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:
130929
Service:
LPD
Call Sign:
KWDA-LD
Channel:
4 (Low VHF)
File Number:
0000089797
FRN:
0019773035
Eligibility Status:
Eligible
Date Submitted:
01/14/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

LMO CHRISTIAN MEDIA, INC.

Doing Business As: LMO CHRISTIAN MEDIA, INC.

Ana K. Guel

8330 LBJ Freeway

Suite 310

Dallas, TX 75243

United States

+1 (214) 331-2800 akguel@mekaddeshgroup.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

Maria C Guel

Lmo Christian Media Inc.

Maria C Guel

8330 LBJ Freeway

Suite 1155

Dallas, TX 75243

United States

+1 (469) 434-5600 mguel@mekaddeshgroup.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. No
Briefly describe transition plan Moving from channel 21 UHF to channel 4 VHF we need to do the following: purchase a new transmitter purchase a new antenna purchase a new coax cable and move to a new transmitter site

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 E1000
Year 2007
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 BE-TV3K0-FAVI
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 3 kW
Justification for New Transmitter We are changing channels from UHF to VHF channel.The old transmitter cannot be re-tuned.

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 Yes
Description We need to put a new electrical installation of 100 amps.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 tons
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

150775

Patch Panel 3 Port w/1 U-Link, 1 5/8" EIA

86705-1 Dummy Load

Dummy Load 5kW 1 5/8" EIA Air cooled 110VAC Input

LPF-5KW-VI

Low Pass Filter 1 5/8" EIA input/Output

HE6P300A-03

Band Pass Filter, VHF Band I Channel 3 6-Pole 170 mm Bandpass Filter Input / Output 1-5/8 EIA female Tuned and tested on Channel 3 ATSC For KWDA-TV, Dallas TX FCC ID # 130929

SHIPPING

Crating, Material, Handling, Off-loading and Freight to Client Transmitter Site.

taxes

Total sales tax

DC3A39 2C-LK

Directional Coupler VHF

SPECIAL BE TV5k0 COAX KIT

Set of 1 5/8" EIA Inter-connecting coaxial line including 2 x 1 5/8" 6' length rigid coax line 6 x 1 5/8" 90 degree elbow 12 x Slip flange and hardware

Install Check-out and Proof

Installation assistance, proof of performance and check out of transmitter. One BE approved technician to assist with the unpacking, positioning, switch-on, and checking the operation of the transmitter system

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? 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
Mounting Top Mount
Antenna position in stack Top
Polarization Horizontal
Type Slotted Coaxial
ERP: 3.0 kW
Manufacturer
Model BC10-21
Year 2011

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 Middle
Polarization Circular
Type Other
Other Antenna Type omnidirectional
ERP: 3.0 kW
Manufacturer
Model JCPD-4/3 (12)-V
Year 2020
Justification for New Antenna We need to move from UHF Channel to VHF Channel.The antenna cannot be re-tuned.

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? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? Yes
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? Yes

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Ownership Owned
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 200 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Type Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 1050 feet per run
Justification for New Transmission Line New installation on tower
Interior RF Systems Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators? No

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)
Ownership Leased
Is this tower consider Complex? Located on Building
Is this tower currently shared with any other stations? No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1064625
Coordinates (NAD83) Latitude (NAD83) 32° 46' 48.0" N-
Longitude (NAD83) 096° 48' 14.0" W-
Overall Structure Height 941.59 feet
Support Structure Height 921.90 feet
Ground Elevation Above Mean Sea Level (AMSL) 426.50 feet
Structure Type BPIPE - Building with Pipe
Tower Owner TELECOMMUINICATION PROPERTIES INC
Date Constructed 03/01/1985


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

Information not provided.

