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:
62354-25-53821
Service:
DRT
Call Sign:
KTLM
Channel:
25 (UHF)
File Number:
0000088519
FRN:
0019509470
Eligibility Status:
Eligible
Date Submitted:
08/30/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

NBC TELEMUNDO LICENSE LLC

Angela Ball

300 NEW JERSEY AVENUE, N.W.

SUITE 700

WASHINGTON, DC 20001

United States

+1 (202) 524-6413 ANGELA.BALL@NBCUNI.COM Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Angela Ball

Assistant Secretary

NBCUniversal, LLC

300 New Jersey Avenue, NW

Suite 700

Washington, DC 20001

United States

+1 (202) 564-6413 angela.ball@nbcuni.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 Install new antenna in place of existing analog antenna and new transmitter for new channel. The old transmitter and antenna will remain in place for interim use until the cut-over.

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 TMU9-5
Year 2014
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 3 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model TMU9-5
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 3 kW
Justification for New Transmitter The old transmitter, Larcan MODULATORSG9, is no longer supported.

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? Yes
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 Yes
Description TBD - post installer arrival on site.
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

Filter Interconnect

Transmitter to Filter Interconnect

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? No
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 12.0 kW
Manufacturer
Model AL8-43
Year 2014

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? No
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Other
Other Antenna Type Slotted Cover
ERP: 15.0 kW
Manufacturer
Model TLP-8B/VP
Year 2018
Justification for New Antenna The old antenna, which was single channel, will not operate on the new channel.

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

Name Description

Installation Costs

Installation costs for Antenna

KTLM DRT Repack - replacement antenna line

KTLM DRT Repack - replacement antenna line

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)
Ownership Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1056488
Coordinates (NAD83) Latitude (NAD83) 26° 31' 02.0" N-
Longitude (NAD83) 098° 39' 08.0" W-
Overall Structure Height 1915.99 feet
Support Structure Height 1915.99 feet
Ground Elevation Above Mean Sea Level (AMSL) 410.10 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Telemundo Rio Grande Valley, LLC
Date Constructed 10/09/1999


Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Tower mapping and report for structural engineer
Tower Reinforcements Please select whether tower reinforcements are needed: No 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 350
Explanation Project oversight of transmitter install, electrical connectivity, tower work, and antenna installation. Additional time will be spent tracking financial and legal process and coordinating with other broadcasters.
Outside RF consulting Engineering Services Perform engineering study for displacement application No
Prepare engineering section of Form FCC Construction Permit Application No
Prepare engineering section of Form FCC License to Cover Application No
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 No
Prepare and file Form FCC License to Cover Application No
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 No
RF exposure measurements Yes
Additional Field Engineering Service Yes
Number of Days 5
Justification Site survey required.

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 No
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)? 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

DTV Medical Facility Notifications

DTV Medical Facility Notifications

Call Support

Call Support

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 $126,943.00 $128,943.00 N/A $3,143.00 N/A
Total for all systems $430,453.70 $484,069.45 N/A $106,084.70 N/A
Primary Transmitter TMU9-5 $126,943.00 $128,943.00 $3,143.00
Transmitter Building Site Survey/Installation $10,000.00 $12,000.00 Install include mobilization to Donna, TX $0.00 N/A
Other Electrical Service: TBD - post installer arrival on site. $7,500.00 $7,500.00 N/A $0.00 N/A
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW $106,300.00 $106,300.00 N/A $0.00 N/A
Filter Interconnect $3,143.00 $3,143.00 N/A $3,143.00 N/A

Components

Actual Information Description File Name
Transmitter Building Site Survey/Installation

Component Description:
Please line item 1 for the installation and mobilization cost
Amount:
$12,000.00
Other Electrical Service: TBD - post installer arrival on site.

Component Description:
Electrical work: Replace existing main distribution, add main disconnect, reconnect building electrical and connect new transmitter
Amount:
$4,957.85

Component Description:
Electrical: Replace existing main distribution, add main disconnect, reconnect building electrical and connect new transmitter
Amount:
$4,957.85
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW

Component Description:
TMU9-5 3kW Transmitter
Amount:
$85,475.00
Filter Interconnect

Component Description:
Interconnect Kit
Amount:
$3,143.00

Component Description:
Transitter to Filter Interconnect for KTLM-DRT
Amount:
$3,143.00

