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:
9375
Service:
DCA
Call Sign:
KEFN-CD
Channel:
20 (UHF)
File Number:
0000027549
FRN:
0030608905
Date Submitted:
11/24/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

ETERNAL FAMILY NETWORK

Doing Business As: ETERNAL FAMILY NETWORK

THOMAS A. FEDERER, ESQ

C/O THOMAS A. FEDERER, ESQ

201 SOUTH FIFTH STREET

ST. CHARLES, MO 63301

United States

+1 (636) 949-2424 tom@federerlaw.com Not-for-Profit

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

Dennis J Kelly

Attorney at Law

Law Office of Dennis J. Kelly

PO Box 41177

Washington, DC 20018

United States

+1 (202) 293-2300 dkellyfcclaw1@comcast.net

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 Station has replaced its former transmitter and antenna with new transmitter and antenna tuned to Channel 20

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 Retune Existing
Use Primary (Main)
Ownership Owned
Owner 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 Superior Broadcast
Model SBTXU-800RE
Year 2015
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 0.8 kW

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed N/A
New Mask Filter
Power 1.5 kW
Other Power N/A
New Exciter Is a new exciter needed? Yes
Exciter Type Single frequency agile

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 No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 tons
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? 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 PSILP12AN
Year 2015

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 Circular
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 8.32 kW
Manufacturer
Model AL12N-20-PLC
Year 2018
Justification for New Antenna We have relocated from Channel 49 to Channel 20, and the existing antenna cannot work on Channel 20.

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna?
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Broadband or Single Channel? N/A
Feed Line Size N/A
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Two 1.625 inch Reducer 50 OHM

50 ohm reducers

Transmission Line Dehydrator

Transmission Line Dehydrator

Tunable Band Pass Filter

Tunable Band Pass Filter

System Sweep

System Sweep

RF Installation

Turnkey Installation

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? No

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 10
Explanation 10 hours on one day
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 Yes
Quantity 1
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 Yes
Quantity 1
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification Yes
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations Yes
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 Yes
RF exposure measurements Yes
Additional Field Engineering Service Yes
Number of Days 1
Justification Antenna installation turned out to take one day

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

FCC Form 2100 Minor Modification

Prepare and File LMS File No 0000034423

Law Office of Dennis J. Kelly

Negotiation for Agreement for KEFN-CD to relocate from digital channel 21 to digital channel 20

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 Yes
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
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? No
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Name Description

Additional Supplies

Additional Items Needed for Channel 20 Transition Purchased from Lowe's, Inc.

Security System

VIVINT security system

St. Louis Metro Electric Supply, Inc.

Siemens QF3 Filler Plate

St. Louis Metro Electric Supply, Inc.

Circuit Breaker Accessory FYCOPDR-B

St. Louis Metro Electric Supply, Inc.

Siemens Q360 Circuit Breaker

St. Louis Metro Electric Supply, Inc.

Circuit Breaker

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 $149,530.00 $142,050.00 N/A $22,136.05 N/A
Total for all systems $388,288.09 $375,358.09 N/A $78,863.42 N/A
Primary Transmitter SBTXU-800RE $149,530.00 $142,050.00 $22,136.05
5 Ton system $20,250.00 $19,250.00 N/A $7,001.05 This actually cost $6,950.00 (less than the estimate)
1.5 kW mask filter $3,030.00 $2,800.00 N/A $0.00 N/A
Single frequency agile exciter $21,050.00 $20,000.00 N/A $15,135.00 MOTV, LLC's taxpayer ID number is 86-2204198 (this invoice was locked as of 10-8-2021).
UHF and VHF - minor banding issues $105,200.00 $100,000.00 N/A $0.00 N/A

Components

Actual Information Description File Name
5 Ton system

Component Description:
Turnkey Purchase and Installation of HEIL Model Number N4A360GHC 5 ton air conditioning condenser unit and HEIL Model Number FEM4X6000BL 5 ton Aluminum Tube Aluminum Fin Evaporator Note: Please Use KEFN-CD's EIN which is 431726467
Amount:
$6,950.00

Component Description:
Miscellaneous items needed for installation
Amount:
$51.05

Component Description:
Security and monitoring system
Amount:
$1,445.78

Component Description:
Electrical equipment required for 5 ton system
Amount:
$354.76

Component Description:
5 Ton Cooling System
Amount:
$6,950.00

Component Description:
Circuit Breakers, Filler Plate and Carbon Monoxide Alarm
Amount:
$354.76

Component Description:
Purchase of Door and Window Sealant, Light Fixture and Duct Tape
Amount:
$51.05

Component Description:
Actual cost of 5 ton air conditioning system
Amount:
$6,950.00