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Move Equipment
Tower Use Primary (Main)
Ownership Leased
Is this tower consider Complex? Located on Building
Is this tower currently shared with any other stations? No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1064625
Coordinates (NAD83) Latitude (NAD83) 32° 46' 48.0" N-
Longitude (NAD83) 096° 48' 14.0" W-
Overall Structure Height 941.59 feet
Support Structure Height 921.90 feet
Ground Elevation Above Mean Sea Level (AMSL) 426.50 feet
Structure Type BPIPE - Building with Pipe
Tower Owner TELECOMMUINICATION PROPERTIES INC
Date Constructed 03/01/1985


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

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 8
Explanation Lmo does not have the expertise. Therefore, they will need to hire outside professional services.
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 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 Yes
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

Name Description

KWDA Installation cover letter

cover letter

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 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

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 $554,213.92 $543,977.05 N/A $182,590.62 N/A
Total for all systems $742,690.42 $730,823.05 N/A $333,207.62 N/A
Primary Transmitter BE-TV3K0-FAVI $554,213.92 $543,977.05 $182,590.62
Install Check-out and Proof $5,250.00 $5,250.00 N/A $5,250.00 N/A
SPECIAL BE TV5k0 COAX KIT $2,931.20 $2,931.20 N/A $2,931.20 N/A
DC3A39 2C-LK $832.00 $832.00 N/A $832.00 N/A
taxes $12,381.29 $12,381.29 N/A $12,381.29 N/A
SHIPPING $4,643.00 $4,643.00 N/A $4,643.00 N/A
HE6P300A-03 $11,744.00 $11,744.00 N/A $11,744.00 N/A
LPF-5KW-VI $8,160.00 $8,160.00 N/A $8,160.00 N/A
86705-1 Dummy Load $7,600.00 $7,600.00 N/A $7,600.00 N/A
150775 $2,216.00 $2,216.00 N/A $2,216.00 N/A
Low VHF - Air Cooled Solid State Transmitter 3 kW $468,086.43 $468,086.43 Cost for transmitter $106,700.00 Manufacturer for the ELMWI transmitter we had put down, is no longer in business. Therefore, we had to quote with Broadcast Electronics.
5 Ton system $20,250.00 $10,013.13 A new installation is need it at the new site. Old a/c install was at the old site and it's part of the property now. $10,013.13 N/A
Other Electrical Service: We need to put a new electrical installation of 100 amps. $10,120.00 $10,120.00 This will be a new electrical installation at a new site where the circuit 220 does not exist. $10,120.00 N/A

Components

Actual Information Description File Name
Install Check-out and Proof

Component Description:
Installation/Check-out and Proof
Amount:
$5,250.00
SPECIAL BE TV5k0 COAX KIT

Component Description:
We are requesting to be reimbursed the total $2,931.20 for line item SPECIAL-BE-TV5k0-COAX_KIT of the invoice attached.
Amount:
$2,931.20
DC3A39 2C-LK

Component Description:
DC3A39/2C-LK
Amount:
$832.00
taxes

Component Description:
Total Sales Tax
Amount:
$12,381.29
SHIPPING

Component Description:
SHIPPING
Amount:
$4,643.00
HE6P300A-03

Component Description:
HP6P300A-03
Amount:
$11,744.00
LPF-5KW-VI

Component Description:
LPF-5KW-VI Low Pass filter 1 5/8" EIA Input/Output
Amount:
$8,160.00
86705-1 Dummy Load

Component Description:
86705-1 Dummy Load 5KW 1 5/8" EIA Air Cooled 110VAC Input
Amount:
$7,600.00
150775

Component Description:
150775 Patch Panel 3 Port x/1 U-Link 1 5/8" EIA
Amount:
$2,216.00
Low VHF - Air Cooled Solid State Transmitter 3 kW

Component Description:
Broadcast Electronics, Genesis Series, Model BE-TV3k0-FAVI
Amount:
$106,700.00

Component Description:
Total amount is request it for VHF transmitter.
Amount:
$305,628.94
5 Ton system

Component Description:
Total of $10,013.13 is due for the installation of 5 ton system.
Amount:
$10,013.13
Other Electrical Service: We need to put a new electrical installation of 100 amps.

