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:
28186
Service:
LPD
Call Sign:
KTOU-LD
Channel:
22 (UHF)
File Number:
0000085358
FRN:
0026907345
Eligibility Status:
Eligible
Date Submitted:
05/05/2023

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

HC2 STATION GROUP, INC.

RENEE ILHARDT

295 MADISON AVENUE, 12TH FLOOR

NEW YORK, NY 10017

United States

+1 (954) 606-5486 RILHARDT@HC2BROADCASTING.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. Yes
Briefly describe transition plan This displaced facility is currently in the process of complying with its new displacement construction permit as part of the repack program.

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 TXUD1500A
Year 2011
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.5 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-5X-U-48-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 3 kW
Justification for New Transmitter The applicant plans on replacing the existing transmitter because of its age and power and technical requirements.

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 Yes
Description Minor electrical
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

Additional Field Engineering Time

Additional Field Engineering Time

Mask Filter

Mask Filter

Rack Configuration

Rack Configuration

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 Other
Other Antenna Type Panel UHF
ERP: 15.0 kW
Manufacturer
Model SWR SWLP8OI
Year 2011

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 Circular
Type Broadband Slot
Number of Stations Supported 1
Number of Panels/Bays 12
Lower Limit 470.00 MHz
Upper Limit 608.00 MHz
Design power capacity in use 100.0 %
ERP: 15.0 kW
Manufacturer
Model RBOT
Year 2019
Justification for New Antenna The applicant plans on replacing the existing antenna to support the new displacement construction permit.

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

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? Yes
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1063237
Coordinates (NAD83) Latitude (NAD83) 35° 23' 14.0" N-
Longitude (NAD83) 097° 29' 57.0" W-
Overall Structure Height 600.39 feet
Support Structure Height 600.39 feet
Ground Elevation Above Mean Sea Level (AMSL) 1279.84 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner PERRY BROADCASTING COMPANY, INC.
Date Constructed 01/01/1988

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
140428 K272FD FX

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: 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 200
Explanation Outside consulting engineering, legal work, and accounting services, as well as project management for regional and comprehensive repack execution.
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 No
RF exposure measurements No
Additional Field Engineering Service No

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Internal Time Costs

Internal Time Costs

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 Yes
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)? 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 $142,500.44 $36,200.44 N/A $10,950.44 N/A
Total for all systems $383,403.87 $182,421.87 N/A $123,172.57 N/A
Primary Transmitter TRN-5X-U-48-C $142,500.44 $36,200.44 $10,950.44
Rack Configuration $240.82 $240.82 N/A $240.82 N/A
Mask Filter $6,594.40 $6,594.40 N/A $6,594.40 N/A
Additional Field Engineering Time $4,115.22 $4,115.22 N/A $4,115.22 N/A
5 Ton system $20,250.00 $20,250.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW $106,300.00 $0.00 The station is re-using the transmitter from WBKH. N/A N/A
Other Electrical Service: Minor electrical $5,000.00 $5,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Rack Configuration

Component Description:
Rack configuration. #90375578
Amount:
$240.82
Mask Filter

Component Description:
Filter costs. #1059028
Amount:
$3,230.00

Component Description:
Filter costs. #FA2106-0917
Amount:
$1,116.00

Component Description:
Filter cost. #7123-01
Amount:
$2,248.40
Additional Field Engineering Time

Component Description:
Additional engineering costs. #071
Amount:
$3,608.62

Component Description:
Additional engineering time. #019
Amount:
$506.60

Component Description:
Additional engineering costs. #071
Amount:
$3,863.62

Component Description:
Additional engineering. #073
Amount:
$784.43

Component Description:
Additional engineering. #071 SUB Repack
Amount:
$3,653.62
5 Ton system Information not provided.
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW Information not provided.
Other Electrical Service: Minor electrical Information not provided.

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $27,887.75 $27,887.75 N/A $10,632.75 N/A
Total for all systems $383,403.87 $182,421.87 N/A $123,172.57 N/A
Primary Antenna RBOT $27,887.75 $27,887.75 $10,632.75
Cable harness (each, for panel antenna system, if not included in antenna cost) $3,000.00 $3,000.00 N/A N/A N/A
Power Dividers (each, for panel antenna system, if not included in antenna cost) $3,900.00 $3,900.00 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, Broadband Slot, 12 bay, 15.0kW input, Circular $10,632.75 $10,632.75 N/A $10,632.75 N/A
Side Mount antenna brackets $4,625.00 $4,625.00 N/A N/A N/A

