FCC Form 399: Reimbursement Request

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.

The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

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).

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.

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.

The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

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.

The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

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) .

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.

The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

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.