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 $34,565.70 $44,940.70 N/A $7,039.35 N/A
Total for all systems $430,453.70 $484,069.45 N/A $106,084.70 N/A
Primary Antenna TLP-8B/VP $34,565.70 $44,940.70 $7,039.35
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A $0.00 N/A
KTLM DRT Repack - replacement antenna line $4,210.70 $4,210.70 KTLM DRT Repack - replacement antenna line $0.00 N/A
Installation Costs $0.00 $0.00 TBD as work has not yet been carried out $0.00 N/A
Side Mount antenna brackets $4,625.00 $15,000.00 Increase estimated costs $7,039.35 N/A
UHF-Low Power, Side Mount, Other, 15.0kW input, Elliptical $20,000.00 $20,000.00 N/A $0.00 N/A

Components

Actual Information Description File Name
Sweep test of transmission line and antenna

Component Description:
Antenna and Transmission line test
Amount:
$3,500.00

Component Description:
Antenna and transmission line sweep
Amount:
$3,500.00
KTLM DRT Repack - replacement antenna line

Component Description:
Flexible transmission line
Amount:
$4,210.70
Installation Costs Information not provided.
Side Mount antenna brackets

Component Description:
WB ANTENNA INPUT ELBOW ONLY
Amount:
$7,039.35
UHF-Low Power, Side Mount, Other, 15.0kW input, Elliptical

Component Description:
Low power side mount
Amount:
$17,945.00

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 $178,750.00 $159,250.00 N/A $0.00 N/A
Total for all systems $430,453.70 $484,069.45 N/A $106,084.70 N/A
Primary Tower TOWER $178,750.00 $159,250.00 $0.00
Tower Rigging Tall Tower (greater than 500') $157,750.00 $157,750.00 N/A $0.00 N/A
Tower mapping and report for structural engineer $21,000.00 $1,500.00 N/A $0.00 N/A

Components

Actual Information Description File Name
Tower Rigging Tall Tower (greater than 500')

Component Description:
Tower crew- remove and replace antenna and transmission line
Amount:
$22,000.00

Component Description:
tower and rigging cost are requesting
Amount:
$22,000.00
Tower mapping and report for structural engineer

Component Description:
ATC Tower services
Amount:
$1,500.00

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $64,555.00 $125,273.75 N/A $93,652.45 N/A
Total for all systems $430,453.70 $484,069.45 N/A $106,084.70 N/A
Outside Professional Services $64,555.00 $125,273.75 $93,652.45
Additional Field Engineering Service, 5 Days $7,500.00 $7,500.00 N/A $0.00 N/A
RF Exposure Measurements $12,100.00 $10,283.75 N/A $10,283.75 N/A
Project management of the transition $36,925.00 $100,000.00 Project management cost exceed than estimate $78,434.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,170.00 N/A $285.60 N/A
Form 399 assistance or other Program Management costs $6,320.00 $6,320.00 N/A $4,649.10 N/A

Components

Actual Information Description File Name
Additional Field Engineering Service, 5 Days Information not provided.
RF Exposure Measurements

Component Description:
RF Survey and Safety report
Amount:
$10,283.75
Project management of the transition

Component Description:
Project management services
Amount:
$474.00

Component Description:
Project management services
Amount:
$4,466.00

Component Description:
Project management services for the station
Amount:
$6,468.00

Component Description:
Project management services
Amount:
$3,476.00

Component Description:
Project management services
Amount:
$770.00

Component Description:
Professional services for the station
Amount:
$1,738.00

Component Description:
Professional services for the station
Amount:
$2,909.00

Component Description:
Professional services for the station
Amount:
$2,212.00

Component Description:
Professional services for the station
Amount:
$1,343.00

Component Description:
Professional services for the station
Amount:
$12,026.00

Component Description:
Professional services for the station
Amount:
$1,106.00

Component Description:
Professional services for the station KTLM-DRT
Amount:
$2,291.00

Component Description:
Professional services for the station KTLM-DRT
Amount:
$553.00

Component Description:
Professional services for the station
Amount:
$8,864.00

Component Description:
Professional services for the station KTLM-DRT
Amount:
$2,844.00

Component Description:
Professional services for the station
Amount:
$6,478.00

Component Description:
Professional services for the station
Amount:
$6,162.00

Component Description:
Professional services for the station
Amount:
$5,272.00

Component Description:
Professional services for the station
Amount:
$8,318.00

Component Description:
project management services
Amount:
$435.00

Component Description:
Engineering servies, interference Analysis and technical exhibit for channel 14
Amount:
$3,500.00

Component Description:
Project management services
Amount:
$316.00

Component Description:
Project management services
Amount:
$474.00

Component Description:
Repack Finance Resource- project Management services
Amount:
$3,476.00

