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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:
72076-19
Service:
DRT
Call Sign:
WFTV
Channel:
19 (UHF)
File Number:
0000082339
FRN:
0014359285
Eligibility Status:
Eligible
Date Submitted:
06/14/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WFTV, LLC

Doing Business As: WFTV, LLC

Chief Engineer

490 E South St, WFTV

Orlando, FL 32801

United States

 +1 (407) 822-8410 jeff.juniet@wftv.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

Jeffrey Juniet

Director of Engineering

WFTV

Jeffrey Juniet

490 E South St

ORLANDO, FL 32801

United States

 +1 (407) 822-8410 jeff.juniet@wftv.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 WFTV's plan for the digital replacement translator is to replace the current antenna with a broader band antenna that will cover channels 19 & 20. Once the antenna is in place, we will need to replace the digital mask filter, retune the exciter.

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Retune Existing
Use Primary (Main)
Ownership Owned
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer GatesAir
Model UAX 1000
Year 2013
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1 kW

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New Mask Filter Does the transmitter require a new mask filter? Yes
Mask Filter Type Stringent
Power Other
Other Power 1000 W
New Exciter Is a new exciter needed? No

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

Information not provided.

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
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: 15.0 kW
Manufacturer
Model AR15
Year 2013

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 Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model AL12E-19/20-PL
Year 2019
Justification for New Antenna The current antenna is for channel 20 only and will not work 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? 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? No

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? 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 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? No
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1280971
Coordinates (NAD83) Latitude (NAD83) 28° 51' 10.3" N-
Longitude (NAD83) 081° 04' 02.6" W-
Overall Structure Height 499.01 feet
Support Structure Height 499.01 feet
Ground Elevation Above Mean Sea Level (AMSL) 17.72 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Entravision Communications Corporation
Date Constructed 04/26/2012

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
46969 WNUE-FM FM

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 100
Explanation WFTV1 does not have sufficient resource capacity and expertise in house to handle all activities necessary for completion of the station's build by the construction deadline. WFTV1 will hire an outside firm to facilitate a timely transition.
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 No
Prepare request for Special Temporary Authority No
Prepare Form 601 Yes
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility Yes
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 Yes
Additional Field Engineering Service Yes
Number of Days 1
Justification Proof of performance.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Attorney Fees - Prepare Construction Permit Application - Aux Facility

Attorney Fees - Prepare Construction Permit Application - Aux Facility

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? No
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 $19,000.00 $10,000.00 N/A $7,857.74 N/A
Total for all systems $192,699.03 $151,225.03 N/A $70,829.21 N/A
Primary Transmitter UAX 1000 $19,000.00 $10,000.00 $7,857.74
Retune - UHF and VHF - minor re-channel issues $11,000.00 $2,000.00 Proof of Performance N/A N/A
Other 1000 w mask filter Stringent $8,000.00 $8,000.00 Channel 19 Mask Filter that is needed for the transmitter final output. Field sweep and check/tuning for the mask filter. $7,857.74 N/A

Components

Actual Information Description File Name
Retune - UHF and VHF - minor re-channel issues Information not provided.
Other 1000 w mask filter Stringent

Component Description:
Translator Mask Filter
Amount:
$4,312.74

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

Component Description:
50% DEPOSIT DUE WITH ORDER
Amount:
$3,545.00

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 $16,370.40 $16,370.40 N/A $16,370.40 N/A
Total for all systems $192,699.03 $151,225.03 N/A $70,829.21 N/A
Primary Antenna AL12E-19/20-PL $16,370.40 $16,370.40 $16,370.40
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal $0.00 $0.00 N/A N/A N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal $16,370.40 $16,370.40 ***System Notice: Estimate adjusted and locked because line has been superseded.***Please see attached ERI Proposal 20180927-379 Rev A. $16,370.40 N/A

Components

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

Component Description:
Translator Antenna
Amount:
$9,258.45

Component Description:
50% DEPOSIT DUE WITH ORDER
Amount:
$7,111.95

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 $56,190.00 $12,000.00 N/A $12,000.00 N/A
Total for all systems $192,699.03 $151,225.03 N/A $70,829.21 N/A
Primary Tower TOWER $56,190.00 $12,000.00 $12,000.00
Tower Rigging Short Tower (less than 500') $56,190.00 $12,000.00 Please see Clifton Tower Service Inc estimate CH9OSTRP19 $12,000.00 N/A

Components

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

Component Description:
Remove existing antenna and install customer provided antenna
Amount:
$12,000.00

