $11,550.00 $9,000.00 N/A $3,848.00 N/A
MVPD Notification of Channel Change $9,000.00 $9,000.00 N/A $1,500.00 N/A
Develop and air announcement of upcoming channel change $3,500.00 $3,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges

Component Description:
New Primary Antenna, Freight
Amount:
$1,094.45
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Non-zoning permits Information not provided.
FCC Filing Fees - Form 2100 license to cover application

Component Description:
KAJN-610-FCC Filing Fee - License to Cover Application
Amount:
$335.00
DTV Medical Facility Notification

Component Description:
Mailing: Print and mail a two page, black and white generically addressed letter with a specifically addressed USPS barcoded route sorted envelope
Amount:
$3,848.00
MVPD Notification of Channel Change

Component Description:
Prepare letters to MVPDs. Research and contact all relevant MVPD entities impacted by station move by mail and/or email. Prepare report for station.
Amount:
$1,500.00
Develop and air announcement of upcoming channel change Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $599,515.00 $344,100.80 $205,777.47

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. Yes

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.

David Thompson

Station Manager


02/10/2021

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.

David Thompson

Station Manager


02/10/2021

Attachments

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