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:
30580
Service:
DCA
Call Sign:
WPBM-CD
Channel:
15 (UHF)
File Number:
0000027927
FRN:
0004958898
Date Submitted:
10/08/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

PROCLAIM BROADCASTING, INC.

Doing Business As: PROCLAIM BROADCASTING, INC.

David Benz

9406 NEW GLASGOW ROAD

SCOTTSVILLE, KY 42164

United States

+1 (270) 618-8831 tv31@nctc.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

Matthew H. McCormick

Fletcher, Heald & Hildreth, P.L.C.

Matthew H. McCormick

1300 N. 17th Street

Eleventh Floor

Arlington, VA 22209

United States

+1 (703) 812-0400 mccormick@fhhlaw.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 Applicant owns its own tower and there aren't any other broadcast television stations co-located on the tower. Applicant plans to remove the existing 3 bay antenna and install the new antenna in its place.

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 CU1000BRD
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.0 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 TMx9 transmitter system
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.0 kW
Justification for New Transmitter Station is changing frequency from Channel 46 to Channel 15 which is too wide of a spread for components.

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 Transmitter will use existing service in building.
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A tons
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 Class A
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 LP24OI
Year 2009

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 Class A
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: 7.7 kW
Manufacturer
Model PSILPD12OI-15-EP
Year 2019
Justification for New Antenna Existing antenna cannot be retuned from Channel 46 to Channel 15

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? No

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? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 36° 49' 59.9" N-
Longitude (NAD83) 086° 05' 59.9" W-
Overall Structure Height 498.68 feet
Support Structure Height 498.68 feet
Ground Elevation Above Mean Sea Level (AMSL) 700.12 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Proclaim Broadcast
Date Constructed 01/01/1991


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

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 80
Explanation Station doesn't employ anyone with the technical knowledge to manage changes.
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 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

Name Description

Comprehensive Engineering Services

Package of engineering services of various types needed for repack

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? 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

Additional Legal Expenses in Connection with Required Reports

Legal fees for preparing, reviewing and/or filing FCC required reports regarding transition

Antenna

Shipping charges

Consumer Notifications Legal Expenses

Legal fees for advising station regarding consumer notifications of station channel change

Medical Facility Notification

Legal fees for advising station regarding medical facility notification of station channel change

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 $127,530.00 $89,141.64 N/A $87,611.64 N/A
Total for all systems $520,444.00 $425,775.39 N/A $163,902.44 N/A
Primary Transmitter TMx9 transmitter system $127,530.00 $89,141.64 $87,611.64
Other Electrical Service: Transmitter will use existing service in building. $1,530.00 $1,530.00 Installation of new wiring and necessary moving of existing wiring took additional time. N/A N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $87,611.64 Licensee is increasing its estimated cost due to a price increase by the manufacturer for the same transmitter, plus the addition of the amount of a required sales tax payment. $87,611.64 N/A

Components

Actual Information Description File Name
Other Electrical Service: Transmitter will use existing service in building. Information not provided.
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Invoice for transmitter and associated equipment plus sales tax
Amount:
$87,611.64

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 $33,030.00 $19,825.00 N/A $17,325.00 N/A
Total for all systems $520,444.00 $425,775.39 N/A $163,902.44 N/A
Primary Antenna PSILPD12OI-15-EP $33,030.00 $19,825.00 $17,325.00
Sweep test of existing antenna $6,730.00 $2,500.00 . N/A N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $17,325.00 N/A $17,325.00 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna Information not provided.
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
Cost of replacement antenna
Amount:
$17,325.00

Cost Information

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Transmission Line

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 $268,500.00 $230,000.00 N/A $5,500.00 N/A
Total for all systems $520,444.00 $425,775.39 N/A $163,902.44 N/A
Primary Tower TOWER $268,500.00 $230,000.00 $5,500.00
Short Tower (less than 500') $84,200.00 $80,000.00 N/A $5,500.00 N/A
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A N/A N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $0.00 Included in comprehensive engineering services N/A N/A

Components

Actual Information Description File Name
Short Tower (less than 500')

Component Description:
Emergency completion of antenna installation after other tower worker injury
Amount:
$5,500.00
Minor tower reinforcement/modifications Information not provided.
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study 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 $62,690.00 $64,118.75 N/A $40,737.50 N/A
Total for all systems $520,444.00 $425,775.39 N/A $163,902.44 N/A
Outside Professional Services $62,690.00 $64,118.75 $40,737.50
Prepare and or review reimbursement form $2,630.00 $10,168.75 Form more complex and time-consuming than expected. $10,168.75 N/A
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 $2,868.75 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $2,000.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A N/A N/A
Project management of the transition $12,640.00 $9,000.00 N/A N/A N/A
Comprehensive Engineering Services $27,700.00 $27,700.00 This amount replaces prior estimates of individual costs included in comprehensive bill, now reduced to $0 which previously totaled $32,700 - a clear savings. $27,700.00 N/A

