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:
68704
Service:
LPT
Call Sign:
K21OF-D
Channel:
21 (UHF)
File Number:
0000087785
FRN:
0004376646
Eligibility Status:
Eligible
Date Submitted:
04/22/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

UHF TV ASSOCIATION

Applicant

Doing Business As: UHF TV ASSOCIATION

PO Box 187

Tucumcari, NM 88401

United States

+1 (806) 331-9852 zdavis@newschannel10.com Other

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

Tony Zummallen

Anywave Communications Technologies

Tony Zummallen

300 Knightsbridge Parkway, ste. 150

Lincolnshire, IL 60069

United States

+1 (816) 882-5600 tony.zummallen@anywavecom.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. Yes
Briefly describe transition plan Replace the transmitter per the channel reassignment project with reasonable and customary engineering and business practices. Replace the shared line and shared antenna per the channel reassignment project.

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? Yes
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model 30 watts
Year 2007
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 30 W

Facility ID's and Call Signs of all stations with whom the transmitter is shared.

Facility ID Call Sign
68703 K46BU-D
68702 K50CX-D
68705 K40DK-D

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-U-200-D-FB
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 200 W
Justification for New Transmitter New channel requires new combiner with sharper tuning, resulting in more loss. Larger transmitter required to overcome that loss.

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 No
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 tons
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

Shipping

Estimated costs for shipping and freight of the transmitter.

Decommissioning

Estimated costs to de-install, disconnect and decommission existing transmitter

Site Prep

Estimated costs to prepare site for installation of new transmitter

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? Yes
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
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Circular
Type Slotted Coaxial
ERP: 0.61 kW
Manufacturer
Model SL-8
Year 2007

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID Call Sign
68705 K40DK-D
68702 K50CX-D
68703 K46BU-D

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? Yes
Is antenna directional? No
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 Horizontal
Type Slotted Coaxial
ERP: 1.0 kW
Manufacturer
Model SL-8
Year 2019
Justification for New Antenna Original antenna cannot support new channels.

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? Yes
Type New
Number of channels supported 4
Frequencies of channels supported Upper and lower frequency
Frequency 512.0 MHz - 548.0 MHz
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? 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

Combiner Shipping fees

Estimated shipping costs for combiner

Antenna Shipping fees

Estimated shipping costs to ship antenna to site.

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? Yes
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 50 feet per run

Facility ID's and Call Signs of all stations with whom the transmission line is shared.

Facility ID Call Sign
68705 K40DK-D
68702 K50CX-D
68703 K46BU-D

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 1/2 inches
Number of parallel runs 1
Length 100 feet per run
Justification for New Transmission Line Line being replaced due to the old line being RG-58, it cannot handle the power level of the transmitters combined and the antenna end on the line connector is type-n and on the side of the combiner is type-n as well.
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

Name Description

Shipping

Estimated shipping costs not included on quote

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? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? No
Coordinates (NAD83) Latitude (NAD83) 35° 08' 12.0" N-
Longitude (NAD83) 103° 41' 56.9" W-
Overall Structure Height 39.00 feet
Support Structure Height 33.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 4777.00 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner UHF TV Association
Date Constructed 01/01/1990

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
68703 K46BU-D LPT
68705 K40DK-D LPT
68702 K50CX-D LPT

Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: No study needed
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 50
Explanation Required to assist in the turnkey management of the channel relocation project in order that the existing internal personnel can maintain and operate the station's daily operational requirements and plans.
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 Yes
Quantity 1
Prepare Form 601 Yes
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
Negotiation of Lease and other Matter for Shared Locations Yes
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 No
Additional Field Engineering Service No

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Engineering-General

Engineering consulting

Attorney Fees

Attorney fees related to repack

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 Yes
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)? 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

Information not provided.

