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:
61015
Service:
LPT
Call Sign:
WBNM-LD
Channel:
25 (UHF)
File Number:
0000087144
FRN:
0005869664
Eligibility Status:
Eligible
Date Submitted:
05/20/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WORD BROADCASTING NETWORK, INC.

Doing Business As: WORD BROADCASTING NETWORK, INC.

3701 FERN VALLEY ROAD

LOUISVILLE, KY 40219

United States

+1 (502) 964-2121 TOM@WBNA21.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

The Preparer is same as the reimbursement contact.

 

 

 

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 Licensee is transitioning on 10/11/19 to its new spectrum in accordance with the previously granted construction permit.

Transmitters

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Section Question Response
Transmitter Related Expenses Do you have transmitter related expenses? Yes

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Ownership Owned
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model UNKNOWN
Year 1900
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model TRN-5X-U-18-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.1 kW
Justification for New Transmitter Existing transmitter not compatible with new spectrum allocation as more power is required to transmit signal

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Other Transmitter Costs
Does the transmitter installation require a Transmitter Building Site Survey/Installation? No
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Rigid Conduit and Wiring No
Other Electrical Service No
HVAC Service Does the replacement transmitter require HVAC Service? No
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Primary Transmitter - Installation

Primary Transmitter - Installation

MASK FILTER

New 10 kW upgraded mask filter, like-for-like mask filter is 3 kW.

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Ownership Owned
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? Yes
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Middle
Polarization Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model ALP32L3-8SW
Year 2006

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Change Type Purchase New
Ownership Owned
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Middle
Polarization Elliptical
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model ATC-BCE316C5-V2-25
Year 2019
Justification for New Antenna Existing antenna is incompatible with new spectrum allocation.

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? 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 Purchase New
Use Primary (Main)
Ownership Owned
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 3 1/8 inches
Segment Length 20 inches
Number of parallel runs 1
Length 400 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 400 feet per run
Justification for New Transmission Line Needed for new antenna, existing is in disrepair.
Interior RF Systems Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators? No

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Move Equipment
Tower Use Primary (Main)
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1028414
Coordinates (NAD83) Latitude (NAD83) 38° 21' 55.2" N-
Longitude (NAD83) 085° 50' 24.2" W-
Overall Structure Height 464.89 feet
Support Structure Height 459.97 feet
Ground Elevation Above Mean Sea Level (AMSL) 962.91 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner SBA GC Towers, LLC
Date Constructed 01/25/1996

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
38464 WDYL-LD LPD
69113 WUOL-FM FM
91679 W270CR FX
91916 W205BT FX
38621 WFPK FM
4258 WFPL FM
64024 WKYI AM

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 194
Explanation WBNM-LD requires the aid of outside project management services in order to fulfill the requirements of the repack. WBNM-LD does not have sufficient resource capacity and expertise in-house to handle all the necessary activities.
Outside RF consulting Engineering Services Perform engineering study for displacement application Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Prepare Form 601 No
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Negotiation of Lease and other Matter for Shared Locations No
Prepare or Review FCC Form 399 for Reimbursement Yes
Form 399 assistance or other program management costs Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements Yes
Additional Field Engineering Service Yes
Number of Days 4
Justification Installation of new transmitter and supervision of installation for transmission line and antenna @ $2,000 per day

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
Permit and Filing Costs FCC Construction Permit Major Change 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
Point to Point Microwave (STL/ICR) Frequency Coordination for Unidirection System No
Frequency Coordination for Bi-Direction System No
New Point to Point Microwave System No

Other Expenses

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Other Expenses Not Listed

Name Description

IP BASED STL

Replacement of existing STL system with an IP based transport system to connect studios/programming source with transmitter

Internal Labor

Internal Labor

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 $94,152.20 $91,072.20 N/A $91,072.20 N/A
Total for all systems $365,649.77 $339,977.62 N/A $246,684.64 N/A
Primary Transmitter TRN-5X-U-18-C $94,152.20 $91,072.20 $91,072.20
MASK FILTER $3,702.20 $3,702.20 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $3,702.20 N/A
Primary Transmitter - Installation $6,450.00 $6,450.00 Please See: WBNM-LD Primary Transmitter Installation Budget Revision Justification Cover Letter.pdf $6,450.00 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $80,920.00 Please see Anywave proposal 7359-01-6-14-2019 $80,920.00 N/A

