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:
23929
Service:
DTV
Call Sign:
WXGA-TV
Channel:
7 (High VHF)
File Number:
0000027648
FRN:
0001844976
Date Submitted:
03/10/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GEORGIA PUBLIC TELECOMMUNICATIONS COMMISSION

260 14TH ST NW

ATLANTA, GA 30318

United States

+1 (404) 685-2400 elaprade@gpb.org Government Entity

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

Robert Gehman

Kessler and Gehman Associates, Inc.

Robert Gehman

507 NW 60 Street

Suite D

Gainesville, FL 32607

United States

+1 (352) 332-3157 bob@kesslerandgehman.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 Replace transmitter.

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 PTCD11P2
Year 2008
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 4.8 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? Yes
Manufacturer
Model MPTV-PRLX-V3
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 4.3 kW
Justification for New Transmitter Manufacturer of existing transmitter advises that the existing transmitter cannot be re-tuned to the assigned channel. See Attachment.

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) Yes
Transformer (480V) Yes
Power 150 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 100.0 feet
Other Electrical Service No
Description N/A
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

Name Description

Additional Interior RF System

Interior RF System Existing Transmitter to Interim Transmission line

Standby Exciter and Switch

Standby Exciter with Automatic Change Over Switch

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 Retune Existing
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? No
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 Top Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Other
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 Batwing
ERP: 35.3 kW
Manufacturer Dielectric
Model TF-14HT-DC
Year 2008

Primary Antenna

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Adjustment to Existing Antenna

Section Question Response
Sweep Test of Existing Antenna Do you need a sweep test of existing antenna? Yes

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

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? 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 60
Explanation It will be necessary to schedule and coordinate multiple vendors, complete progress reports, and update Schedule 399. Station does not have available personnel or personnel trained in project management for such complex projects.
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 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 Yes
Number of Days 13
Justification It will be necessary to survey the site, plan the equipment, develop specifications for purchasing, and oversee multiple vendor RF projects. Station does not have available personnel or personnel trained in such services.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Other Legal Services

Legal services not already included in a pre-established OPS section.

Other Engineering Services

Engineering services not already included in a pre-established OPS section.

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 No
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

Electrical Design

Electrical Design

System Design and Site Survey

System Design and Site Survey

Electrical Work

Electrical Work

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 $418,450.00 $305,445.00 N/A $139,945.00 N/A
Total for all systems $610,356.70 $493,501.95 N/A $248,876.25 N/A
Primary Transmitter MPTV-PRLX-V3 $418,450.00 $305,445.00 $139,945.00
3" Rigid Conduit and Wiring (Cost per foot) $5,200.00 $4,900.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $24,300.00 N/A N/A N/A
Standby Exciter and Switch $25,000.00 $25,000.00 N/A N/A N/A
Additional Interior RF System $75,000.00 $75,000.00 N/A N/A N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A
High VHF - Liquid Cooled Solid State Transmitter 3.3 . 6.5 kW $249,500.00 $139,945.00 See attached / uploaded file "Comark S10461-1 v190912jgv1.pdf" $139,945.00 N/A

Components

Actual Information Description File Name
3" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Transformer 3 phase/480v - 150 KVA Information not provided.
Standby Exciter and Switch Information not provided.
Additional Interior RF System Information not provided.
Switchgear - industrial 800 amp Information not provided.
High VHF - Liquid Cooled Solid State Transmitter 3.3 . 6.5 kW

Component Description:
Comark S10461-1 v190912jgv1
Amount:
$139,945.00

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 $6,730.00 $6,851.25 N/A $6,851.25 N/A
Total for all systems $610,356.70 $493,501.95 N/A $248,876.25 N/A
Primary Antenna TF-14HT-DC $6,730.00 $6,851.25 $6,851.25
Sweep test of existing antenna $6,730.00 $6,851.25 See attached / uploaded PDF files titled "Wallace Twr 1368 v200226jgv1.pdf" and "Radio Works 1997 v200626jgv1.pdf" $6,851.25 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
Radio Works 1997 v200626jgv1
Amount:
$2,992.50

