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:
70161
Service:
DCA
Call Sign:
WALV-CD
Channel:
17 (UHF)
File Number:
0000028118
FRN:
0006173322
Date Submitted:
03/22/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

VIDEOHIO, INC.

Denise A. Branson, Sr. Paralegal

8350 BROAD STREET, SUITE 2000

Tysons, VA 22102

United States

+1 (703) 873-6606 dbranson@tegna.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

Gary Davis

Regional Head of Technology and Operations

TEGNA

Gary Davis

8350 Broad Street

Suite 2000

Tysons, VA 22102

United States

+1 (404) 873-9199 gadavis@tegna.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 Remove and replace existing antenna. Remove and replace existing transmission line. Remove and replace main transmitter. Co-located on tower shared with WTHR.

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 Sigma CD
Year 1998
Type Inductive Output Tube
IOT Power Type Other
Other IOT Power Type Former IOT transmitter converted to 1.1 kW solid state for LPTV
Power Capacity 1.1 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? Yes
Manufacturer
Model EC704HP-BB
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 3.4 kW
Justification for New Transmitter Per attached Gates Air letter, existing transmitter cannot be retuned to low band channel 17.

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) Yes
Transformer (480V) Yes
Power 150 kVA
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service Yes
Description Conduit and wiring run from switchgear to new transmitter.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 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

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)
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 Full Power
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 TFU-30 DSC-R O4
Year 2002

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 Circular
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: 8.18 kW
Manufacturer
Model AL8-17-PMC
Year 2019
Justification for New Antenna Existing antenna cannot 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?
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? No
Broadband or Single Channel? N/A
Feed Line Size N/A
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

Name Description

Weather Days

Weather Days

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 Rigid
Diameter 3 1/8 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 926 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 Rigid
Diameter 3 1/8 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 926 feet per run
Justification for New Transmission Line Existing transmission line section length incompatible with channel 17

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Replace coax switch and load

Coax switch and load are high band UHF, not compatible with channel 17

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)
Description of Use N/A
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 Yes
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1024109
Coordinates (NAD83) Latitude (NAD83) 39° 55' 43.0" N-
Longitude (NAD83) 086° 10' 55.0" W-
Overall Structure Height 1039.36 feet
Support Structure Height 929.45 feet
Ground Elevation Above Mean Sea Level (AMSL) 823.81 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner VideoIndiana, Inc.
Date Constructed 01/01/1984

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
70162 WTHR DTV

Other Types of Users

Users
Echostar LCF

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 needed for documented 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 300
Explanation Antenna analysis and spec, transmitter spec, installation drawings, installation supervision, accounting, legal, internal
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 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 Yes
RF exposure measurements Yes
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 Engineering Services

Other Engineering Services

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 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)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? No
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

Equipment Delivery and Handling Charges

Equipment Delivery and Handling Charges

Sales Tax

Sales Tax

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 $249,600.00 $214,024.00 N/A $141,312.80 N/A
Total for all systems $1,146,748.52 $885,411.55 N/A $181,043.52 N/A
Primary Transmitter EC704HP-BB $249,600.00 $214,024.00 $141,312.80
Other Electrical Service: Conduit and wiring run from switchgear to new transmitter. $10,000.00 $10,000.00 N/A $5,250.00 N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW $155,600.00 $143,224.00 See attached / uploaded PDF files titled "Comark S10430-1 v200312jgv3.pdf" and "See attached / uploaded PDF file titled "Comark S10430-2 v200312jgv3.pdf" $136,062.80 N/A
5 Ton system $20,250.00 $19,250.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $5,250.00 N/A N/A N/A

Components

Actual Information Description File Name
Other Electrical Service: Conduit and wiring run from switchgear to new transmitter.

Component Description:
Storms-McMullen 2019010045 v200603pmv2
Amount:
$5,250.00
Switchgear - industrial 800 amp Information not provided.
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW

Component Description:
Comark S10430-2 v210322jgv4
Amount:
$85,934.40

Component Description:
Comark S10430-1 v210322jgv4
Amount:
$50,128.40
5 Ton system Information not provided.
Transformer 3 phase/480v - 150 KVA 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 $42,130.00 $32,278.00 N/A $9,100.00 N/A
Total for all systems $1,146,748.52 $885,411.55 N/A $181,043.52 N/A
Primary Antenna AL8-17-PMC $42,130.00 $32,278.00 $9,100.00
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $0.00 N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $16,778.00 N/A $0.00 N/A
Weather Days $9,100.00 $9,100.00 See attached invoice and it's quote and change order $9,100.00 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
ERI WALV-500 v200121pmv1
Amount:
$3,125.00

Component Description:
ERI WALV-37442 v200121pmv1
Amount:
$2,500.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
ERI WALV-37442 v200121pmv1
Amount:
$6,664.00

Component Description:
ERI WALV-500 v200121pmv1
Amount:
$6,664.00
Weather Days

Component Description:
ERI 54616 v200508pmv1
Amount:
$9,100.00

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 $102,150.00 $86,938.00 N/A $0.00 N/A
Total for all systems $1,146,748.52 $885,411.55 N/A $181,043.52 N/A
Primary Transmission Line $102,150.00 $86,938.00 $0.00
Rigid Transmission Line - copper, 3 1/8" $96,304.00 $81,092.00 N/A $0.00 N/A
Replace coax switch and load $5,846.00 $5,846.00 N/A N/A N/A