Components

Actual Information Description File Name
Cable harness (each, for panel antenna system, if not included in antenna cost) Information not provided.
Power Dividers (each, for panel antenna system, if not included in antenna cost) Information not provided.
Sweep test of transmission line and antenna Information not provided.
UHF-Low Power, Side Mount, Broadband Slot, 12 bay, 15.0kW input, Circular

Component Description:
Antenna costs. #3173
Amount:
$10,632.75
Side Mount antenna brackets 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 $178,750.00 $84,068.00 N/A $84,068.00 N/A
Total for all systems $383,403.87 $182,421.87 N/A $123,172.57 N/A
Primary Tower TOWER $178,750.00 $84,068.00 $84,068.00
Tower mapping and report for structural engineer $21,000.00 $8,350.00 N/A $8,350.00 N/A
Tower Rigging Tall Tower (greater than 500') $157,750.00 $75,718.00 N/A $75,718.00 N/A

Components

Actual Information Description File Name
Tower mapping and report for structural engineer

Component Description:
Mobilize to KTOU TV Oklahoma Cidy; Obtain structural data as needed by structural engineer. #3292
Amount:
$1,850.00

Component Description:
Tower mapping. #3150
Amount:
$6,500.00
Tower Rigging Tall Tower (greater than 500')

Component Description:
Tower work, down. #3174-INV
Amount:
$29,909.00

Component Description:
Mobilize to tower site; Rig tower; Remove current antenna and install new CP antenna. #3231
Amount:
$11,400.00

Component Description:
Tower work, balance. #3174-INV.2
Amount:
$29,909.00

Component Description:
Structural analysis. #9768M
Amount:
$4,500.00

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 $27,155.14 $27,155.14 N/A $14,855.84 N/A
Total for all systems $383,403.87 $182,421.87 N/A $123,172.57 N/A
Outside Professional Services $27,155.14 $27,155.14 $14,855.84
Internal Time Costs $1,345.14 $1,345.14 N/A $1,335.14 N/A
Form 399 assistance or other Program Management costs $3,000.00 $3,000.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A N/A N/A
Project management of the transition $21,100.00 $21,100.00 N/A $13,520.70 N/A

Components

Actual Information Description File Name
Internal Time Costs

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 44 stations. #IL-HC2-08202020-AG
Amount:
$15.48

Component Description:
Internal labor cost. #IL-HC2-10042020-RH
Amount:
$36.05

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 42 stations. #IL-HC2-08202020-DD
Amount:
$10.00

Component Description:
Internal labor cost. #IL-HC2-09222021-PD
Amount:
$135.20

Component Description:
Internal labor cost. #IL-HC2-08252020-RI
Amount:
$1,130.01

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 44 stations. #IL-HC2-08202020-IM
Amount:
$8.40

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 42 stations. #IL-HC2-08202020-DD
Amount:
$10.00
Form 399 assistance or other Program Management costs Information not provided.
Prepare/ Review 399 reimbursement form Information not provided.
Project management of the transition

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 12 stations. #478
Amount:
$3,593.75

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 8 stations. #327
Amount:
$402.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 29 stations. #188
Amount:
$656.55

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 8 stations. #391
Amount:
$275.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 4 stations. #460
Amount:
$1,312.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 10 stations. #436
Amount:
$1,348.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 5 stations. #304
Amount:
$952.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 22 stations. #191
Amount:
$974.31

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 8 stations. #337
Amount:
$1,600.93

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 8 stations. #311
Amount:
$518.12

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 40 stations. #477015
Amount:
$406.37

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 40 stations. #1149
Amount:
$302.67

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 8 stations. #357
Amount:
$630.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 8 stations. #425
Amount:
$547.50

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 $7,110.54 $7,110.54 N/A $2,665.54 N/A
Total for all systems $383,403.87 $182,421.87 N/A $123,172.57 N/A
Other Expenses $7,110.54 $7,110.54 $2,665.54
Equipment Delivery and Handling Charges $2,665.54 $2,665.54 N/A $2,665.54 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $3,000.00 $3,000.00 N/A 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

Components

Actual Information Description File Name
Equipment Delivery and Handling Charges

Component Description:
Mask filter shipping. #1060034
Amount:
$1,293.41

Component Description:
Transmitter shipping. #80996766608
Amount:
$1,372.13
FCC Filing Fees - Form 2100 license to cover application Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $383,403.87 $182,421.87 $123,172.57

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.

Michael Voge

Director of Engineering Operations


05/05/2023

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.

Michael Voge

Director of Engineering Operations


05/05/2023

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.

Michael Voge

Director of Engineering Operations


05/05/2023

Attachments

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