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:
41601
Service:
LPX
Call Sign:
K12PO
Channel:
3 (Low VHF)
File Number:
0000129910
FRN:
0002965655
Eligibility Status:
Not Determined
Date Submitted:
07/01/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

CHANNEL 51 OF SAN DIEGO, INC.

4575 Viewridge Avenue

San Diego, CA 92123

United States

+1 (858) 505-5150 swift@kusi.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

Fred V Swift , Mr .

Chief Engineer

Mc Kinnon Broadcasting

Fred Swift

4575 Viewridge Avenue

San Diego, CA 92123

United States

+1 (858) 571-5151 swift@kusi.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 K12PO went silent on March 15, 2019 when KDOC was was repacked to Ch. 12 in Anaheim, CA. K12PO was eventually assigned to Ch. 3. We are constructing facilities to move from UFH to VHF and will be serving the Murietta Community.

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 TXV-1000
Year 2004
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 TAUD-1000
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1 kW
Justification for New Transmitter The "Old" Transmitter is an Analog NTSC type. A Band change from VHF high (Ch.12) to VHF low (Ch.3) band the old transmitter is not re-tunable to new channel assignment. Also transition from analog to digital requires a ATSC replacement transmitter.

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 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 Middle
Polarization Horizontal
Type Other
Other Antenna Type 2 Panel Dipole (3) Omni
ERP: 1.0 kW
Manufacturer
Model 2RYDDP
Year 2003

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? Yes
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 Horizontal
Type Yagi
ERP: 3.0 kW
Manufacturer
Model AST0301337
Year 2020
Justification for New Antenna The Current antenna is a VHF high band omni directional .The new CP requires a Directional and the new assigned channel is VHF low band.

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? No
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 150 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 Flexible Foam
Diameter Other
Other Diameter 1 1/4 inches
Number of parallel runs 1
Length 150 feet per run
Justification for New Transmission Line The current 1 5/8 foam line is 17 plus years old.
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 Leased
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? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1016098
Coordinates (NAD83) Latitude (NAD83) 33° 35' 34.4" N-
Longitude (NAD83) 117° 08' 53.9" W-
Overall Structure Height 131.89 feet
Support Structure Height 130.90 feet
Ground Elevation Above Mean Sea Level (AMSL) 1729.97 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner American Towers LLC
Date Constructed 08/01/2003

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
63912 KXFG FM

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: Major 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

Name Description

Custom Mount

New Custom mount for Dual Yagi with 45 degree offset

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 150
Explanation Several filings and engineering studies were required over the use of Channel 15 due to LA County STA on Channel 15 .Ultimately we were assigned Channel 3
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 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 Yes
Quantity 1
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 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

Chief Engineer

Hours spent researching FCC databases for use of Channel 15 in Riverside County and Los Angeles County and TV Stations in Tijuana B.C. Mexico

Communication Technologies

Engineering data to support Channel 15 use in Temecula for K12PO

WBK Law

Legal representation and filings related to Channel 15 for K12PO replacement .The STA for Los Angeles County RICS .

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 No
FCC License to Cover Application No
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 $26,095.00 $26,095.00 N/A $0.00 N/A
Total for all systems $290,329.98 $244,565.98 N/A $86,412.52 N/A
Primary Transmitter TAUD-1000 $26,095.00 $26,095.00 $0.00
Low VHF - Air Cooled Solid State Transmitter 1000.0 Watts $26,095.00 $26,095.00 N/A $0.00 N/A

Components

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 $5,720.00 $10,616.00 N/A $0.00 N/A
Total for all systems $290,329.98 $244,565.98 N/A $86,412.52 N/A
Primary Antenna AST0301337 $5,720.00 $10,616.00 $0.00
Side Mount antenna brackets $4,625.00 $4,625.00 N/A N/A N/A
Low-VHF, Low Power,Yagi/Cross dipole/Log Periodic Transmit antenna $1,095.00 $5,991.00 Custom Pattern required for Mexico and Los Angeles requirements 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 $1,868.64 $1,868.64 N/A $0.00 N/A
Total for all systems $290,329.98 $244,565.98 N/A $86,412.52 N/A
Primary Transmission Line $1,868.64 $1,868.64 $0.00
Flexible Foam Transmission Line - 1 1/4" 1 parallel runs 150 feet $1,868.64 $1,868.64 N/A N/A N/A