Component Description:
Vendor is requesting total payment for the electric installation.
Amount:
$10,120.00

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 $96,495.00 $101,855.00 N/A $96,955.00 N/A
Total for all systems $742,690.42 $730,823.05 N/A $333,207.62 N/A
Primary Antenna JCPD-4/3 (12)-V $96,495.00 $101,855.00 $96,955.00
Low VHF-Low Power, Side Mount, Other, 3.0kW input, Circular $89,620.00 $89,620.00 N/A $86,970.00 N/A
Side Mount antenna brackets $4,625.00 $9,985.00 Side mount antenna brackets are for the specific jampro antenna that will be install. Old brackets will not match with this type of antenna. $9,985.00 To have a quality signal on VHF we need to go to circular polarization. The antenna that we are going to be using is a circular polarization. We already tried horizontal polarization and the quality of signal is very poor.
$750.00 $750.00 N/A N/A N/A
Pattern scatter analysis for side mount (if not included in antenna base cost) $1,500.00 $1,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Low VHF-Low Power, Side Mount, Other, 3.0kW input, Circular

Component Description:
This antenna is an upgrade to the Horizontally Polarized antenna previously used. Therefore, we are only asking to be reimburse for $86,970 which is the amount the horizontal estimate is for.
Amount:
$86,970.00
Side Mount antenna brackets

Component Description:
Total amount of $9,985 is due with order as shown on the proforma invoice attached.
Amount:
N/A

Component Description:
Total payment of $9,985 is due at time of order as shown on invoice SDC 102720B-R1 attached.
Amount:
$9,985.00
Information not provided.
Pattern scatter analysis for side mount (if not included in antenna base cost) Information not provided.

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 $25,200.00 $14,212.00 N/A $14,212.00 N/A
Total for all systems $742,690.42 $730,823.05 N/A $333,207.62 N/A
Primary Transmission Line $25,200.00 $14,212.00 $14,212.00
Flexible Foam Transmission Line - dielectric, 1 5/8" $25,200.00 $14,212.00 N/A $14,212.00 N/A

Components

Actual Information Description File Name
Flexible Foam Transmission Line - dielectric, 1 5/8"

Component Description:
Vendor is requiring full payment up front for the 1-5/8" coax cable
Amount:
$14,212.00

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 $22,900.00 $22,900.00 N/A $22,900.00 N/A
Total for all systems $742,690.42 $730,823.05 N/A $333,207.62 N/A
Primary Tower BPIPE $0.00 $0.00 $0.00
Primary Tower BPIPE $22,900.00 $22,900.00 $22,900.00
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas) $22,900.00 $22,900.00 N/A $22,900.00 N/A

Components

Actual Information Description File Name
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas)

Component Description:
Requesting reimbursement of $22,900 for the installation of equipment.
Amount:
$22,900.00

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $42,436.50 $46,434.00 N/A $16,550.00 N/A
Total for all systems $742,690.42 $730,823.05 N/A $333,207.62 N/A
Outside Professional Services $42,436.50 $46,434.00 $16,550.00
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $5,062.50 Additional time spent on lease negotiations $5,062.50 Greater amount of time spent for negotiation of lease
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
Perform engineering study for displacement application $1,800.00 $1,800.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $3,500.00 The amount charged by the engineer $3,500.00 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
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,825.00 Costs for preparation and review of CP application $3,825.00 Greater period of time spent for preparation and filing of application
KWDA Installation cover letter $22,900.00 $22,900.00 N/A $0.00 N/A
Project management of the transition $844.00 $844.00 N/A N/A N/A
Form 399 assistance or other Program Management costs $4,162.50 $4,162.50 Addition time needed for Eligibility Showing; Additional time needed for FCC Form 399 $4,162.50 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A

Components

Actual Information Description File Name
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
Assistance for negotiation and draft of lease
Amount:
$5,062.50
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Perform engineering study for displacement application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Total amount paid
Amount:
$3,500.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Legal fees for drafting and filing of CP application
Amount:
$3,825.00
KWDA Installation cover letter

Component Description:
Total payment is due upon receipt as shown on invoice for installation of equipment
Amount:
$22,900.00
Project management of the transition Information not provided.
Form 399 assistance or other Program Management costs

Component Description:
Total amount invoiced
Amount:
$4,162.50
Prepare/ Review 399 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 $1,445.00 $1,445.00 N/A $0.00 N/A
Total for all systems $742,690.42 $730,823.05 N/A $333,207.62 N/A
Other Expenses $1,445.00 $1,445.00 $0.00
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A $0.00 N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,110.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $742,690.42 $730,823.05 $333,207.62

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
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.

Ana K Guel

President


01/14/2021

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.

Ana K Guel

President


01/14/2021

Attachments

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