Component Description:
Wallace Twr 1368 v200226jgv1
Amount:
$3,858.75

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 $91,703.20 $96,188.20 N/A $32,062.50 N/A
Total for all systems $610,356.70 $493,501.95 N/A $248,876.25 N/A
Outside Professional Services $91,703.20 $96,188.20 $32,062.50
Other Engineering Services $20,000.00 $20,000.00 N/A $8,975.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 N/A N/A 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 $1,732.50 N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $750.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,000.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $4,000.00 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $9,425.00 The Estimate Cost includes Form 399 submissions including ongoing Actual Cost invoice prep and submission, and amendments as needed. $9,425.00 N/A
Project management of the transition $9,480.00 $9,000.00 N/A $2,100.00 N/A
Other Legal Services $5,513.20 $5,513.20 Other Legal Services related to the station's transition to its post-Repack channel $3,080.00 N/A
Additional Field Engineering Service, 13 Days $26,000.00 $26,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Other Engineering Services

Component Description:
KGA 554-843 v201208jgv1
Amount:
$200.00

Component Description:
KGA 554-645 v190702pmv1
Amount:
$1,250.00

Component Description:
KGA 554-671 v200218jgv1
Amount:
$850.00

Component Description:
KGA 554-700 v200218jgv1
Amount:
$1,225.00

Component Description:
KGA 554-777 v200609jgv1
Amount:
$550.00

Component Description:
KGA 554-920 v210402jgv1
Amount:
$250.00

Component Description:
KGA 554-909 v210402jgv1
Amount:
$75.00

Component Description:
KGA 554-628 v190620pmv1
Amount:
$2,100.00

Component Description:
KGA 554-972 v210402jgv1
Amount:
$50.00

Component Description:
KGA 554-616 v190620pmv1
Amount:
$800.00

Component Description:
KGA 554-728 v200218jgv1
Amount:
$525.00

Component Description:
KGA 554-744 v200218jgv1
Amount:
$200.00

Component Description:
KGA 554-679 v200218jgv1
Amount:
$175.00

Component Description:
KGA 554-819 v200902jgv1
Amount:
$725.00
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
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:
WXGA amount, Refer to GMP master summary invoice WXGA with attached invoice.Refer to letter and attachments uploaded from GPB 8.2.18
Amount:
$1,347.50

Component Description:
WXGA amount. Refer to GMP master summary invoice WXGA with attached invoice. Refer to letter and attachments uploaded from GPB 8.2.18
Amount:
$385.00
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
KGA 554-805 v200619pmv1
Amount:
$750.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Prepare engineering section of Form 2100 (main)
Amount:
$2,000.00
Perform engineering study for new channel assignment and antenna development

Component Description:
Perform engineering study for new channel assignment
Amount:
$4,000.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Prepare and or review reimbursement form

Component Description:
KGA 554-1062 v220309pmv1
Amount:
$280.00

Component Description:
KGA 554-650 v190702pmv1
Amount:
$50.00

Component Description:
KGA 554-855 v201208jgv1
Amount:
$1,980.00

Component Description:
KGA 554-801 v200618pmv1
Amount:
$25.00

Component Description:
KGA 554-1030 v211230pmv1
Amount:
$25.00

Component Description:
KGA 554-931 v210402jgv1
Amount:
$125.00

Component Description:
KGA 554-877 v201208jgv1
Amount:
$50.00

Component Description:
KGA 554-996 v210630jgv1
Amount:
$500.00

Component Description:
KGA 554-615 v190620pmv1
Amount:
$250.00

Component Description:
KGA 554-937 v210402jgv1
Amount:
$375.00

Component Description:
KGA 554-626 v190620pmv1
Amount:
$320.00

Component Description:
KGA 554-1054 v220204pmv1
Amount:
$160.00

Component Description:
Prepare and review reimbursement form
Amount:
$2,500.00

Component Description:
KGA 554-925 v210402jgv1
Amount:
$50.00

Component Description:
KGA 554-658 v200609jgv1
Amount:
$360.00

Component Description:
KGA 554-684 v200218jgv1
Amount:
$600.00

Component Description:
KGA 554-786 v200618pmv1
Amount:
$375.00

Component Description:
KGA 554-1019 v211222jgv1
Amount:
$125.00

Component Description:
KGA 554-628 v190620pmv1
Amount:
$25.00

Component Description:
KGA 554-709 v200218jgv1
Amount:
$525.00

Component Description:
KGA 554-780 v200618pmv1
Amount:
$500.00

Component Description:
KGA 554-894 v201208jgv1
Amount:
$225.00
Project management of the transition

Component Description:
KGA inv #554-557 Form 387 2018 Q3 by RG UL20190426jgv2
Amount:
$150.00

