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:
28155
Service:
DTV
Call Sign:
WSWG
Channel:
31 (UHF)
File Number:
0000028741
FRN:
0024469108
Date Submitted:
08/31/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

MARQUEE BROADCASTING GEORGIA, INC.

Doing Business As: Marquee Broadcasting Georgia Inc.

Patricia Lane

PO Box 4009

Salisbury, MD 21803

United States

+1 (410) 742-4747 patricia_lane@marqueebroadcasting.com 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

Samuel Hariton

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. No
Briefly describe transition plan WSWG is replacing its existing non-retunable transmitter, antenna, and utilizing the existing transmission line. The station will not be installing any interim equipment.

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 Ultimate
Year 2006
Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power Capacity 3 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 ULXTE-12
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 8.5 kW
Justification for New Transmitter The existing Ultimate series Transmitter cannot be re-tuned to the new frequency.

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) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service Yes
Description The new transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors.
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
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? Yes
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: 50.0 kW
Manufacturer
Model TLP 16J
Year 2006

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? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
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: 39.5 kW
Manufacturer
Model TLP-16J/VP
Year 2018
Justification for New Antenna The existing antenna is a single channel antenna and cannot be used on the newly assigned channel.

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? No
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

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 Utilize Existing
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 Dielectric
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 960 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Sweep Test

Sweep test of existing transmission line

Transmission Line - Additional Pieces

Transmission Line - Additional Pieces

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 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? No
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1017424
Coordinates (NAD83) Latitude (NAD83) 31° 10' 18.7" N-
Longitude (NAD83) 083° 21' 56.6" W-
Overall Structure Height 955.04 feet
Support Structure Height 898.94 feet
Ground Elevation Above Mean Sea Level (AMSL) 227.03 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Pinnacle Towers LLC
Date Constructed 10/28/1994

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
67098 WVKV FM
71343 WKAA 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 needed for undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor 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

Move Equipment

Replace existing antenna with new antenna

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 900
Explanation Strategic Support
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 Yes
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
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

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
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 No
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? Yes
Does this relocation require Equipment Storage? Yes
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

Security

Site Security during transition

Taxes

State and Local Taxes

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 $498,075.00 $295,701.65 N/A $295,701.65 N/A
Total for all systems $1,487,730.93 $1,254,002.58 N/A $502,130.52 N/A
Primary Transmitter ULXTE-12 $498,075.00 $295,701.65 $295,701.65
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW $494,500.00 $292,126.65 see Estimated Cost Justification WSWG-110-New 1st Primary Transmitter v0 $292,126.65 N/A
Other Electrical Service: The new transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors. $3,575.00 $3,575.00 Invoice Ooten and Associates #1805.5 $3,575.00 N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW

Component Description:
ULXTE-12 Transmitter
Amount:
$62,831.47

Component Description:
ULXTE-12 Transmitter
Amount:
$35,492.47

Component Description:
ULXTE-12 Transmitter
Amount:
$3,780.00

Component Description:
ULXTE-12 Transmitter
Amount:
$190,022.71
Other Electrical Service: The new transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors.

Component Description:
Electrical Engineer CAD/Clerical
Amount:
$3,575.00

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $36,924.58 $36,594.58 N/A $33,863.86 N/A
Total for all systems $1,487,730.93 $1,254,002.58 N/A $502,130.52 N/A
Primary Antenna TLP-16J/VP $36,924.58 $36,594.58 $33,863.86
UHF - High Power, Side Mount, basic slot antenna, 40 kW input, directional,, elliptically or circularly polarized $30,194.58 $30,194.58 N/A $27,463.86 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $6,400.00 N/A

Components

Actual Information Description File Name
UHF - High Power, Side Mount, basic slot antenna, 40 kW input, directional,, elliptically or circularly polarized

