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:
166986
Service:
LPD
Call Sign:
W25FC-D
Channel:
25 (UHF)
File Number:
0000089498
FRN:
0011406899
Eligibility Status:
Eligible
Date Submitted:
12/04/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

Combs Broadcasting, Inc.

1812 5th Ave. South

Jasper, AL 35501

United States

+1 (205) 648-3000 tommy.combs.b17q@statefarm.com 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

The Preparer is same as the reimbursement contact.

 

 

 

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 and antenna per the channel reassignment project using 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 800W
Year 2012
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 800 W

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-2000-FA
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2.2 kW
Justification for New Transmitter New transmitter required for new channel.

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

Decommission

De-install old transmitter

Encoder

Encoder for new channel

Converter

Converter for new channel

Taxes

Estimated sales tax

Site Prep

Prepare site for new transmitter

Shipping

Estimated shipping

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? 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 Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model 16-bay
Year 2012

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 Horizontal
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model ATC-BCH416M-25
Year 2019
Justification for New Antenna New antenna required for new channel.

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Taxes

Estimated sales tax

Shipping

Estimated shipping and freight

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? No

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Ownership Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1050552
Coordinates (NAD83) Latitude (NAD83) 33° 50' 42.0" N-
Longitude (NAD83) 087° 18' 26.0" W-
Overall Structure Height 606.95 feet
Support Structure Height 606.95 feet
Ground Elevation Above Mean Sea Level (AMSL) 390.42 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Combs Broadcasting, Inc.
Date Constructed 01/01/1968


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: Major 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

Mod design

Modification Design based on failing structural analysis

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 Required to assist in the turnkey management of the channel relocation project in order that the existing internal personnel 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 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 Yes
Number of Days 5
Justification Estimated field engineering services during transition activities.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

A and E walk

Site walk coordinated with A&E firm

Building Permit Application

Flat fee for preparation of BP application

Complex zoning

Potential for complex zoning with hearing

Construction drawings

Construction drawings

Field and Technical Project Management

Field and Technical Project Management pertaining to REPACK

General Engineering

Engineering consultations pertaining to REPACK

NEPA and SHPO compliance

NEPA/SHPO compliance

Permit Pickup

Flat fee for picking up permit

Zoning and Permitting Determination

Flat fee service for zoning/permitting determination

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 $135,523.76 $109,315.76 N/A $74,148.04 N/A
Total for all systems $1,030,628.76 $880,124.16 N/A $739,183.04 N/A
Primary Transmitter TRN-U-2000-FA $135,523.76 $109,315.76 $74,148.04
Taxes $2,000.00 $2,000.00 3/30/2020- Working to obtain quote which may be delayed due to coronavirus pandemic $0.00 N/A
Encoder $8,065.72 $8,065.72 Actual cost of invoice $0.00 N/A
Converter $1,352.00 $1,352.00 Actual cost of invoice $0.00 N/A
Site Prep $5,156.04 $5,156.04 3/30/2020- Working to obtain quote which may be delayed due to coronavirus pandemic $5,156.04 N/A
Shipping $1,200.00 $1,200.00 Estimated shipping costs not included on quote. Actual costs to be determined. $1,200.00 N/A
Decommission $3,500.00 $3,500.00 Estimated costs to de-install, disconnect and decommission old transmitter in preparation for new transmitter. $0.00 N/A
Transmitter Building Site Survey/Installation $10,000.00 $11,500.00 Cost determined by invoices. $11,500.00 N/A
5 Ton system $20,250.00 $20,250.00 3/30/2020- Working to obtain quote which may be delayed due to coronavirus pandemic $0.00 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $56,292.00 Cost determined by invoice $56,292.00 N/A

Components

Actual Information Description File Name
Taxes Information not provided.
Encoder

Component Description:
encoder/decoder
Amount:
$8,065.72
Converter

Component Description:
IP to ASI converter
Amount:
$1,352.00
Site Prep

Component Description:
Cost of Site Prep
Amount:
$5,156.04
Shipping

Component Description:
Cost of shipping
Amount:
$1,200.00
Decommission Information not provided.
Transmitter Building Site Survey/Installation

