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:
187680
Service:
LPT
Call Sign:
WNXG-LD
Channel:
33 (UHF)
File Number:
0000089912
FRN:
0018223693
Eligibility Status:
Eligible
Date Submitted:
03/29/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GRAY TELEVISION LICENSEE, LLC

4370 PEACHTREE ROAD, NE

Atlanta, GA 30319

United States

+1 (540) 433-9191 Robert.Folliard@gray.tv Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Samuel Hariton

Widelity

4031 University Dr

Suite 100

Fairfax, VA 22030

United States

+1 (339) 222-8107 sam.hariton@widelity.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. Yes
Briefly describe transition plan WNXG-LD is planning to purchase a like-for-like transmitter, antenna, and transmission line. Station is being forced to move by the existing tower owner, who did not permit installation of receive dish, nor responsive to other request.

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 Retune Existing
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 Anywave
Model ACT-5XU-1000-A-C
Year 2014
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.67 kW

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New Mask Filter Does the transmitter require a new mask filter? Yes
Mask Filter Type Full Service
Power 1.1-2kW
New Exciter Is a new exciter needed? No

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) Yes
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

Information not provided.

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 ACT-5XU-1000-A-C
Year 2014
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.67 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 UAXTE-4-G2
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2 kW
Justification for New Transmitter WNXG originally planned to retune their transmitter. This is no longer the case, as the retuned transmitter would not have worked with the post-displacement equipment.

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) Yes
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

Information not provided.

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 Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model SWLP16OI
Year 2010

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? Yes
Is antenna directional? No
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Broadband Panel
Number of Stations Supported 4
Number of Panels/Bays 4
Lower Limit 491.00 MHz
Upper Limit 587.00 MHz
Design power capacity in use 2.6 %
ERP: 15.0 kW
Manufacturer
Model TUM-O4-10/40H-1-R
Year 2019
Justification for New Antenna Replacement of the antenna is necessary because the existing tower owner will not permit installation of a receive dish to provide programming to the tower and is not responsive to WUFX on issues related to the repack

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? Yes
Type New
Number of channels supported 4
Frequencies of channels supported RF channel
Elbow Complex Do you require the separate purchase of the Elbow Complex? 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
Power Dividers Does the panel antenna require power dividers? No
Cable Harness Does the panel antenna require cable harness? No

Enter a list of RF channel numbers.

RF Channel Number
20
30
33
17

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 Air
Diameter 1 5/8 inches
Number of parallel runs 1
Length 800 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? No
Type Rigid
Diameter 6 1/8 inches
Segment Length 19 1/2 inches
Number of parallel runs 1
Length 900 feet per run
Justification for New Transmission Line Replacement of the transmission line is necessary because the existing tower owner will not permit installation of a receive dish to provide programming to the tower and is not responsive to WUFX on issues related to the repack.
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 Modify Existing
Tower Use Primary (Main)
Ownership Owned
Is this tower consider Complex? No
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? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1031203
Coordinates (NAD83) Latitude (NAD83) 30° 34' 28.0" N-
Longitude (NAD83) 084° 12' 09.0" W-
Overall Structure Height 898.94 feet
Support Structure Height 833.32 feet
Ground Elevation Above Mean Sea Level (AMSL) 144.36 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner Gray Television Group, Inc.
Date Constructed 06/01/2017

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
3032 WVUP-CD 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: Study need for guyed or free-standing tower
Tower Reinforcements Please select whether tower reinforcements are needed: No reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 254
Explanation WUFX-LD does not have sufficient resource capacity & expertise in house to handle the reimbursement filing, tracking, coordination, progress reporting, budget creation, review & tracking & all other activities necessary to facility on-time completion
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 Yes
Quantity 1
Prepare Form 601 Yes
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Negotiation of Lease and other Matter for Shared Locations No
Prepare or Review FCC Form 399 for Reimbursement Yes
Form 399 assistance or other program management costs No
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service No

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Permit and Filing Costs FCC Construction Permit Major Change Yes
FCC Construction Permit Minor Change Yes
FCC License to Cover Application Yes
FCC Special Temporary Authority Application No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? 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 $122,200.00 $99,222.53 N/A $70,263.11 N/A
Total for all systems $512,226.50 $317,363.88 N/A $96,446.96 N/A
Primary Transmitter ACT-5XU-1000-A-C $0.00 $0.00 $0.00
Primary Transmitter UAXTE-4-G2 $122,200.00 $99,222.53 $70,263.11
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $70,263.11 Please see Estimated Cost Justification WNXG-LD-110-UHF-Air Cooled Solid State Transmitter 1-2.5 kW v0 $70,263.11 N/A
Switchgear - industrial 800 amp $38,200.00 $28,959.42 Please see Estimated Cost Justification WNXG-LD-110-Primary Transmitter - Switchgear V0 $0.00 N/A