Component Description:
Security and Monitoring System
Amount:
$1,445.78
1.5 kW mask filter Information not provided.
Single frequency agile exciter

Component Description:
Package price for transmitter retune from channel 49 to channel 20
Amount:
$15,135.00

Component Description:
Actual Purchase Price Paid for KEFN Transmitter Package. Canceled checks are attached to the contract.
Amount:
$15,135.00
UHF and VHF - minor banding issues 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 $63,911.50 $62,281.50 N/A $42,683.75 N/A
Total for all systems $388,288.09 $375,358.09 N/A $78,863.42 N/A
Primary Antenna AL12N-20-PLC $63,911.50 $62,281.50 $42,683.75
RF Installation $15,904.00 $15,904.00 N/A $15,904.00 This is amended with a revised cover letter 11-24-2021 to respond to an FCC e-mail dated 11-03-2021
Tunable Band Pass Filter $6,135.00 $6,135.00 N/A $6,135.00 This is amended with a revised cover letter 11-24-2021 to respond to an FCC e-mail dated 11-03-2021
System Sweep $6,250.00 $6,250.00 N/A $6,250.00 This is amended with a revised cover letter 11-24-2021 to respond to an FCC e-mail dated 11-03-2021
Two 1.625 inch Reducer 50 OHM $467.50 $467.50 N/A $416.50 This is amended with a revised cover letter 11-24-2021 to respond to an FCC e-mail dated 11-03-2021
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $25,000.00 N/A $11,853.25 This is amended with a revised cover letter 11-24-2021 to respond to an FCC e-mail dated 11-03-2021. We also amended the responses to the type of antenna polarization and that the equipment acquired was upgraded equipment.
Transmission Line Dehydrator $2,125.00 $2,125.00 N/A $2,125.00 This is amended with a revised cover letter 11-24-2021 to respond to an FCC e-mail dated 11-03-2021
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $0.00 N/A

Components

Actual Information Description File Name
RF Installation

Component Description:
Antenna Installation turnkey component (quote and installation report submitted as separate PDFs to this Form 399) (one of six components on same invoice). This was amended with a new cover letter 10-8-21 to respond to an FCC e-mail
Amount:
$15,904.00

Component Description:
RF Installation component
Amount:
$15,904.00

Component Description:
Antenna Installation turnkey component (quote and installation report submitted as separate PDFs to this Form 399)
Amount:
$15,904.00
Tunable Band Pass Filter

Component Description:
Tunable Band Pass Filter (quote is attached as a PDF to this Form 399) (one of six components on the same invoice). This was amended with a new cover letter 10-8-21 to respond to an FCC e-mail
Amount:
$6,135.00

Component Description:
Tunable Band Pass Filter (quote is attached as a PDF to this Form 399)
Amount:
$6,135.00

Component Description:
Tunable Band Pass Filter
Amount:
$6,135.00
System Sweep

Component Description:
System Sweep component of overall antenna package (quote and sweep report PDFs are also attached to this Form 399) (one of six components on same invoice). This was amended with a new cover letter 10-8-21 to respond to an FCC e-mail
Amount:
$6,250.00

Component Description:
System Sweep component of overall antenna package (quote and sweep report PDFs are also attached to this Form 399)
Amount:
$6,250.00

Component Description:
System sweep component of the overall antenna package
Amount:
$6,250.00
Two 1.625 inch Reducer 50 OHM

Component Description:
50 Ohm Reducers (One of six components on same invoice); this was amended to respond to an FCC e-mail
Amount:
$416.50

Component Description:
50 Ohm Reducers (quote is provided in a PDF to this Form 399)
Amount:
$467.50

Component Description:
50 Ohm Reducers
Amount:
$467.50
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
This is for the original antenna we proposed to acquire, which was an ERI Model AL12N-20-PL (as it turned out, an upgraded Model ERI AL12N-20-PLC Antenna was acquired
Amount:
$11,853.25

Component Description:
ERI AL12N-20-PLC Antenna
Amount:
$15,882.25

Component Description:
This is the total package price for the antenna, including labor (it excludes one piece of equipment that was determined to be needed at time of installation)
Amount:
$47,234.07

Component Description:
ERI AL12N-20-PLC Antenna (quote is provided as separate PDF to this Form 399)
Amount:
$15,882.25

Component Description:
Additional equipment needed at time of installation not included on package proposal
Amount:
$467.50
Transmission Line Dehydrator

Component Description:
Transmission Line Dehydrator (one of six components on same invoice); this was amended with a new cover letter 10-8-21 to respond to an FCC e-mail
Amount:
$2,125.00

Component Description:
Transmission Line Dehydrator (quote is also attached as a PDF to this Form 399)
Amount:
$2,125.00

Component Description:
Transmission Line Dehydrator
Amount:
$2,125.00
Sweep test of existing antenna Information not provided.