Components

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $105,420.00 $57,670.00 N/A $0.00 N/A
Total for all systems $290,329.98 $244,565.98 N/A $86,412.52 N/A
Primary Tower TOWER $105,420.00 $57,670.00 $0.00
Major tower reinforcement/modifications $37,030.00 $37,030.00 N/A N/A N/A
Tower Rigging Short Tower (less than 500') $56,190.00 $15,640.00 N/A N/A N/A
Custom Mount $3,500.00 $3,500.00 N/A N/A N/A
Study needed for guyed or free-standing tower $8,700.00 $1,500.00 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 $151,226.34 $148,316.34 N/A $86,412.52 N/A
Total for all systems $290,329.98 $244,565.98 N/A $86,412.52 N/A
Outside Professional Services $151,226.34 $148,316.34 $86,412.52
WBK Law $88,705.84 $88,705.84 Multiple filing to obtain Channel 15 for K12PO,Los Angles County had a STA for Ch.15 $79,324.42 re-reviewed the invoices some costs for K12PO reimbursement were omitted
Communication Technologies $19,413.00 $19,413.00 Back and forth Engineering work with Channel 15 Land Mobile filings to justify channel 15,antenna patterns,etc to accommodate LA County RICS system. $7,088.10 The calculated estimate was incorrect ,the corrected actual costs have been uploaded
Chief Engineer $11,900.00 $11,900.00 time spent on Ch.15 research,LACO RICS studies,antenna pattern work,Field trips to look at LACO RICS propigation. N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $600.00 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
Project management of the transition $15,825.00 $15,825.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,442.00 N/A N/A N/A
Perform engineering study for displacement application $1,800.00 $1,500.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A
Form 399 assistance or other Program Management costs $600.00 $600.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $2,500.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,280.00 $965.50 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

Components

Actual Information Description File Name
WBK Law

Component Description:
K12PO Displacement filing,email for additional information for K12PO displacement
Amount:
$285.00

Component Description:
withdrawal app. for review,research withdrawal of Ch.15 appl. memo to FCC regarding Ch.3 CP,research status of Silent STA for K12PO,FCC work on Ch.3 CP
Amount:
$2,558.50

Component Description:
Reply opposition to Petition to Deny,review LACo reply,tele.conf. regarding LACO reply,Confer with B.Higgins regarding T band policies ,
Amount:
$1,551.46

Component Description:
res.status of 312(g) tolling req.phone call regarding K12PO with F.Swift.follow up with FCC about reimbursement,telephone calls with FCC for Ch.3 reg. auth.Conf. call with C.Beverage and F. Swift on Ch3 appl.Coord. STA work on new CP appl for Ch.3
Amount:
$4,820.00

Component Description:
Channel 15 application ,K12PO and KDOC ,Petition for Waiver,prep for FCC staff meeting regarding Ch.15 application.
Amount:
$6,501.00

Component Description:
K12PO next steps,research WNEP-TV applicability to LACO,K12PO STA request,work on appl.for Ch.15,File STA
Amount:
$4,837.50

Component Description:
Amend K15MG-D ,work on Ch.15 appl, work on Ch.15 application,Initiate appl.for "Silent STA",FCC staff follow up
Amount:
$3,428.00

Component Description:
Memo from/to F. Swift status of CP for Ch.3,research Status of Silent K12PO STA,obtaining grant for extension of Silent STA
Amount:
$1,553.00

Component Description:
Legal work on Ch.15 appl,denial,petitions,review LACO reports,response to LACO pet. to deny.
Amount:
$15,804.96

Component Description:
Ph.Call Ch.15 issues,Ch.15 Appl.prep for call w. F.Swift,C.Beverage & B Higgins,follow up Ch.15 issues
Amount:
$4,555.00

Component Description:
email FCC special application displacement window,email about house bill about reimbursement,email updating interference to TV/LPTV,update about omnibus bill regarding displaced LPTV
Amount:
$500.00

Component Description:
Telephone conference with Clarence Beverage (CommTech Engineer),Analysis of K12PO displacement application,Review emails from F. Swift and C.Beverage regarding K12PO prelim draft,File K12PO Displacement Application
Amount:
$783.00