Components

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

Component Description:
Transmitter
Amount:
$11,577.00

Component Description:
Transmitter
Amount:
$868.27

Component Description:
UAXTE-4-G2-R37 HIGH EFFICIENCY
Amount:
$57,817.84
Switchgear - industrial 800 amp 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 $5,730.00 $5,730.00 N/A $0.00 N/A
Total for all systems $512,226.50 $317,363.88 N/A $96,446.96 N/A
Primary Antenna TUM-O4-10/40H-1-R $5,730.00 $5,730.00 $0.00
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A
UHF-Low Power, Top Mount, Broadband Panel, 4 bay, 15.0kW input, Elliptical $0.00 $0.00 Sharing station WCTV is paying and requesting reimbursement for these costs per Dielectric Proposal C-71415-1 and DTVPros Quotes JEHQ1717 and 1704. N/A N/A

Components

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 $165,600.00 $0.00 N/A $0.00 N/A
Total for all systems $512,226.50 $317,363.88 N/A $96,446.96 N/A
Primary Transmission Line $165,600.00 $0.00 $0.00
Rigid Transmission Line - copper, 6 1/8" $165,600.00 $0.00 Sharing station WCTV is paying and requesting reimbursement for these costs per DTVPros quote JEHQ1702-02. 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 $166,450.00 $166,450.00 N/A $0.00 N/A
Total for all systems $512,226.50 $317,363.88 N/A $96,446.96 N/A
Primary Tower GTOWER $166,450.00 $166,450.00 $0.00
Tower Rigging Tall Tower (greater than 500') $157,750.00 $157,750.00 N/A N/A N/A
Study needed for guyed or free-standing tower $8,700.00 $8,700.00 N/A N/A N/A

Components

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 $40,099.50 $33,814.35 N/A $23,591.85 N/A
Total for all systems $512,226.50 $317,363.88 N/A $96,446.96 N/A
Outside Professional Services $40,099.50 $33,814.35 $23,591.85
Project management of the transition $26,797.00 $19,691.85 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $19,691.85 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,280.00 $750.00 Please see WUFX-LD RF Engineering - Special Temporary Authority Budget Revision Justification Letter $750.00 N/A
Perform engineering study for displacement application $1,800.00 $3,150.00 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $3,150.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A
Prepare Form 601 $755.00 $755.00 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$1,779.80

Component Description:
Project Management
Amount:
$658.40

Component Description:
Project Management
Amount:
$567.00

Component Description:
Project Management
Amount:
$90.15

Component Description:
Project Management
Amount:
$12.40

Component Description:
Project Management
Amount:
$172.50

Component Description:
Project Management
Amount:
$1,725.80

Component Description:
Project Management
Amount:
$380.45

Component Description:
Project Management
Amount:
$104.25

Component Description:
Project Management
Amount:
$303.60

Component Description:
Project Management
Amount:
$80.25

Component Description:
Project Management
Amount:
$78.45

Component Description:
Project Management
Amount:
$75.15

Component Description:
Project Management
Amount:
$116.10

Component Description:
Project Management
Amount:
$1,227.45

Component Description:
Project Management
Amount:
$25.35

Component Description:
Project management
Amount:
$4,600.15

Component Description:
Project Management
Amount:
$540.35

Component Description:
Project management
Amount:
$1,502.90

Component Description:
Project management
Amount:
$1,061.65

Component Description:
Project Management
Amount:
$62.45

Component Description:
Project management
Amount:
$20.70

Component Description:
Project Management
Amount:
$459.05

Component Description:
Project Management
Amount:
$279.95

Component Description:
Project Management
Amount:
$18.45

Component Description:
Project Management
Amount:
$1,675.90

Component Description:
Project Management
Amount:
$2,073.20
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization

Component Description:
WUFX-LD-530-RF Eng- STA
Amount:
$750.00
Perform engineering study for displacement application

Component Description:
Consulting Engineer - Hourly
Amount:
$650.00

Component Description:
Develop final technical parameters for prospective facility at its licensed site. Preparation of engineering exhibits of displacement application.
Amount:
$1,525.00

Component Description:
Regarding displacement CP for Ch-33
Amount:
$200.00

Component Description:
Review of make/model substitution for shared antenna
Amount:
$375.00

Component Description:
Various discussions regarding antenna/line/TPO
Amount:
$400.00
Prepare/ Review 399 reimbursement form Information not provided.
Prepare Form 601 Information not provided.

Cost Information

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Other Expenses

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $12,147.00 $12,147.00 N/A $2,592.00 N/A
Total for all systems $512,226.50 $317,363.88 N/A $96,446.96 N/A
Other Expenses $12,147.00 $12,147.00 $2,592.00
FCC Filing Fees - Form 2100 Major change CP application $4,960.00 $4,960.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,110.00 N/A N/A N/A
Equipment Delivery and Handling Charges $5,742.00 $5,742.00 Please see Estimated Cost Justification WNXG-LD-610-Equipment Delivery and Handling v0 $2,592.00 N/A

Components

Actual Information Description File Name
FCC Filing Fees - Form 2100 Major change CP application Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
Equipment Delivery and Handling Charges

Component Description:
FREIGHT
Amount:
$3,150.00

Component Description:
FREIGHT AND SHIPPING
Amount:
$2,592.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $512,226.50 $317,363.88 $96,446.96

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.

Robert Folliard , III .

Assistant Secretary


03/29/2021

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.

Robert Folliard , III .

Assistant Secretary


03/29/2021

Attachments

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