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:
187964
Service:
LPD
Call Sign:
KCKS-LD
Channel:
19 (UHF)
File Number:
0000089941
FRN:
0019530740
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

HEARTLAND BROADCASTING LLC

Doing Business As: HEARTLAND BROADCASTING LLC

Brian L Short

PO Box 130

Auburn, KS 66402

United States

+1 (913) 638-7373 b@tv25.tv 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

Tony Z

zumMallen

QCommunications, LLC

Tony zumMallen

705B SE Melody LN #314

Lee's Summit, MO 64063

United States

+1 (816) 729-1177 tony@qcomm.tv

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan Replace the transmitter, line and antenna per the channel reassignment with reasonable and customary engineering and business practices.

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 TRN-5X-U-46D-C
Year 2015
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? No
Manufacturer
Model TRN-U-3000-FA
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 3 kW
Justification for New Transmitter Mask Filtration for adjacent interference reduction and antenna type for pattern required additional power to meet authorized 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? 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? 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

Transmitter Decommissioning

Harvesting and removal of old transmitter

Site Prep

Preparation of site for new transmitter

Transmitter Shipping fee

Shipping fees for new transmitter

Transmitter Taxes

Sales tax for 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? 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 Circular
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model LP8/25
Year 2015

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? 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 Circular
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model ATC-BCC418M-V3-19
Year 2019
Justification for New Antenna Site Move required, due to interference with clients at existing site.

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 1 5/8 inches inches
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

Antenna Sales Tax

Sales tax for new antenna

Antenna Shipping fee

Shipping fees for new antenna

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 Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 350 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 Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 350 feet per run
Justification for New Transmission Line Site Move required, due to interference with clients at existing site.
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

Transmission line taxes

Sales tax for new line

Transmission line shipping

Shipping fees for new line

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 Move Equipment
Tower Use Primary (Main)
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? 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 1032494
Coordinates (NAD83) Latitude (NAD83) 39° 05' 32.0" N-
Longitude (NAD83) 094° 56' 43.0" W-
Overall Structure Height 240.15 feet
Support Structure Height 210.96 feet
Ground Elevation Above Mean Sea Level (AMSL) 999.99 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Heartland Tower Inc.
Date Constructed 12/01/1964


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

Tower Mapping

Tower Mapping

Tower Structural Analysis

Structural Analysis on tower

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 Required to assist in the turnkey management of the channel relocation project in order that the existing internal personal can maintain and operate the stations 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 No
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 Yes
Number of Days 5
Justification Estimated field engineering services during transition activities. Actual costs to be determined.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

General Engineering Services

Engineering services provided

KCKS Extension

KCKS Extension Request

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 $143,800.00 $163,800.00 N/A $0.00 N/A
Total for all systems $432,784.80 $447,186.05 N/A $82,695.35 N/A
Primary Transmitter TRN-U-3000-FA $143,800.00 $163,800.00 $0.00
Transmitter Taxes $10,000.00 $10,000.00 4/2/2020- Working to obtain quote which may be delayed due to coronavirus pandemic. N/A N/A
Transmitter Shipping fee $2,500.00 $2,500.00 Estimated shipping costs for transmitter. Actual costs to be determined. N/A N/A
Site Prep $8,000.00 $8,000.00 4/2/2020- Working to obtain quote which may be delayed due to coronavirus pandemic. N/A N/A
Transmitter Decommissioning $7,000.00 $7,000.00 Estimated costs of harvesting and removal of old transmitter from site. Revised upon Site Survey. N/A N/A
Transmitter Building Site Survey/Installation $10,000.00 $30,000.00 4/2/2020- Working to obtain quote which may be delayed due to coronavirus pandemic. N/A N/A
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW $106,300.00 $106,300.00 Cost determined from order invoice submitted on 4.2.20 N/A N/A