Component Description:
follow up on Ch.15 appl.tele.call with C.Beverage on next steps to obtain grant on Ch.15 appl.
Amount:
$285.00

Component Description:
email mon. conflicts with K12PO ,email regards to satus K12PO conflicts ,Check status of K12PO,review FCC database for mutually exclusive LPTV appl. Memo to M.McKinnon et.al. regarding PN catalog for LPTV reimbursement,
Amount:
$570.00

Component Description:
email about K12PO LPTV displacement apllication,email to advise filing of K12PO displacement application,email regarding accepting K12PO displacement application
Amount:
$285.00

Component Description:
Initiate K12PO Displacement application,Conference with additional counsel for K12PO
Amount:
$586.00

Component Description:
Draft STA extension,extend Silent STA,sec.312(g) waiver req.,tolling request ,consider options on K12PO,consult with C.beverage,F. Swift on possibility of using Ch.21,Channel changes in general for Ch.15 options,
Amount:
$10,027.00

Component Description:
Research K03JB-D reimbursement certification ,Research for M.Mc Kinnon &F. Swift on obtaining reimbursement ,Form 399 coaching/advice
Amount:
$1,649.00

Component Description:
Review issues raised by Engineers regarding pending LPTV application,telephone call and email FCC staff about issues LMR , with F. Swift & C.Beverage,telephone call with F. Swift regarding Channel 15 Broadcasting from Tijuana ,BC,Mexico
Amount:
$4,946.00

Component Description:
Rev. LACO Opposition,reply to LACO opposition,research and draft reply to Opp. for review ,Replay to LACOopp.,reimburse conversation,finalize reply to opp.work on LPTV amendment.
Amount:
$9,381.92

Component Description:
Grant,review CP and memo,research reimbursement from FCC,talk to FCC staff to discuss Form 399
Amount:
$965.50

Component Description:
Draft appl. rev .dismissal of K12PO Ch.15 appl.work on Appl. for review and memos from C. Beverage ,revise appl.Final review
Amount:
$9,047.00

Component Description:
KDOC phase time line ,Memo to M. Mc Kinnon actions on LPTV reimbursement ,inquiry for eligibility for reimbursement,Conf. about no CP eligibility for LPTV
Amount:
N/A

Component Description:
Draft appl.
Amount:
$8,214.50

Component Description:
Draft reason for STA request for Ch.3,work on STA for Ch.3 for K12PO displacement ,letter to FCC staff for guidance for change to Ch.3,follow up with C.Beverage and F.Swift regarding application
Amount:
$3,786.50
Communication Technologies

Component Description:
Continued work on K12PO application for Ch.15 ,Engineering work for counter LMR issue with Los Angeles County .
Amount:
$4,544.35

Component Description:
Continued work on K12PO STA,Channel 15 LMR study work,Evaluate Ch.3 options and antennas,system design.
Amount:
$2,543.75

Component Description:
Update Allocation Study (Ch.03)formalize prior amendment to prior displacement application
Amount:
$1,250.00

Component Description:
Continued Engineering work on Channel 3 change and Antenna calculations for best performance.Review CH.15 reconsiderations
Amount:
$601.25

Component Description:
K12PO study for a displacement operational channel 2-13 and 14-36 .Formalize the results
Amount:
$1,500.00

Component Description:
Continued work on K12PO displacement channel 15, work on interference potential with Tijuana Mexico Ch.15,work with WBK_Law and F. Swift to develop engineering input for Ch.15 use.
Amount:
$4,347.50

Component Description:
Prepare FCC LMS filing for application ,Engineering and Environmental.
Amount:
$1,202.50

Component Description:
Continue engineering work on attempting to retain Ch.15 for K12PO displacement,work to find alternate channel for Ch.15 due to LA County opposition.
Amount:
$3,423.75
Chief Engineer Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Project management of the transition Information not provided.
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/ Review 399 reimbursement form Information not provided.
Form 399 assistance or other Program Management costs Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application 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 $0.00 $0.00 N/A $0.00 N/A
Total for all systems $290,329.98 $244,565.98 N/A $86,412.52 N/A
Other Expenses $0.00 $0.00 $0.00

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $290,329.98 $244,565.98 $86,412.52

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.

Fred V Swift , Mr .

Chief Engineer


07/01/2021

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.

Fred V Swift , Mr .

Chief Engineer


07/01/2021

Attachments

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