Component Description:
Transmitter install and site survey
Amount:
$11,500.00

Component Description:
Transmitter installation
Amount:
$8,200.00

Component Description:
Credit memo for tx installation
Amount:
($8,200.00)
5 Ton system Information not provided.
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Cost of Transmitter
Amount:
$56,292.00

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 $31,355.00 $31,355.00 N/A $18,000.00 N/A
Total for all systems $1,030,628.76 $880,124.16 N/A $739,183.04 N/A
Primary Antenna ATC-BCH416M-25 $31,355.00 $31,355.00 $18,000.00
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal $18,000.00 $18,000.00 ***System Notice: Estimate adjusted and locked because line has been superseded.***Per attached Alive quote. $18,000.00 N/A
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A
Side Mount antenna brackets $4,625.00 $4,625.00 N/A N/A N/A
Shipping $1,000.00 $1,000.00 Estimated shipping costs not included on quote. Actual costs to be determined. $0.00 N/A
Taxes $2,000.00 $2,000.00 Estimated sales tax N/A N/A

Components

Actual Information Description File Name
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal

Component Description:
Cost of antenna
Amount:
$18,000.00
Sweep test of transmission line and antenna Information not provided.
Side Mount antenna brackets Information not provided.
Shipping Information not provided.
Taxes Information not provided.

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 $721,750.00 $597,300.00 N/A $597,300.00 N/A
Total for all systems $1,030,628.76 $880,124.16 N/A $739,183.04 N/A
Primary Tower TOWER $721,750.00 $597,300.00 $597,300.00
Major tower reinforcement/modifications $537,000.00 $537,000.00 Major tower mods required due to failing structural analysis. Quote provided by the contractor performing work. Supporting documentation uploaded. $537,000.00 Actual invoices submitted.
Tower mapping and report for structural engineer $21,000.00 $25,250.00 Estimate determined by invoices. $25,250.00 N/A
Tower Rigging Tall Tower (greater than 500') $157,750.00 $29,050.00 Per submitted invoice $29,050.00 N/A
Mod design $6,000.00 $6,000.00 Mod design per attached Branch quote. $6,000.00 N/A

Components

Actual Information Description File Name
Major tower reinforcement/modifications

Component Description:
Phase1 of tower mods
Amount:
$110,000.00

Component Description:
Phase 2 of tower mods
Amount:
$427,000.00

Component Description:
Phase 1 invoice for materials fabrication only
Amount:
$110,000.00
Tower mapping and report for structural engineer

Component Description:
Structural Analysis
Amount:
$25,250.00
Tower Rigging Tall Tower (greater than 500')

Component Description:
Antenna install
Amount:
$29,050.00

Component Description:
Antenna install
Amount:
$29,050.00
Mod design

Component Description:
Mod design
Amount:
$6,000.00

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 $128,790.00 $128,943.40 N/A $49,735.00 N/A
Total for all systems $1,030,628.76 $880,124.16 N/A $739,183.04 N/A
Outside Professional Services $128,790.00 $128,943.40 $49,735.00
Project management of the transition $10,550.00 $29,285.00 Actual invoices submitted + remaining costs per estimate #1216 $31,105.00 Actual invoices submitted.
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $2,235.00 N/A N/A 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
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
Zoning and Permitting Determination $650.00 $650.00 Per estimate #1216. Fixed-fee price. N/A N/A
Permit Pickup $700.00 $700.00 N/A N/A N/A
NEPA and SHPO compliance $2,500.00 $2,500.00 N/A $400.00 N/A
General Engineering $3,100.00 $3,100.00 Cost determined by invoices $3,100.00 N/A
Field and Technical Project Management $10,000.00 $10,000.00 Cost determined by invoices. Estimate based on scope of work required. $1,026.60 Actual costs only submitted
Construction drawings $3,500.00 $3,500.00 N/A N/A N/A
Complex zoning $2,000.00 $2,000.00 Per estimate #1216 - non-complex. Fixed-fee price. N/A N/A
Building Permit Application $1,500.00 $1,500.00 Per estimate #1216. Fixed-fee price. N/A N/A
A and E walk $4,500.00 $4,500.00 N/A N/A N/A
Prepare Form 601 $755.00 $755.00 3/30/2020- 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), 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
Perform engineering study for displacement application $1,800.00 $1,800.00 N/A N/A N/A
Form 399 assistance or other Program Management costs $5,890.00 $5,890.00 Per attached Anywave quote. $500.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $13,603.40 Cost determined by invoices. $13,603.40 cost of actual invoices
Additional Field Engineering Service, 5 Days $12,500.00 $12,500.00 Estimated field engineering services during transition activities. N/A N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $22,125.00 Per Quote #QU-171167 N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Technical PM & 399 Assistance - 11.22
Amount:
$3,950.00