Component Description:
Professional services for the station
Amount:
$13,000.00

Component Description:
Professional services for the station
Amount:
$3,318.00

Component Description:
Professional Services for the station
Amount:
$435.00

Component Description:
KTLM-Rio Grande-Repack Finance Resource-Project Management Services- 62354
Amount:
$474.00

Component Description:
Project management service for KTMD.
Amount:
$6,468.00

Component Description:
KTLM-Rio Grande-Engagement Leader- Project Management Services- 62354
Amount:
$316.00

Component Description:
Project management services for the station KTLM-DRT
Amount:
$770.00

Component Description:
Project management services for the station KTLM-DRT
Amount:
$4,466.00

Component Description:
Invoice of $4466 for 29 hours of Project Management work carried out by Point B
Amount:
$4,466.00

Component Description:
Repack Finance Resource- project Management services
Amount:
$474.00

Component Description:
Invoice of $770 for 5 hours of Project Management work carried out by Point B
Amount:
$770.00

Component Description:
Invoice of $435 for 3 hours of Project Management work carried out by Point B
Amount:
$435.00

Component Description:
Invoice of $6468 for 42 hours of Project Management work carried out by Point B
Amount:
$6,468.00
Prepare/ Review 399 reimbursement form

Component Description:
Patty Chuh- Outside professional legal fees for the Repack Station
Amount:
$178.50

Component Description:
Patty Chuh- Outside professional legal fees for the Repack Station
Amount:
$107.10
Form 399 assistance or other Program Management costs

Component Description:
Review FCC IB staff regarding status of coordination with Mexico to process pending displacement application for the channel.
Amount:
$405.00

Component Description:
Review 399 reimbursable items and other documents- legal fees
Amount:
$137.70

Component Description:
Patty Chuh- Outside professional legal fees for the Repack Station
Amount:
$107.10

Component Description:
Patty Chuh- Outside professional legal fees for the Repack Station
Amount:
$35.70

Component Description:
Review eligibility for reimbursement for pending displacement application for channel 43 DRT.
Amount:
$315.00

Component Description:
Review FCC IB staff regarding status of coordination with Mexico to process pending displacement application for the channel.
Amount:
$810.00

Component Description:
Gathered eligible documentation for 399 reimbursement and review for the station
Amount:
$2,205.00

Component Description:
Legal fees for the station
Amount:
$183.60

Component Description:
Legal Consultant fees for the station
Amount:
$450.00

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 $25,640.00 $25,662.00 N/A $2,249.90 N/A
Total for all systems $430,453.70 $484,069.45 N/A $106,084.70 N/A
Other Expenses $25,640.00 $25,662.00 $2,249.90
DTV Medical Facility Notifications $5,000.00 $5,000.00 N/A $2,000.00 N/A
Equipment Storage $5,000.00 $5,000.00 TBD $0.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $357.00 Exceed predetermined cost $249.90 N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $305.00 N/A $0.00 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $0.00 $0.00 TBD N/A N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 TBD $0.00 N/A
Call Support $5,000.00 $5,000.00 N/A $0.00 N/A

Components

Actual Information Description File Name
DTV Medical Facility Notifications

Component Description:
KTLM-DRT Medical Notification Mailing complete per FCC Repack
Amount:
$2,000.00

Component Description:
KTLM (DRT) FCC ID 62354 Medical Notification Mailing Complete per FCC Repack
Amount:
$2,000.00
Equipment Storage

Component Description:
Storage expenses, please see line 2 from the attached invoice
Amount:
$1,595.00

Component Description:
PAF Van Storage (Two) months
Amount:
$1,595.00
FCC Filing Fees - Form 2100 license to cover application

Component Description:
Patty Chuh - Outside professional legal fees for the Repack Station
Amount:
$107.10

Component Description:
Patty Chuh- Outside professional legal fees for the Repack Station
Amount:
$249.90
FCC Filing Fees - Special Temporary Authorization request Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Equipment Delivery and Handling Charges

Component Description:
Shipping and Handling expenses
Amount:
$2,102.50

Component Description:
Using station EIN for reimbursement submission
Amount:
$5,710.60

Component Description:
Freight and Shipping - FedEx overnight delivery
Amount:
$7,330.50

Component Description:
Freight and shipping - PAF van delivery
Amount:
$2,102.50
Call Support Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $430,453.70 $484,069.45 $106,084.70

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.

Angela Ball

Assistant Secretary


08/30/2022

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.

Angela Ball

Assistant Secretary


08/30/2022

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.

Angela Ball

Assistant Secretary


08/30/2022

Attachments

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