Components

Actual Information Description File Name
MASK FILTER

Component Description:
FILTER UT6E11F-10K W/ 3-50 PORTS
Amount:
$3,702.20

Component Description:
This is the quote for a Dielectric new filter we already had in our inventory for another project but we decided to use it for this repack. Attached is a quote for this item. We do not have the original invoice for this item.
Amount:
$9,126.91

Component Description:
WBNM Filter Retune
Amount:
$933.58
Primary Transmitter - Installation

Component Description:
Engineering Services W50CI - Anywave Transmitter Install
Amount:
$6,450.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
WBNM Transmitter Invoice and Proposal
Amount:
$80,920.00

Component Description:
Parts for Transmitter Install
Amount:
$650.00

Component Description:
Transmitter, UHF, Air Cooled
Amount:
$80,920.00

Component Description:
Retune of Filter for WBNM to Ch 25.
Amount:
$933.58

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 $37,255.00 $36,630.00 N/A $24,400.00 N/A
Total for all systems $365,649.77 $339,977.62 N/A $246,684.64 N/A
Primary Antenna ATC-BCE316C5-V2-25 $37,255.00 $36,630.00 $24,400.00
Side Mount antenna brackets $4,625.00 $4,000.00 N/A $0.00 N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical $26,900.00 $26,900.00 Please see Alive Telecom quote dated 5-9-2019, lines 1 and 1a $22,900.00 N/A
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A $1,500.00 N/A

Components

Actual Information Description File Name
Side Mount antenna brackets Information not provided.
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical

Component Description:
Antenna
Amount:
$22,900.00

Component Description:
Invoice to be resubmitted
Amount:
N/A
Sweep test of transmission line and antenna

Component Description:
WBNM Line Sweep by Ultranet Wireless
Amount:
$1,500.00

Component Description:
WBNM-LD-210-Primary Antenna - Sweep Test
Amount:
$1,500.00

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 $9,600.00 $6,244.40 N/A $0.00 N/A
Total for all systems $365,649.77 $339,977.62 N/A $246,684.64 N/A
Primary Transmission Line $9,600.00 $6,244.40 $0.00
Flexible Foam Transmission Line - dielectric, 1 5/8" $9,600.00 $6,244.40 N/A $0.00 N/A

Components

Actual Information Description File Name
Flexible Foam Transmission Line - dielectric, 1 5/8"

Component Description:
WBNM-LD-310-Primary Transmission Line - 1 5/8" Flexible Foam
Amount:
$6,244.40

Component Description:
Transmission Line for WBNM
Amount:
$6,244.40

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 $56,190.00 $22,875.00 N/A $22,875.00 N/A
Total for all systems $365,649.77 $339,977.62 N/A $246,684.64 N/A
Primary Tower GTOWER $56,190.00 $22,875.00 $22,875.00
Tower Rigging Short Tower (less than 500') $56,190.00 $22,875.00 Please see Tower Maintenance Estimate #1053 $22,875.00 N/A

Components

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

Component Description:
WBNM Tower Work Down Payment 50%
Amount:
$11,437.50

Component Description:
Tower Work for WBNM last payment
Amount:
$11,437.50

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 $124,434.50 $139,137.95 N/A $68,615.45 N/A
Total for all systems $365,649.77 $339,977.62 N/A $246,684.64 N/A
Outside Professional Services $124,434.50 $139,137.95 $68,615.45
Project management of the transition $20,467.00 $34,599.20 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $34,599.20 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A $2,805.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A $0.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A $740.00 N/A
Form 399 assistance or other Program Management costs $20,000.00 $20,000.00 200 man hours @$100 p/h $0.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A $0.00 N/A
Additional Field Engineering Service, 4 Days $8,000.00 $8,000.00 N/A $0.00 N/A
RF Exposure Measurements $12,100.00 $12,000.00 N/A $0.00 N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $52,600.00 N/A $28,000.00 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A $0.00 N/A
Perform engineering study for displacement application $1,800.00 $2,471.25 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $2,471.25 N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$232.50