Components

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 $43,955.00 $45,330.00 N/A $29,900.00 N/A
Total for all systems $432,784.80 $447,186.05 N/A $82,695.35 N/A
Primary Antenna ATC-BCC418M-V3-19 $43,955.00 $45,330.00 $29,900.00
Antenna Sales Tax $2,800.00 $2,800.00 Estimated sales tax collected by vendors as part of the repack. Actual costs to be determined. N/A N/A
Antenna Shipping fee $2,000.00 $2,000.00 Estimated shipping costs for antenna. Actual costs to be determined. $2,000.00 N/A
Side Mount antenna brackets $4,625.00 $6,000.00 Cost determined by invoices. $6,000.00 N/A
Elbow complex, single channel, 1 5/8” input (if needed) $6,900.00 $6,900.00 N/A N/A N/A
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Circular $21,900.00 $21,900.00 Per attached Alive invoice. $21,900.00 N/A

Components

Actual Information Description File Name
Antenna Sales Tax Information not provided.
Antenna Shipping fee

Component Description:
Cost of shipping
Amount:
$2,000.00
Side Mount antenna brackets

Component Description:
Cost of mount brackets.
Amount:
$6,000.00
Elbow complex, single channel, 1 5/8” input (if needed) Information not provided.
Sweep test of transmission line and antenna Information not provided.
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Circular

Component Description:
Payment for antenna minus v-pol upgrade.
Amount:
$5,475.00

Component Description:
Antenna payment minus V-pol upgrade.
Amount:
$10,950.00

Component Description:
Antenna Payment minus V-pol upgrade.
Amount:
$5,475.00

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 $10,400.00 $10,400.00 N/A $0.00 N/A
Total for all systems $432,784.80 $447,186.05 N/A $82,695.35 N/A
Primary Transmission Line $10,400.00 $10,400.00 $0.00
Transmission line taxes $1,000.00 $1,000.00 Estimated sales tax collected by vendors as part of the repack. Actual costs to be determined. N/A N/A
Flexible Foam Transmission Line - dielectric, 1 5/8" $8,400.00 $8,400.00 N/A $0.00 N/A
Transmission line shipping $1,000.00 $1,000.00 Estimated shipping costs for new line. Actual costs to be determined. N/A N/A

Components

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 $66,185.00 $66,185.00 N/A $9,995.00 N/A
Total for all systems $432,784.80 $447,186.05 N/A $82,695.35 N/A
Primary Tower TOWER $66,185.00 $66,185.00 $9,995.00
Tower Mapping $4,000.00 $4,000.00 Tower Mapping per actual costs $4,000.00 N/A
Tower Structural Analysis $5,995.00 $5,995.00 Structural analysis $5,995.00 N/A
Tower Rigging Short Tower (less than 500') $56,190.00 $56,190.00 N/A N/A N/A

Components

Actual Information Description File Name
Tower Mapping

Component Description:
Tower Mapping - Heartland Tower - INV HTI052421
Amount:
$4,000.00
Tower Structural Analysis

Component Description:
Heartland Tower - structural - INV HTI060721
Amount:
$5,995.00
Tower Rigging Short Tower (less than 500') 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 $155,234.80 $148,261.05 N/A $42,800.35 N/A
Total for all systems $432,784.80 $447,186.05 N/A $82,695.35 N/A
Outside Professional Services $155,234.80 $148,261.05 $42,800.35
KCKS Extension $3,034.50 $3,034.50 Extension Request $3,034.50 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $3,700.00 Cost determined from submitted invoice. $3,700.00 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 FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A N/A 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
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,280.00 $1,280.00 N/A N/A N/A
General Engineering Services $8,769.00 $8,769.00 Engineering services provided for LPTV Repack. $8,769.00 N/A
Additional Field Engineering Service, 5 Days $12,500.00 $12,500.00 Estimated field engineering services during transition activities. Actual costs to be determined. N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $26,125.00 Per-attached quote number 976-R for antenna pattern verification 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
Form 399 assistance or other Program Management costs $23,361.30 $23,361.30 Cost determined by invoices $21,698.10 Actual costs same as estimated
Project management of the transition $36,925.00 $53,900.00 Estimated 350 hours at $154/hr N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $2,500.00 Per attached QCommunications quote. $2,500.00 N/A
Perform engineering study for displacement application $1,800.00 $3,098.75 Cost determined from submitted invoice $3,098.75 N/A

Components

Actual Information Description File Name
KCKS Extension

Component Description:
Extension request - Brooks - INV 4018565
Amount:
$3,034.50
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
Lease negotiation
Amount:
$3,700.00