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 $96,896.00 $108,277.00 N/A $33,023.45 N/A
Total for all systems $192,699.03 $151,225.03 N/A $70,829.21 N/A
Outside Professional Services $96,896.00 $108,277.00 $33,023.45
Project management of the transition $10,550.00 $24,663.75 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $24,663.75 N/A
Attorney Fees - Prepare Construction Permit Application - Aux Facility $478.50 $478.50 Please see WFTV1 Attorney - Construction Permit (Aux) Budget Revision Justification Letter N/A N/A
Additional Field Engineering Service, 1 Days $2,700.00 $2,700.00 N/A N/A N/A
RF Exposure Measurements $12,100.00 $12,100.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $52,600.00 N/A $1,930.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $2,342.10 Please see WFTV1 Attorney STA Budget Revision Justification Letter $2,342.10 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $3,254.25 Please see WFTV1 Attorney - Other Matters Budget Revision Justification Letters. The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $3,254.25 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $395.90 Please see WFTV1 Attorney - License to Cover (Main) Budget Revision Justification Letter. The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $395.90 N/A
Prepare Form 601 $755.00 $755.00 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 $79.75 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
Perform engineering study for displacement application $1,800.00 $150.00 Please see WFTV1 RF Eng Study for Displacement Application Budget Revision Justification Letter $0.00 N/A
Form 399 assistance or other Program Management costs $2,000.00 $2,000.00 Consultant time for system design and cost assessment. $150.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A $207.70 N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$1,125.00

Component Description:
Project Management
Amount:
$348.75

Component Description:
Project Management
Amount:
$3,220.00

Component Description:
Project Management
Amount:
$387.50

Component Description:
Project management
Amount:
$155.00

Component Description:
Project Management
Amount:
$348.75

Component Description:
Project Management
Amount:
$503.75

Component Description:
Project Management
Amount:
$658.75

Component Description:
Project Management
Amount:
$503.75

Component Description:
Project Management
Amount:
$2,402.50

Component Description:
Project Management
Amount:
$4,146.25

Component Description:
Project Management
Amount:
$116.25

Component Description:
Project Management
Amount:
$7,788.75

Component Description:
Project management
Amount:
$483.75

Component Description:
Project Management
Amount:
$193.75

Component Description:
Project Management
Amount:
$990.00

Component Description:
Project management
Amount:
$1,058.75

Component Description:
Project Management
Amount:
$232.50
Attorney Fees - Prepare Construction Permit Application - Aux Facility Information not provided.
Additional Field Engineering Service, 1 Days Information not provided.
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed

Component Description:
PROVIDE DRIVE TEST MAPING WITH ELECTRONIC REPORT FOR RF CHANNELS 19, DATA FILES PROVIDED FOR KML OVERLAYS.
Amount:
$1,930.00
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
For services rendered through April 30, 2018
Amount:
$2,342.10
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
For services rendered through August 31, 2020
Amount:
$127.60

Component Description:
For services rendered through March 31, 2020
Amount:
$1,575.05

Component Description:
For services rendered through February 29, 2020
Amount:
$604.10

Component Description:
Professional Services
Amount:
$241.00

Component Description:
For services rendered through April 30, 2018
Amount:
$706.50
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
WFTV1-550-Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application
Amount:
$395.90
Prepare Form 601 Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
WFTV1-550-Attorney - Construction Permit Application (Main)
Amount:
$79.75
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for displacement application

Component Description:
FOR PROFESSIONAL SERVICES RENDERED
Amount:
$150.00
Form 399 assistance or other Program Management costs

Component Description:
Invoice 1119001-T from Merrill Weiss Group LLC is for planning WFTV Digital Replacement Translator. This work was to determine the channel, location, and power for the application.
Amount:
$150.00
Prepare/ Review 399 reimbursement form

Component Description:
Professional Services
Amount:
$29.30

Component Description:
WFTV1-590-Prepare/Review 399 Reimbursement Form
Amount:
$31.90

Component Description:
For services rendered through November 30, 2019
Amount:
$146.50

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 $4,242.63 $4,577.63 N/A $1,577.62 N/A
Total for all systems $192,699.03 $151,225.03 N/A $70,829.21 N/A
Other Expenses $4,242.63 $4,577.63 $1,577.62
Equipment Delivery and Handling Charges $602.63 $602.63 Please see WFTV1 Equipment Delivery and Handling Budget Revision Justification Letter $602.62 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $3,000.00 $3,000.00 Disposal of old channel 20 antenna. N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $805.00 Please see WFTV1 FCC Filing Fee STA Budget Revision Justification Letter $805.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $170.00 Please see WFTV1 FCC Filing Fee - License to Cover Budget Revision Justification Letter $170.00 N/A

Components

Actual Information Description File Name
Equipment Delivery and Handling Charges

Component Description:
5500LB 19' Shooting Boom Forklift
Amount:
$602.62
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
FCC Filing Fees - Special Temporary Authorization request

Component Description:
For services rendered through May 31, 2018
Amount:
$805.00
FCC Filing Fees - Form 2100 license to cover application

Component Description:
For services rendered through April 30, 2020
Amount:
$170.00

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $192,699.03 $151,225.03 $70,829.21

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. 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 M Juniet , Juniet .

Director of Engineering


08/01/2022

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 M Juniet

Director of Engineering


08/01/2022

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.

Jeffrey M Juniet

Director of Engineering


08/01/2022

Attachments

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