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:
61044
Service:
LPD
Call Sign:
K29NL-D
Channel:
29 (UHF)
File Number:
0000089617
FRN:
0006159552
Eligibility Status:
Eligible
Date Submitted:
09/06/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

VENTANA TELEVISION, INC.

Doing Business As: VENTANA TELEVISION, INC.

Eric Yonkin

1 HSN Drive

St. Petersburg, FL 33729

United States

+1 (727) 872-7443 EASnotice@hsn.net Corporation

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

Ari Q. Fitzgerald

Hogan Lovells US LLP

555 Thirteenth Street, NW

Washington, DC 20004

United States

+1 (202) 637-2257 ari.fitzgerald@hoganlovells.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 Over 5 days, a local engineer team is assisting with the delivery of the transmitter and antenna, assembly of the transmitter, and supervision of the tower crew.

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 TXUP-2500
Year 2005
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 0.8 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? No
Manufacturer
Model EC703HP-BB
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2.25 kW
Justification for New Transmitter The existing transmitter is unable to deliver the required TPO for the new antenna pattern and ERP.

Primary Transmitter

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Other Transmitter Costs

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

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Hitachi Invoice No. S10683-1

EC703HP-BB-SD 220VAC D29, Transmitter

Linder and Assoc. Invoice No. 7682

Install new 208 Volt Service - PO HN813202784

NFB Consulting LLC - Invoice No. 20201027

Software, Statmon - STC-Plugin

Hitachi Invoice N. S10683-2

EC703HP-BB-SD 220VAC D29, Transmitter - Final Payment

Hitachi Invoice No. 14297

Ship/Han PO HN813184174

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Ownership Owned
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? Yes
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model CS-2030-B-16 EP
Year 2020

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Change Type Purchase New
Ownership Owned
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
ERP: 1.5 kW
Manufacturer
Model CS-2030-B-16 E/P
Year 2020
Justification for New Antenna Previous channel 20 antenna would not work on channel 18. Very different directional pattern.

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

Name Description

Micronetixx Invoice No. C2273-B, CS-2030-B-16 EP Final Payment for Antenna

Final Payment for Antenna CS-2030-B-16 EP

Micronetixx Invoice No. C2273-C, CS-2030-B-16 EP, Freight and Shipping

Freight and shipping costs for Antenna CS-2030-B-16 EP

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? Yes

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Ownership Owned
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Air
Diameter 4 inches
Number of parallel runs 1
Length 640 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Air
Diameter 4 inches
Number of parallel runs 1
Length 640 feet per run
Justification for New Transmission Line Station had to relocate due to structural deficiencies in the previous tower antenna mounting area.
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

Connectors and Adapters

Connectors and adapters needed to connect the line to the antenna and to the transmitter.

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 Yes
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1022759
Coordinates (NAD83) Latitude (NAD83) 37° 41' 53.0" N-
Longitude (NAD83) 097° 19' 11.0" W-
Overall Structure Height 336.94 feet
Support Structure Height 329.72 feet
Ground Elevation Above Mean Sea Level (AMSL) 1301.82 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner SBA Structures, LLC
Date Constructed 03/02/1999

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
72358 KSNW DTV
72364 KMUW FM
6506 KCVW FM
67886 KWKD-LD LPD
56518 KSMI-LD LPT

Other Types of Users

Users
Cellular

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: Serious 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

Name Description

Hodge -18G001802.1 Guyed Tower, PO No. HN813188008

Tower Structural Study

Precision, Addendum to Proposal 210502-5, Invoice No. 0546

For freight on materials for Antenna Installation.

Precision, Proposal 210502-5 Antenna System

Tall Tower Antenna Installation.

Hodge - 18G001802.2, Guyed Tower, PO No HN813188008

Tower Structural Study

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? No
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 Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 5
Justification The station requires a comprehensive coverage verification via field study to confirm that the station's post repack coverage is accurate. The station will be contracting a third party that performs field studies with the use of unmanned aerial vehicles.

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 No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? No
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 $227,969.00 $227,969.00 N/A $85,124.20 N/A
Total for all systems $538,206.19 $501,005.13 N/A $237,241.33 N/A
Primary Transmitter EC703HP-BB $227,969.00 $227,969.00 $85,124.20
Hitachi Invoice No. S10683-1 $63,616.00 $63,616.00 N/A $34,193.60 N/A
Hitachi Invoice No. 14297 $787.00 $787.00 N/A $787.00 N/A
Hitachi Invoice N. S10683-2 $63,616.00 $63,616.00 N/A $34,193.60 N/A
Linder and Assoc. Invoice No. 7682 $15,500.00 $15,500.00 N/A $15,500.00 N/A
NFB Consulting LLC - Invoice No. 20201027 $450.00 $450.00 N/A $450.00 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $84,000.00 N/A $0.00 N/A

Components

Actual Information Description File Name
Hitachi Invoice No. S10683-1

Component Description:
EC703HP-BB Transmitter - 50 percent down payment.
Amount:
$34,193.60
Hitachi Invoice No. 14297

Component Description:
Ship/Han Costs for transmitter
Amount:
$787.00
Hitachi Invoice N. S10683-2

Component Description:
EC703HP-BB - New Transmitter - Final Payment
Amount:
$34,193.60
Linder and Assoc. Invoice No. 7682

Component Description:
Installation of new 208 Volt service and panel for transmitter
Amount:
$15,500.00
NFB Consulting LLC - Invoice No. 20201027