Component Description:
Project Management
Amount:
$1,231.40

Component Description:
Project Management
Amount:
$97.65

Component Description:
Project Management
Amount:
$9,809.45

Component Description:
Project Management
Amount:
$6,060.90

Component Description:
Project Management
Amount:
$9,492.95

Component Description:
Project Management
Amount:
$119.05

Component Description:
Project Management
Amount:
$1,872.40

Component Description:
Project Management
Amount:
$2,055.30

Component Description:
Project Management
Amount:
$961.25

Component Description:
Project Management
Amount:
$103.85

Component Description:
Project Management
Amount:
$655.15

Component Description:
Project Management
Amount:
$1,478.90

Component Description:
Project Management
Amount:
$428.45
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Combined Legal Fees for WBNM
Amount:
$2,805.00
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

Component Description:
WBNM-LD-530-RF Eng - Construction Permit Application (Main)
Amount:
$740.00

Component Description:
Prepping for engineering filing for WBNM
Amount:
$740.00
Form 399 assistance or other Program Management costs

Component Description:
Project Management Labor for Tom Fawbush for WBNM.
Amount:
$15,750.00

Component Description:
Project Management Labor for Glenn Brown, In house Engineer for WBNM
Amount:
$3,586.00
Prepare/ Review 399 reimbursement form Information not provided.
Additional Field Engineering Service, 4 Days

Component Description:
Transmitter install for WBNM
Amount:
$5,800.00
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed

Component Description:
Engineering Services
Amount:
$28,000.00

Component Description:
Ultranet Signal Study
Amount:
$28,500.00

Component Description:
Engineering Services
Amount:
$28,500.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Perform engineering study for displacement application

Component Description:
Communication with Client regarding ERI and Alive Products
Amount:
$601.25

Component Description:
Restudy of Signal for WBNM
Amount:
$601.25

Component Description:
Displacement Channel Analysis to Determine possible displacement channel
Amount:
$1,870.00

Component Description:
Signal Study for WBNM
Amount:
$1,870.00

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 $44,018.07 $44,018.07 N/A $39,721.99 N/A
Total for all systems $365,649.77 $339,977.62 N/A $246,684.64 N/A
Other Expenses $44,018.07 $44,018.07 $39,721.99
Disposal Costs (for equipment and other waste, net of any salvage value) $2,000.00 $2,000.00 N/A $0.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A $0.00 N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,110.00 N/A $0.00 N/A
Equipment Delivery and Handling Charges $1,420.24 $1,420.24 Please see Estimated Cost Justification WBNM-LD-610-Equipment Delivery and Handling v0 $1,194.16 N/A
Equipment Storage $4,000.00 $4,000.00 N/A $3,975.00 N/A
IP BASED STL $14,987.20 $14,987.20 Please see Estimated Cost Justification WBNM-LD-610-IP Based STL v0 $14,387.20 N/A
Internal Labor $20,165.63 $20,165.63 Please see Estimated Cost Justification WBNM-LD-610-Internal Labor v0 $20,165.63 N/A

Components

Actual Information Description File Name
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.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
Equipment Delivery and Handling Charges

Component Description:
Expense Report- Truck Rental for the movement of the WBNM antenna from its storage site to the transmitter site.
Amount:
$220.24

Component Description:
Shipping for Antenna WBNM
Amount:
$1,200.00

Component Description:
Invoice to be resubmitted.
Amount:
N/A

Component Description:
Penske Truck Rental WBNM
Amount:
$220.25

Component Description:
Equip delivery
Amount:
$973.92
Equipment Storage

Component Description:
Storage of WBNM's antenna at EWPC for several months
Amount:
$3,975.00
IP BASED STL

Component Description:
See Cover Letter to invoice. This is an IP based STL link that replaced the existing system.
Amount:
$14,387.20
Internal Labor

Component Description:
In House Labor by Station Engineer, Glenn Brown
Amount:
$4,284.50

Component Description:
Expenses incurred for In House Labor by Station General Manager, Tom Fawbush
Amount:
$15,881.13

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $365,649.77 $339,977.62 $246,684.64

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. Yes
Construction of final facilities or all necessary modifications are complete. No
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator. No

Certification

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Section Question Response
Submission of Estimated Expenses Statements

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.

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

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

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

  4. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).

  5. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  6. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.

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

  8. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Tom Fawbush

General Manager


05/20/2022

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.

Tom Fawbush

GM


05/20/2022

Attachments

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