Component Description:
N/A
Amount:
N/A

Component Description:
Lease agreement
Amount:
$3,700.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
General Engineering Services

Component Description:
General Engineer Services.
Amount:
$906.50

Component Description:
General Engineering Services
Amount:
$7,862.50

Component Description:
General Engineer Service
Amount:
$7,862.50

Component Description:
Engineering consulting.
Amount:
$906.50
Additional Field Engineering Service, 5 Days Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Form 399 assistance or other Program Management costs

Component Description:
AUGUST 22 PM- QCOMM INV 20220829 KCKS
Amount:
$1,663.20

Component Description:
August 2021 PM - QComm - INV 230017
Amount:
$508.20

Component Description:
Dec 2021 PM - QComm - INV 2022002
Amount:
$361.90

Component Description:
Jan 2022 PM - QComm - INV 220024
Amount:
$231.00

Component Description:
March 2022 PM - QComm - INV 20220302
Amount:
$154.00

Component Description:
JUly 2022 PM - QComm - INV 20220804
Amount:
$646.80

Component Description:
PM Paperwork
Amount:
$1,740.20

Component Description:
Nov 2021 PM - QComm - INV 230087
Amount:
$154.00

Component Description:
PM of the Repack transition
Amount:
$1,016.40

Component Description:
Paperwork PM
Amount:
$924.00

Component Description:
PM Paperwork
Amount:
$1,293.60

Component Description:
June 2022 PM - QComm INV 20220705
Amount:
$154.00

Component Description:
April 2022 PM - Qcomm - INV 20220505
Amount:
$154.00

Component Description:
Paperwork PM
Amount:
$916.30

Component Description:
Paperwork PM
Amount:
$646.80

Component Description:
Paperwork PM
Amount:
$977.90

Component Description:
PM Paperwork
Amount:
$1,432.20

Component Description:
Paperwork PM
Amount:
$492.80

Component Description:
PM Paperwork
Amount:
$1,001.00

Component Description:
PM Paperwork
Amount:
$1,139.60

Component Description:
Sept 2021 PM - QComm - INV 230049
Amount:
$616.00

Component Description:
Paperwork PM
Amount:
$862.40

Component Description:
Paperwork PM
Amount:
$754.60

Component Description:
Prepare and Process Form 399
Amount:
$500.00

Component Description:
PM Paperwork
Amount:
$862.40

Component Description:
PM Paperwork
Amount:
$1,786.40

Component Description:
May 2022 PM - QComm - INV 20220608
Amount:
$616.00

Component Description:
Oct 2021 PM - QComm - INV 230071
Amount:
$585.20

Component Description:
Form 399 Assistance and PM Costs
Amount:
$800.80

Component Description:
Project management of the Repack transition period.
Amount:
$369.60
Project management of the transition Information not provided.
Prepare/ Review 399 reimbursement form

Component Description:
Form 399 Submission
Amount:
$2,500.00
Perform engineering study for displacement application

Component Description:
Displacement study
Amount:
$3,098.75

Component Description:
Displacement study
Amount:
$3,098.75

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 $13,210.00 $13,210.00 N/A $0.00 N/A
Total for all systems $432,784.80 $447,186.05 N/A $82,695.35 N/A
Other Expenses $13,210.00 $13,210.00 $0.00
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,110.00 N/A N/A N/A
Equipment Storage $2,000.00 $2,000.00 Expecting multiple staggered equipment deliveries from different vendors and need to store and stage new equipment prior to installation date. N/A N/A
Equipment Delivery and Handling Charges $2,000.00 $2,000.00 Estimated transport, forklift rental and handling fees from staging area to transmitter site. Actuals to be determined. N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $2,500.00 $2,500.00 Estimated 4-6 yard disposal bin on site to capture all waste from on site system integration and tower vendors. Actual costs to be determined. N/A N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $305.00 N/A N/A N/A
FCC Filing Fees - Form 2100 Major change CP application $4,960.00 $4,960.00 4/2/2020- Working to obtain quote which may be delayed due to coronavirus pandemic. N/A N/A
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 $432,784.80 $447,186.05 $82,695.35

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.

Brian Short

COO


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.

Brian Short

COO


09/06/2022

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