Components

Actual Information Description File Name
Rigid Transmission Line - copper, 3 1/8"

Component Description:
ERI WALV-37442 v200121pmv1
Amount:
$32,209.62

Component Description:
ERI WALV-500 v200121pmv1
Amount:
$32,209.62
Replace coax switch and load 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 $223,100.00 $180,447.00 N/A $0.00 N/A
Total for all systems $1,146,748.52 $885,411.55 N/A $181,043.52 N/A
Primary Tower TOWER $223,100.00 $180,447.00 $0.00
Tall Tower (greater than 500') $210,500.00 $175,447.00 N/A $0.00 N/A
Structural engineering tower load study for well documented tower $12,600.00 $5,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Tall Tower (greater than 500')

Component Description:
ERI WALV-500 v200121pmv1
Amount:
$87,723.50

Component Description:
ERI WALV-37442 v200121pmv1
Amount:
$70,178.80
Structural engineering tower load study for well documented tower 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 $177,407.50 $169,147.50 N/A $11,846.50 N/A
Total for all systems $1,146,748.52 $885,411.55 N/A $181,043.52 N/A
Outside Professional Services $177,407.50 $169,147.50 $11,846.50
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
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A N/A N/A
Project management of the transition $47,400.00 $45,000.00 N/A $6,449.00 N/A
Other Engineering Services $2,407.50 $2,407.50 See attached invoices $2,407.50 N/A
RF Exposure Measurements $21,050.00 $20,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,990.00 See attached invoices $2,990.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A N/A N/A

Components

Actual Information Description File Name
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.
Project management of the transition

Component Description:
Osborn 40960 v201215pmv1
Amount:
$158.00

Component Description:
Osborn 40655 v201215pmv1
Amount:
$158.00

Component Description:
Osborn 40021 v201215pmv1
Amount:
$316.00

Component Description:
Osborn 39006 v200717pmv1
Amount:
$1,817.00

Component Description:
Osborn 39688 v201215pmv1
Amount:
$1,185.00

Component Description:
Osborn 36190 v200924jgv2
Amount:
$79.00

Component Description:
Osborn 40307 v201215pmv1
Amount:
$316.00

Component Description:
Osborn 38632 v200717pmv1
Amount:
$1,156.00

Component Description:
Osborn 39394 v201116pmv1
Amount:
$1,027.00

Component Description:
Osborn 38334 v200724pmv1
Amount:
$237.00
Other Engineering Services

Component Description:
Osborn 39688 v201215pmv1
Amount:
$1,942.50

Component Description:
Osborn 38632 v200717pmv1
Amount:
$465.00
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Prepare and or review reimbursement form

Component Description:
Osborn 40655 v201215pmv1
Amount:
$175.00

Component Description:
Osborn 40021 v201215pmv1
Amount:
$545.00

Component Description:
Osborn 39688 v201215pmv1
Amount:
$165.00

Component Description:
Osborn 38632 v200717pmv1
Amount:
$1,010.00

Component Description:
Osborn 38334 v200724pmv1
Amount:
$300.00

Component Description:
Osborn 39394 v201116pmv1
Amount:
$795.00
Perform engineering study for new channel assignment and antenna development 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 $43,831.02 $40,161.02 N/A $18,784.22 N/A
Total for all systems $1,146,748.52 $885,411.55 N/A $181,043.52 N/A
Other Expenses $43,831.02 $40,161.02 $18,784.22
Equipment Delivery and Handling Charges $4,286.00 $4,286.00 See attached / uploaded PDF files titled "Comark S10430-1 v200312jgv3.pdf" and "See attached / uploaded PDF file titled "Comark S10430-2 v200312jgv3.pdf" $4,071.70 N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 N/A $1,743.00 N/A
Develop and air announcement of upcoming channel change $5,000.00 $5,000.00 N/A N/A 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
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $0.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $9,000.00 N/A $4,372.00 N/A
Sales Tax $9,050.02 $9,050.02 See attached / uploaded PDF files titled "Comark S10430-1 v200312jgv3.pdf" and "See attached / uploaded PDF file titled "Comark S10430-2 v200312jgv3.pdf" $8,597.52 N/A

Components

Actual Information Description File Name
Equipment Delivery and Handling Charges

Component Description:
Comark S10430-2 v210322jgv4
Amount:
$2,571.60

Component Description:
Comark S10430-1 v210322jgv4
Amount:
$1,500.10
MVPD Notification of Channel Change

Component Description:
Osborn 39006 v200717pmv1
Amount:
$1,743.00
Develop and air announcement of upcoming channel change Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) 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.
DTV Medical Facility Notification

Component Description:
Osborn 39006 v200717pmv1
Amount:
$4,372.00
Sales Tax

Component Description:
Comark S10430-2 v210322jgv4
Amount:
$5,430.01

Component Description:
Comark S10430-1 v210322jgv4
Amount:
$3,167.51

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,146,748.52 $885,411.55 $181,043.52

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. 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.

Jeffrey C Gehman

Engineering Associate


03/22/2021

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.

Jeffrey C Gehman

Engineering Associate


03/22/2021

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