Components

Actual Information Description File Name
Prepare and or review reimbursement form

Component Description:
Legal fees for advice and counsel with regard to reimbursement of repack expenses and necessary actions to obtain same
Amount:
$100.00

Component Description:
Legal fees for advice regarding obtaining reimbursement of repack expenses
Amount:
$125.00

Component Description:
Legal fees for advice and counsel with regard to reimbursement of repack expenses and necessary actions to obtain same
Amount:
$7,422.50

Component Description:
Legal advice and assistance with requesting reimbursement of repack expenses.
Amount:
$315.00

Component Description:
Legal fees for advice and representation with regard to strategy, necessary information, preparation, and filing of information and forms needed for reimbursement
Amount:
$950.00

Component Description:
Fees for legal advice and representation with regard to forms required for reimbursement payments
Amount:
$187.50

Component Description:
Legal fees for advice and representation in connection with forms necessary for reimbursement and preparation and filing of same
Amount:
$956.25

Component Description:
Legal fees for advice and representation with regard to obtaining reimbursement of repack expenses
Amount:
$112.50
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:
Legal fees for advice and representation in connection with Form 2100 repack c.p. application
Amount:
$1,237.50

Component Description:
Fees for legal advice and advocacy related to repack c.p. application
Amount:
$187.50

Component Description:
Legal fees for advice and representation in connection with Form 2100 repack c.p. application
Amount:
$1,106.25

Component Description:
Fees for legal advice in connection with Form 2100 repack. c.p. application
Amount:
$112.50

Component Description:
Legal advice with regard to channel assignment to be specified in Form 2100 c.p. application
Amount:
$112.50

Component Description:
Legal advice concerning application needed for repack and application deadline
Amount:
$112.50
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.
Perform engineering study for new channel assignment and antenna development Information not provided.
Project management of the transition Information not provided.
Comprehensive Engineering Services

Component Description:
Comprehensive engineering services needed for repack
Amount:
$27,700.00

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 $28,694.00 $22,690.00 N/A $12,728.30 N/A
Total for all systems $520,444.00 $425,775.39 N/A $163,902.44 N/A
Other Expenses $28,694.00 $22,690.00 $12,728.30
Medical Facility Notification $135.00 $135.00 N/A $135.00 N/A
Consumer Notifications Legal Expenses $270.00 $270.00 N/A $270.00 N/A
Antenna $0.00 $0.00 N/A N/A N/A
Additional Legal Expenses in Connection with Required Reports $4,000.00 $4,000.00 Assistance needed with regard to reports required by FCC in connection with transition to report on progress and other matters. $3,235.00 N/A
MVPD Notification of Channel Change $2,994.00 $2,994.00 The actual charges by service providers are more than initially anticipated. $2,994.00 N/A
Develop and air announcement of upcoming channel change $1,000.00 $1,000.00 N/A N/A N/A
Equipment Storage $4,800.00 $4,800.00 N/A N/A N/A
Equipment Delivery and Handling Charges $1,500.00 $1,500.00 N/A $498.30 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $1,000.00 $1,000.00 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
DTV Medical Facility Notification $11,550.00 $5,596.00 N/A $5,596.00 N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A

Components

Actual Information Description File Name
Medical Facility Notification

Component Description:
Legal fees associated with advising station regarding required medical facility notification of station channel change
Amount:
$135.00
Consumer Notifications Legal Expenses

Component Description:
Legal fees associated with advising station regarding required consumer notifications for station channel change
Amount:
$270.00
Antenna Information not provided.
Additional Legal Expenses in Connection with Required Reports

Component Description:
Legal fees for advice and representation in connection with preparation and filing of required quarterly repack progress report
Amount:
$2,827.50

Component Description:
Legal fees for advice and representation in connection with preparation and filing of required quarterly repack progress report
Amount:
$407.50
MVPD Notification of Channel Change

Component Description:
Charges for completing notification of MVPD providers of new WPBM-CD channel and parameters
Amount:
$2,994.00
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage Information not provided.
Equipment Delivery and Handling Charges

Component Description:
Freight charges for delivery of antenna
Amount:
$498.30
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.
DTV Medical Facility Notification

Component Description:
Prepare and complete notification to medical facilities of WPBM-CD post-repack channel
Amount:
$5,596.00
FCC Filing Fees - Form 2100 minor change CP application Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $520,444.00 $425,775.39 $163,902.44

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. Yes
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. Yes

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.

David Benz

General Manager


10/08/2021

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.

David Benz

General Manager


10/08/2021

Certification

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Section Question Response
Submission of Final Allocation or Accounting Information 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 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 acknowledges that all certifications and attached documentation are considered material representations.

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

  3. The above-named entity certifies that all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates.

  4. 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.

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

  6. 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.

David Benz

General Manager


10/08/2021

Attachments

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