Component Description:
KGA 554-752 v200609jgv1
Amount:
$150.00

Component Description:
KGA 554-601 v190620pmv1b
Amount:
$150.00

Component Description:
Project Management Bob Gehman
Amount:
$225.00

Component Description:
Project management Bob Gehman
Amount:
$225.00

Component Description:
KGA inv #554-544 Form 387 2018 Q2 by RG UL20190426jgv2
Amount:
$150.00

Component Description:
Form 387 4Q18
Amount:
$150.00

Component Description:
KGA 554-763 v200609jgv1
Amount:
$150.00

Component Description:
Project management Bob Gehman
Amount:
$300.00

Component Description:
KGA 554-790 v200618pmv1
Amount:
$150.00

Component Description:
KGA 554-665 v200218jgv1
Amount:
$150.00

Component Description:
KGA 554-714 v200218jgv1
Amount:
$150.00
Other Legal Services

Component Description:
Repack Prep legal invoices
Amount:
$77.00

Component Description:
GMP 32248 v200618pmv1
Amount:
$346.50

Component Description:
GMP 26903 v220308jgv1
Amount:
$2,279.20

Component Description:
GMP 28033 v220308jgv1
Amount:
$154.00

Component Description:
GMP 32422 v200618pmv1
Amount:
$577.50

Component Description:
GMP 30549 v200218jgv1
Amount:
$462.00

Component Description:
WXGA amount. Refer to GMP matter summary Jan-April 2018. Refer to letter and attachments uploaded from GPB 8.2.18
Amount:
$38.50

Component Description:
GMP 30914 v200218jgv1
Amount:
$154.00

Component Description:
GMP 31278 v200218jgv1
Amount:
$77.00

Component Description:
GMP 32082 v200618pmv1
Amount:
$115.50

Component Description:
WXGA amount. Refer to GMP master summary invoice WXGA with attached invoice.
Amount:
$38.50

Component Description:
GMP 34971 v211222jgv1
Amount:
$77.00

Component Description:
GMP 32603 v201208jgv1
Amount:
$577.50

Component Description:
WXGA amount. Refer to GMP master summary invoice WXGA with attached invoice.
Amount:
$38.50

Component Description:
GMP 30381 v190702pmv1
Amount:
$231.00

Component Description:
WXGA amount. Refer to GMP matter summary May 2018.Refer to letter and attachments uploaded from GPB 8.2.18
Amount:
$154.00

Component Description:
WXGA amount. Refer to GMP master summary invoice WXGA with attached invoice.
Amount:
$115.50
Additional Field Engineering Service, 13 Days 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 $93,473.50 $85,017.50 N/A $70,017.50 N/A
Total for all systems $610,356.70 $493,501.95 N/A $248,876.25 N/A
Other Expenses $93,473.50 $85,017.50 $70,017.50
Electrical Work $44,225.00 $44,225.00 See attached / uploaded PDF file titled "All-State 3698 v200902jgv1.pdf" $44,225.00 N/A
System Design and Site Survey $15,300.00 $15,300.00 See attached / uploaded file "Comark 12832 v190912jgv1.pdf" $15,300.00 N/A
Electrical Design $5,547.50 $5,547.50 See attached / uploaded PDF file titled "NBP Eng 18301 v200303jgv1.pdf" $5,547.50 N/A
MVPD Notification of Channel Change $1,851.00 $1,851.00 N/A $1,851.00 N/A
Equipment Storage $5,000.00 $5,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $0.00 $0.00 N/A N/A N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $5,000.00 $5,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $3,094.00 N/A $3,094.00 N/A

Components

Actual Information Description File Name
Electrical Work

Component Description:
All-State 3698 v200902jgv1
Amount:
$44,225.00
System Design and Site Survey

Component Description:
Comark 12832 v190912jgv1
Amount:
$15,300.00
Electrical Design

Component Description:
NBP Eng 18301 v200319jgv2
Amount:
$5,547.50
MVPD Notification of Channel Change

Component Description:
KGA 554-761 v200609jgv1
Amount:
$1,851.00
Equipment Storage Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
DTV Medical Facility Notification

Component Description:
KGA 554-760 v200609jgv1
Amount:
$3,094.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $610,356.70 $493,501.95 $248,876.25

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.

Jeffrey C Gehman

Engineering Associate


03/10/2022

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.

Jeffrey C Gehman

Engineering Associate


03/10/2022

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