Cost Information

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Transmission Line

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

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 $149,805.00 $148,175.00 N/A $11,725.00 N/A
Total for all systems $388,288.09 $375,358.09 N/A $78,863.42 N/A
Outside Professional Services $149,805.00 $148,175.00 $11,725.00
Law Office of Dennis J. Kelly $4,550.00 $4,550.00 See uploaded cover letter $0.00 This cost component was not contemplated when the original costs wee estimated.
FCC Form 2100 Minor Modification $1,400.00 $1,400.00 N/A $1,400.00 N/A
Additional Field Engineering Service, 1 Days $0.00 $0.00 N/A $0.00 N/A
RF Exposure Measurements $21,050.00 $20,000.00 N/A $0.00 N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A $0.00 N/A
ASR modification (prepare FCC Form 854) $2,105.00 $2,000.00 N/A $0.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 N/A $1,050.00 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 N/A $0.00 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A $1,225.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $3,850.00 N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A $0.00 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
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $0.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $0.00 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $1,575.00 N/A $1,575.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $2,625.00 Additional cost resulted from necessity of resubmission of Form 399
Project management of the transition $1,580.00 $8,400.00 N/A $0.00 N/A

Components

Actual Information Description File Name
Law Office of Dennis J. Kelly

Component Description:
Legal services re: negotiations with T-Mobile related to moving from Channel 21 to Channel 20
Amount:
$4,550.00
FCC Form 2100 Minor Modification

Component Description:
Prepare and File Minor Mod Application
Amount:
$1,400.00
Additional Field Engineering Service, 1 Days Information not provided.
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
ASR modification (prepare FCC Form 854) Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
Legal Services for Legal STA Request
Amount:
$1,050.00

Component Description:
Legal Services related to STA request
Amount:
$3,500.00
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Legal Services for Covering License Application
Amount:
$1,225.00

Component Description:
Services for Covering LIcense Application
Amount:
$2,250.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Legal Services re preparation and filing of original FCC Form 2100 application
Amount:
$3,850.00

Component Description:
All legal services relative to filing construction permit application
Amount:
$5,000.00
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for new channel assignment and antenna development Information not provided.
Address transition timing and coordination issues w/ other stations and wireless

Component Description:
Legal Services re Transition Timing
Amount:
$1,575.00
Prepare and or review reimbursement form

Component Description:
Legal Services for Original Submission and re-submission of Form 399
Amount:
$2,625.00

Component Description:
Preparation of Reimbursement Forms
Amount:
$2,500.00
Project management of the transition

Component Description:
Prepare and file Form 2100 modification of CP to move to Channel 20 (from 21)
Amount:
$1,000.00

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 $25,041.59 $22,851.59 N/A $2,318.62 N/A
Total for all systems $388,288.09 $375,358.09 N/A $78,863.42 N/A
Other Expenses $25,041.59 $22,851.59 $2,318.62
St. Louis Metro Electric Supply, Inc. $354.76 $354.76 When KEFN-CD's Channel 20 facility was being constructed, the contractors performing the installation determined that circuit breakers and related supplies were needed for a successful installation of the RF transmitting equipment $267.57 N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $0.00 N/A $0.00 N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $2,000.00 N/A
Security System $1,445.78 $1,445.78 N/A $0.00 N/A
Additional Supplies $51.05 $51.05 N/A $51.05 N/A
MVPD Notification of Channel Change $10,000.00 $10,000.00 N/A $0.00 N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $0.00 N/A $0.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $0.00 N/A $0.00 N/A

Components

Actual Information Description File Name
St. Louis Metro Electric Supply, Inc.

Component Description:
Circuit Breaker Accessory FYCOPDR-B Plug In CO DET 0
Amount:
$46.32

Component Description:
Circuit Breaker
Amount:
$217.98

Component Description:
Siemens QF-3 Filler Plate
Amount:
$3.27

Component Description:
Siemens Q360 Circuit Breaker
Amount:
$87.19
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
DTV Medical Facility Notification

Component Description:
DTV Medical Facility Notifications (we have additionally submitted our quote on this cost as a PDF to this Form 399)
Amount:
$2,000.00

Component Description:
Notification mailings to medical facilities near KEFN-CD
Amount:
$2,000.00

Component Description:
TIN unknown
Amount:
$2,000.00
Security System

Component Description:
Security System for DTV Transmitter Building
Amount:
$1,445.78
Additional Supplies

Component Description:
Items needed for channel 20 installation
Amount:
$51.05
MVPD Notification of Channel Change Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $388,288.09 $375,358.09 $78,863.42

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.

Thomas A. Federer

Vice-President


11/24/2021

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.

Thomas A. Federer

Vice-President


11/24/2021

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