Component Description:
Technical PM & 399 Assistance - 10.22
Amount:
$3,230.00

Component Description:
Technical PM & 399 Assistance - 9.22
Amount:
$1,990.00

Component Description:
Technical PM and 399 assistance - 06.22
Amount:
$3,270.00

Component Description:
Technical PM and 399 assistance - 04.22
Amount:
$3,100.00

Component Description:
Technical PM and 399 assistance - 08.22 - 09.22
Amount:
$3,000.00

Component Description:
Technical PM and 399 assistance 05.22
Amount:
$2,220.00

Component Description:
Technical PM and 399 assistance - 03.22
Amount:
$5,250.00

Component Description:
Technical PM and 399 assistance - 02.22
Amount:
$2,935.00

Component Description:
Technical PM and 399 assistance
Amount:
$2,160.00
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Zoning and Permitting Determination Information not provided.
Permit Pickup Information not provided.
NEPA and SHPO compliance

Component Description:
NEPA applicability review
Amount:
$400.00
General Engineering

Component Description:
Engineering Consultation
Amount:
$1,500.00

Component Description:
Egnineering consultation
Amount:
$1,000.00

Component Description:
Engineering Consultation
Amount:
$600.00
Field and Technical Project Management

Component Description:
Technical project management.
Amount:
$1,026.60

Component Description:
Technical Project Management
Amount:
$1,026.60
Construction drawings Information not provided.
Complex zoning Information not provided.
Building Permit Application Information not provided.
A and E walk Information not provided.
Prepare Form 601 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.
Perform engineering study for displacement application Information not provided.
Form 399 assistance or other Program Management costs

Component Description:
399 assistance
Amount:
$500.00
Prepare/ Review 399 reimbursement form

Component Description:
PM Paperwork 12/21
Amount:
$723.80

Component Description:
PM Paperwork 10/21
Amount:
$862.40

Component Description:
399 Form submittal
Amount:
$2,500.00

Component Description:
Pm Paperwork
Amount:
$1,170.40

Component Description:
PM Paperwork
Amount:
$1,170.40

Component Description:
PM Paperwork 10/21
Amount:
$862.40

Component Description:
PM Paperwork
Amount:
$831.60

Component Description:
PM Paperwork
Amount:
$831.60

Component Description:
PM Paperwork
Amount:
$800.80

Component Description:
PM Paperwork
Amount:
$1,324.40

Component Description:
PM Paperwork
Amount:
$693.00

Component Description:
PM Paperwork
Amount:
$1,801.80

Component Description:
PM Paperwork 01/22
Amount:
$231.00

Component Description:
PM Paperwork
Amount:
$154.00

Component Description:
PM Paperwork
Amount:
$1,262.80

Component Description:
PM Paperwork
Amount:
$1,247.40
Additional Field Engineering Service, 5 Days Information not provided.
Comprehensive coverage verification via field study, if needed 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 $13,210.00 $13,210.00 N/A $0.00 N/A
Total for all systems $1,030,628.76 $880,124.16 N/A $739,183.04 N/A
Other Expenses $13,210.00 $13,210.00 $0.00
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. Anticipate 6-24 months of storage time. 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
Disposal Costs (for equipment and other waste, net of any salvage value) $2,000.00 $2,000.00 4-6 yard disposal bin on site to capture all waste from on site system integration and tower vendors. 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 3/30/2020- 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 $1,030,628.76 $880,124.16 $739,183.04

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. 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.

Tommy Combs

CEO


12/04/2022

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.

Tommy Combs

CEO


12/04/2022

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