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 $61,750.00 $41,320.90 N/A $23,285.00 N/A
Total for all systems $264,688.60 $148,676.00 N/A $70,559.10 N/A
Primary Transmitter TRN-U-200-D-FB $61,750.00 $41,320.90 $23,285.00
UHF - Air Cooled Solid State Transmitter 160 - 300 Watts $24,300.00 $23,085.00 Cost of transmitter $23,085.00 N/A
5 Ton system $20,250.00 $1,035.90 Attached quote for $4143.61; shared equally between (4) stations N/A N/A
Transmitter Building Site Survey/Installation $10,000.00 $10,000.00 N/A N/A N/A
Shipping $200.00 $200.00 Estimated shipping costs of transmitter not included quote. Actual costs to be determined. $200.00 N/A
Site Prep $4,000.00 $4,000.00 Estimated costs to prepare site for new transmitter. Includes receiving and inventory of new transmitter and all components; pre-assembly of cabinets and subassemblies; ensure site has all materials ready for installation crew. N/A N/A
Decommissioning $3,000.00 $3,000.00 Estimated costs to de-install and disconnect old transmitter in preparation for the installation of the new transmitter. N/A N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 160 - 300 Watts

Component Description:
Cost of transmitter
Amount:
$23,085.00
5 Ton system Information not provided.
Transmitter Building Site Survey/Installation Information not provided.
Shipping

Component Description:
Cost of shipping
Amount:
$200.00
Site Prep Information not provided.
Decommissioning 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 $27,437.00 $13,222.50 N/A $7,492.50 N/A
Total for all systems $264,688.60 $148,676.00 N/A $70,559.10 N/A
Primary Antenna SL-8 $27,437.00 $13,222.50 $7,492.50
UHF-Low Power, Side Mount, Slotted Coaxial, 1.0kW input, Horizontal $2,507.00 $2,507.00 Cost determined by invoice. $2,507.00 N/A
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A
1 kW UHF Combiner (per channel) $18,800.00 $4,585.50 Cost of combiner split between 4 stations $4,585.50 N/A
Combiner Shipping fees $100.00 $100.00 Estimated shipping fees for combiner (1/4 of total cost, per shared station). $100.00 N/A
Antenna Shipping fees $300.00 $300.00 Estimated shipping fees for antenna (1/4 of total cost, per shared station). $300.00 N/A

Components

Actual Information Description File Name
UHF-Low Power, Side Mount, Slotted Coaxial, 1.0kW input, Horizontal

Component Description:
Cost split between 4 ways
Amount:
$2,507.00
Sweep test of transmission line and antenna Information not provided.
1 kW UHF Combiner (per channel)

Component Description:
Cost of antenna split between 4 stations
Amount:
$4,585.50
Combiner Shipping fees

Component Description:
Cost of shipping split between 4 stations.
Amount:
$100.00
Antenna Shipping fees

Component Description:
Cost of shipping split between 4 stations
Amount:
$300.00

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 $400.00 $618.50 N/A $0.00 N/A
Total for all systems $264,688.60 $148,676.00 N/A $70,559.10 N/A
Primary Transmission Line $400.00 $618.50 $0.00
Shipping $50.00 $50.00 1/4 of stimated shipping costs to site not included on quote $0.00 N/A
Flexible Foam Transmission Line - dielectric, 1/2" $350.00 $568.50 Cost determined by invoice $0.00 N/A

Components

Actual Information Description File Name
Shipping

Component Description:
Cost of shipping
Amount:
$50.00

Component Description:
Cost of shipping
Amount:
$50.00
Flexible Foam Transmission Line - dielectric, 1/2"

Component Description:
Cost of transmission line split between 4 stations
Amount:
$568.50

Component Description:
Cost of transmission line split between 4 stations.
Amount:
$568.50

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 $862.50 N/A $0.00 N/A
Total for all systems $264,688.60 $148,676.00 N/A $70,559.10 N/A
Primary Tower TOWER $56,190.00 $862.50 $0.00
Tower Rigging Short Tower (less than 500') $56,190.00 $862.50 Cost determined by invoices. $0.00 N/A

Components

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

Component Description:
Cost split between for stations. Invoice 1 of 2.
Amount:
$862.50

Component Description:
Cost split between 4 stations
Amount:
N/A

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 $102,201.60 $75,941.60 N/A $39,781.60 N/A
Total for all systems $264,688.60 $148,676.00 N/A $70,559.10 N/A
Outside Professional Services $102,201.60 $75,941.60 $39,781.60
Comprehensive coverage verification via field study, if needed $52,600.00 $23,125.00 Cost determined by attached quote. $11,562.50 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $3,262.50 N/A N/A N/A
Project management of the transition $5,275.00 $7,700.00 50 hours at $154/hour $192.50 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A N/A N/A
Prepare Form 601 $755.00 $755.00 4/3/2020- Working to obtain quote which may be delayed due to coronavirus pandemic. N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $2,235.00 N/A N/A N/A
Engineering-General $180.00 $180.00 Cost Determined by invoices. $180.00 N/A
Attorney Fees $915.00 $915.00 Cost determined by invoices. $915.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $2,500.00 Required to assist in the 399 form preparation in order that the existing internal personnel can maintain and operate the station's daily operational requirements and plans. $2,500.00 N/A
Perform engineering study for displacement application $1,800.00 $1,800.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,280.00 $1,280.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A N/A N/A
Form 399 assistance or other Program Management costs $24,431.60 $24,431.60 Cost determined by invoices. $24,431.60 N/A