Component Description:
UHF-Low Power Side Mount
Amount:
$3,241.95

Component Description:
New Primary Antenna-UHF Side Mount
Amount:
$4,601.41

Component Description:
UHG - Low Power Side Mount
Amount:
$8,023.78

Component Description:
UHF Low Power Side Mount
Amount:
$5,521.69

Component Description:
UHF low power side mount TV ANT TLP16J/VP
Amount:
$6,075.03
Sweep test of existing antenna

Component Description:
Primary Antenna Sweep Test
Amount:
$1,920.00

Component Description:
Sweep test New Primary Antenna
Amount:
$1,600.00

Component Description:
Sweep Test (Pre-shipment payment)
Amount:
$1,600.00

Component Description:
Sweep test New Primary Antenna
Amount:
$1,280.00

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 $11,606.35 $11,606.35 N/A $10,124.61 N/A
Total for all systems $1,487,730.93 $1,254,002.58 N/A $502,130.52 N/A
Primary Transmission Line $11,606.35 $11,606.35 $10,124.61
Sweep Test $6,400.00 $6,400.00 N/A $4,918.26 N/A
Transmission Line - Additional Pieces $5,206.35 $5,206.35 Please see WSWG Transmission Line - Additional Pieces Budget Revision Justification Letter $5,206.35 N/A

Components

Actual Information Description File Name
Sweep Test

Component Description:
Engineering field services to sweep line
Amount:
$4,918.26
Transmission Line - Additional Pieces

Component Description:
Elbow 3-50 EIA 6.00 X 6.00 CU
Amount:
$5,206.35

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 $608,800.00 $595,500.00 N/A $84,840.00 N/A
Total for all systems $1,487,730.93 $1,254,002.58 N/A $502,130.52 N/A
Primary Tower TOWER $608,800.00 $595,500.00 $84,840.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $7,000.00 N/A $0.00 N/A
Minor tower reinforcement/modifications $158,000.00 $160,500.00 Includes state and local taxes $0.00 N/A
Move Equipment $214,000.00 $214,000.00 Includes state and local taxes $0.00 N/A
Tall Tower (greater than 500') $210,500.00 $214,000.00 Includes state and local taxes $84,840.00 N/A

Components

Actual Information Description File Name
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study Information not provided.
Minor tower reinforcement/modifications Information not provided.
Move Equipment Information not provided.
Tall Tower (greater than 500')

Component Description:
Tower Rigging Services - Tall Tower (greater than 500')
Amount:
$24,875.00

Component Description:
Tower Rigging Services - Tall Tower (500")
Amount:
$59,965.00

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $167,180.00 $158,750.00 N/A $75,373.20 N/A
Total for all systems $1,487,730.93 $1,254,002.58 N/A $502,130.52 N/A
Outside Professional Services $167,180.00 $158,750.00 $75,373.20
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $1,400.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $1,925.00 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A $0.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $0.00 N/A
Project management of the transition $142,200.00 $135,000.00 N/A $71,851.70 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A $0.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $196.50 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $0.00 N/A

Components

Actual Information Description File Name
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
This invoice covers both Engineering Study and Construction Permit preparation. This portion is for Construction Permit preparation.
Amount:
$1,400.00
Perform engineering study for new channel assignment and antenna development

Component Description:
Engineering Study for New Channel Assignment
Amount:
$1,050.00

Component Description:
This invoice includes both Engineering study and Construction Permit Application. This component is just the Engineering Study.
Amount:
$875.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Prepare and or review reimbursement form Information not provided.
Project management of the transition