Component Description:
SNMP plugins to adapt existing remote control to operate new transmitters. Previous transmitter control systems were serial; new ones require SNMP.
Amount:
$450.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW 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 $34,408.00 $34,408.00 N/A $23,533.00 N/A
Total for all systems $538,206.19 $501,005.13 N/A $237,241.33 N/A
Primary Antenna CS-2030-B-16 E/P $34,408.00 $34,408.00 $23,533.00
Micronetixx Invoice No. C2273-C, CS-2030-B-16 EP, Freight and Shipping $1,783.00 $1,783.00 N/A $1,783.00 N/A
Micronetixx Invoice No. C2273-B, CS-2030-B-16 EP Final Payment for Antenna $10,875.00 $10,875.00 N/A $10,875.00 N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 1.5kW input, Elliptical $21,750.00 $21,750.00 N/A $10,875.00 N/A

Components

Actual Information Description File Name
Micronetixx Invoice No. C2273-C, CS-2030-B-16 EP, Freight and Shipping

Component Description:
Freight and shipping costs for Antenna
Amount:
$1,783.00
Micronetixx Invoice No. C2273-B, CS-2030-B-16 EP Final Payment for Antenna

Component Description:
The station upgraded to an elliptical antenna, previous was horizontal. Because the Fund does not cover upgrades, the station is only requesting reimb. for the price of a horizontal replacement. This is one of the two payments for this equip.
Amount:
$10,875.00
UHF-Low Power, Side Mount, Slotted Coaxial, 1.5kW input, Elliptical

Component Description:
The station upgraded to an elliptical antenna, previous was horizontal. Because the Fund does not cover upgrades, the station is only requesting reimb. for the price of a horizontal replacement. This is one of the two payments for this equip.
Amount:
$10,875.00

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 $54,442.94 $44,716.88 N/A $43,907.88 N/A
Total for all systems $538,206.19 $501,005.13 N/A $237,241.33 N/A
Primary Transmission Line $54,442.94 $44,716.88 $43,907.88
Connectors and Adapters $7,082.94 $7,082.94 N/A $7,082.94 N/A
Flexible Air Transmission Line - dielectric, 4" $47,360.00 $37,633.94 N/A $36,824.94 N/A

Components

Actual Information Description File Name
Connectors and Adapters

Component Description:
This expense is for connectors and adapters for the new transmission line.
Amount:
$7,082.94
Flexible Air Transmission Line - dielectric, 4"

Component Description:
This expense is for a new transmission line. The CyberPower listed is not reimbursable ($809) so it is being deducted off of the total invoice amount.
Amount:
$36,824.94

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 $151,741.25 $151,741.25 N/A $59,551.25 N/A
Total for all systems $538,206.19 $501,005.13 N/A $237,241.33 N/A
Primary Tower TOWER $151,741.25 $151,741.25 $59,551.25
Hodge -18G001802.1 Guyed Tower, PO No. HN813188008 $3,250.00 $3,250.00 N/A $3,250.00 N/A
Precision, Addendum to Proposal 210502-5, Invoice No. 0546 $806.25 $806.25 N/A $806.25 N/A
Precision, Proposal 210502-5 Antenna System $52,245.00 $52,245.00 N/A $52,245.00 N/A
Hodge - 18G001802.2, Guyed Tower, PO No HN813188008 $3,250.00 $3,250.00 N/A $3,250.00 N/A
Serious tower reinforcement/modifications $15,000.00 $15,000.00 N/A N/A N/A
Tower Rigging Short Tower (less than 500') $56,190.00 $56,190.00 N/A N/A N/A
Tower mapping and report for structural engineer $21,000.00 $21,000.00 N/A $0.00 N/A

Components

Actual Information Description File Name
Hodge -18G001802.1 Guyed Tower, PO No. HN813188008

Component Description:
Costs for 50 percent down payment for Engineering Structural Study
Amount:
$3,250.00
Precision, Addendum to Proposal 210502-5, Invoice No. 0546

Component Description:
Freight on materials for antenna installation.
Amount:
$806.25
Precision, Proposal 210502-5 Antenna System

Component Description:
Installment of Antenna System
Amount:
$52,245.00
Hodge - 18G001802.2, Guyed Tower, PO No HN813188008

Component Description:
Final Payment for Engineering Structural Study
Amount:
$3,250.00
Serious tower reinforcement/modifications Information not provided.
Tower Rigging Short Tower (less than 500') Information not provided.
Tower mapping and report for structural engineer 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 $69,310.00 $41,835.00 N/A $25,125.00 N/A
Total for all systems $538,206.19 $501,005.13 N/A $237,241.33 N/A
Outside Professional Services $69,310.00 $41,835.00 $25,125.00
Additional Field Engineering Service, 5 Days $13,500.00 $13,500.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $25,125.00 N/A $25,125.00 N/A
Form 399 assistance or other Program Management costs $1,500.00 $1,500.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A

Components

Actual Information Description File Name
Additional Field Engineering Service, 5 Days Information not provided.
Comprehensive coverage verification via field study, if needed

Component Description:
Antenna Pattern Verification and Field Study
Amount:
$25,125.00
Form 399 assistance or other Program Management costs Information not provided.
Prepare/ Review 399 reimbursement form 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 $335.00 $335.00 N/A $0.00 N/A
Total for all systems $538,206.19 $501,005.13 N/A $237,241.33 N/A
Other Expenses $335.00 $335.00 $0.00
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 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 $538,206.19 $501,005.13 $237,241.33

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.

Eric Yonkin

Associate General Counsel, Legal


09/06/2022

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.

Eric Yonkin

Associate General Counsel, Legal


09/06/2022

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.

Eric Yonkin

Associate General Counsel, Legal


09/06/2022

Attachments

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