Components

Actual Information Description File Name
Comprehensive coverage verification via field study, if needed

Component Description:
1st half PV invoice - QComm - INV 341033
Amount:
$11,562.50

Component Description:
Down payment invoice.
Amount:
$11,562.50
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Project management of the transition

Component Description:
Tech PM
Amount:
$192.50
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare Form 601 Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Engineering-General

Component Description:
Consulting Services
Amount:
$180.00
Attorney Fees

Component Description:
Attorney fees for repack
Amount:
$915.00
Prepare/ Review 399 reimbursement form

Component Description:
399 form submission, flat fee
Amount:
$2,500.00

Component Description:
PM Paperwork
Amount:
$2,500.00
Perform engineering study for displacement application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Form 399 assistance or other Program Management costs

Component Description:
399 Follow up work.
Amount:
$1,093.40

Component Description:
PM Paperwork
Amount:
$893.20

Component Description:
Paperwork PM
Amount:
$1,570.80

Component Description:
PM Paperwork
Amount:
$1,370.60

Component Description:
PM Paperwork
Amount:
$1,401.40

Component Description:
PM Paperwork
Amount:
$893.20

Component Description:
PM Paperwork
Amount:
$1,755.60

Component Description:
Paperwork PM
Amount:
$1,101.10

Component Description:
Oct 2021 PM - Anywave - INV FA2112-1212
Amount:
$1,339.80

Component Description:
PM Paperwork
Amount:
$1,755.60

Component Description:
Paperwork PM
Amount:
$1,008.70

Component Description:
Form 399 Assistance Flat fee
Amount:
$500.00

Component Description:
Requesting partial reimbursement Paperwork PM's
Amount:
$500.00

Component Description:
Aug 2021 PM - Anywave - INV FA2109-1088
Amount:
$847.00

Component Description:
PM Paperwork
Amount:
$831.60

Component Description:
July 2021 PM - Anywave - INV FA2109-1112
Amount:
$908.60

Component Description:
Paperwork PM
Amount:
$1,078.00

Component Description:
PM Paperwork
Amount:
$1,309.00

Component Description:
Paperwork PM
Amount:
$1,524.60

Component Description:
PM Paperwork
Amount:
$1,078.00

Component Description:
PM Paperwork
Amount:
$1,617.00

Component Description:
Paperwork PM
Amount:
$2,048.20

Component Description:
Nov 2021 PM - Anywave - INV FA2202-1278
Amount:
$154.00

Component Description:
PM Paperwork
Amount:
$1,386.00

Component Description:
399 Assistance PM work.
Amount:
$693.00

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 $16,710.00 $16,710.00 N/A $0.00 N/A
Total for all systems $264,688.60 $148,676.00 N/A $70,559.10 N/A
Other Expenses $16,710.00 $16,710.00 $0.00
Disposal Costs (for equipment and other waste, net of any salvage value) $2,500.00 $2,500.00 4-6 Yard disposal bin on site to capture all waste from on site system integration and tower vendors N/A N/A
Equipment Delivery and Handling Charges $2,500.00 $2,500.00 Transport, forklift rental and handling fees from staging area to transmitter site. N/A N/A
Equipment Storage $5,000.00 $5,000.00 Expecting multiple staggered equipment deliveries from different vendors and need to store and stage new equipment prior to installation date. Anticipate 6-24 months of storage time. N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,110.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A
FCC Filing Fees - Form 2100 Major change CP application $4,960.00 $4,960.00 4/3/2020- Working to obtain quote which may be delayed due to coronavirus pandemic. N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $305.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $264,688.60 $148,676.00 $70,559.10

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
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.

Zachary Davis

Applicant


04/22/2022

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.

Zachary Davis

Applicant


04/22/2022

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