Component Description:
Project Management
Amount:
$1,858.45

Component Description:
Project Management
Amount:
$79.05

Component Description:
Project Management
Amount:
$31.25

Component Description:
Project Management
Amount:
$322.50

Component Description:
Project Management
Amount:
$2,949.15

Component Description:
Project Management
Amount:
$2,051.15

Component Description:
Project Management
Amount:
$323.65

Component Description:
Project Management
Amount:
$270.00

Component Description:
Project Management
Amount:
$1,252.40

Component Description:
Project Management
Amount:
$1,158.75

Component Description:
Project Management
Amount:
$2,856.05

Component Description:
Project Management
Amount:
$3,189.45

Component Description:
Project Management
Amount:
$2,137.65

Component Description:
Project Management
Amount:
$52.50

Component Description:
Project Management
Amount:
$193.75

Component Description:
Project Management
Amount:
$143.75

Component Description:
Project Management
Amount:
$306.35

Component Description:
Project Management
Amount:
$2,630.00

Component Description:
Project Management
Amount:
$2,073.75

Component Description:
Project Mgt
Amount:
$28.20

Component Description:
Project management
Amount:
$3,230.15

Component Description:
Transition Related Project Management Costs
Amount:
$1,800.00

Component Description:
Project Mgt
Amount:
$2,218.55

Component Description:
Project Management
Amount:
$28.75

Component Description:
Project Management
Amount:
$232.50

Component Description:
Project Management
Amount:
$2,329.00

Component Description:
Project Management
Amount:
$2,642.70

Component Description:
Project Management
Amount:
$2,414.35

Component Description:
Project Management
Amount:
$4,660.30

Component Description:
Project Management
Amount:
$718.55

Component Description:
Project Management
Amount:
$2,609.85

Component Description:
Project Management
Amount:
$18.85

Component Description:
Project Management
Amount:
$411.25

Component Description:
Project management
Amount:
$1,328.55

Component Description:
Project Mgt
Amount:
$763.95

Component Description:
Project Management
Amount:
$2,079.15

Component Description:
Project Management
Amount:
$1,985.10

Component Description:
Project Management
Amount:
$206.25

Component Description:
Project Management
Amount:
$2,048.80

Component Description:
Project managment
Amount:
$2,456.90

Component Description:
Project Mgt
Amount:
$733.30

Component Description:
Project Mgt
Amount:
$2,701.30

Component Description:
Project Management
Amount:
$2,199.35

Component Description:
Project Management
Amount:
$1,961.10

Component Description:
Project Management
Amount:
$2,314.90

Component Description:
Project Management
Amount:
$133.85

Component Description:
Project Management
Amount:
$2,718.10

Component Description:
Project Management
Amount:
$802.25

Component Description:
Project Management
Amount:
$93.75

Component Description:
Project Management
Amount:
$102.50
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

Component Description:
FCC Credit Memo
Amount:
($196.50)

Component Description:
Professional services
Amount:
$196.50

Component Description:
Attorney CP Application
Amount:
$196.50
Prepare engineering section of FCC Form 2100 (main), License to Cover 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 $165,145.00 $155,850.00 N/A $2,227.20 N/A
Total for all systems $1,487,730.93 $1,254,002.58 N/A $502,130.52 N/A
Other Expenses $165,145.00 $155,850.00 $2,227.20
DTV Medical Facility Notification $11,550.00 $2,265.00 N/A $2,227.20 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A $0.00 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $500.00 $500.00 Based on station estimate $0.00 N/A
Equipment Delivery and Handling Charges $15,000.00 $15,000.00 N/A $0.00 N/A
Equipment Storage $12,000.00 $12,000.00 N/A $0.00 N/A
Develop and air announcement of upcoming channel change $10,000.00 $10,000.00 N/A $0.00 N/A
MVPD Notification of Channel Change $1,000.00 $1,000.00 N/A $0.00 N/A
Security $12,000.00 $12,000.00 N/A $0.00 N/A
Taxes $102,760.00 $102,760.00 N/A $0.00 N/A

Components

Actual Information Description File Name
DTV Medical Facility Notification

Component Description:
Medical Notification
Amount:
$2,227.20
FCC Filing Fees - Form 2100 license to cover application Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Equipment Storage Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
MVPD Notification of Channel Change Information not provided.
Security Information not provided.
Taxes Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,487,730.93 $1,254,002.58 $502,130.52

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.

Ricky Smarr

General Manager


08/31/2021

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.

Ricky Smarr

General Manager


08/31/2021

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