Approved by OMB (Office of Management and Budget) 3060-1178 (REFERENCE COPY - Not for submission) FCC Form 399: Reimbursement Request
Facility 187964 Service: LPD Call KCKS-LD Channel: 19 (UHF) ID: Sign: File 0000089941 Number: FRN: 0019530740 Eligibility Eligible Date 08/18 Status: Submitted: /2021
Applicant Name, Type, and Contact Information Applicant Information Applicant Applicant Address Phone Email Type
HEARTLAND BROADCASTING Brian L +1 (913) b@tv25. Limited LLC Short 638-7373 tv Liability Doing Business As: HEARTLAND PO Box Company BROADCASTING LLC 130 Auburn, KS 66402 United States
Reimbursement Contact Name and Information Reimbursement Contact Applicant Address Phone Email Information [Confidential]
Preparer Contact Name and Information Preparer Contact Applicant Address Phone Email Information Tony Z Tony zumMallen +1 (816) 729- tony@qcomm. zumMallen 705B SE Melody LN 1177 tv QCommunications, #314 LLC Lee's Summit, MO 64063 United States Broadcaster Question Response Information Will the station be sharing equipment with No and another broadcast television station or Transition Plan 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.
Briefly describe transition plan Replace the transmitter, line and antenna per the channel reassignment with reasonable and customary engineering and business practices.
Transmitters Section Question Response
Transmitter Related Do you have transmitter related expenses? Yes Expenses Existing Transmitter Information Primary Transmitter Section Question Response
Existing Transmitter Type of change Purchase Description New
Use Primary (Main)
Ownership Owned
Is this transmitter currently shared with No another station?
Is this transmitter currently in operating Yes condition?
Existing Transmitter Manufacturer Manufacturer and Type Model TRN-5X-U- 46D-C
Year 2015
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 3 kW New Transmitter Costs Primary Transmitter 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.
Other Transmitter Costs Primary Transmitter Section Question Response
Other Transmitter Costs Does the transmitter installation require a Yes Transmitter Building Site Survey /Installation?
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 No HVAC Service?
Transmitter Building Does the Transmitter Building require an No Addition/Modification or addition, modification, other leashold Leasehold Improvement improvement?
Other Transmitter Cost Not Listed Primary Transmitter Name Description
Transmitter Shipping fee Shipping fees for new transmitter
Transmitter Decommissioning Harvesting and removal of old transmitter
Site Prep Preparation of site for new transmitter
Transmitter Taxes Sales tax for new transmitter Antennas Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes Existing Antenna Information Primary Antenna Section Question Response
Existing Antenna Type of change Purchase Description New
Antenna Use Primary (Main)
Ownership Owned
Is the existing antenna shared with another No station or stations?
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity Yes to an antenna farm?
Existing Antenna Mounting Side Mount Manufacturer and Type Antenna position in stack Not in Stack
Polarization Circular
Type Slotted Coaxial
ERP: (Effective Radiated Power) 15.0 kW
Manufacturer
Model LP8/25
Year 2015 New Antenna Costs Primary Antenna 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 No proximity to an antenna farm?
New Antenna Mounting Side Mount Manufacturer and Types Antenna position in stack Not in Stack
Polarization Circular
Type Slotted Coaxial
ERP: (Effective Radiated Power) 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.
Other Antenna Costs Primary Antenna Section Question Response Elbow Complex Do you require the separate purchase of Yes the Elbow Complex?
Broadband or Single Channel? Single Channel
Feed Line Size 1 5/8 inches inches
Side Mount Brackets Do you require the separate purchase of Yes side mount brackets for a high power antenna?
Pattern Scatter Analysis Do you require separate purchase of No pattern scatter analysis for a side mount high or medium power antenna?
Sweep Test Do you require the sweep testing of Yes transmission line and antenna?
Other Antenna Cost Not Listed Primary Antenna Name Description
Antenna Shipping fee Shipping fees for new antenna
Antenna Sales Tax Sales tax for new antenna TransmissionSection Question Response Line Transmission Line Do you have transmission line related Yes Related Expenses expenses? Existing Transmission Line Primary TransmissionSection Question Response Line Existing Transmission Type of change Purchase Line Description New
Use Primary (Main)
Ownership Owned
Is the existing transmission line shared with No another station or stations?
Is Transmission Line in operating condition? Yes
Existing Transmission Manufacturer Line Manufacturer and Type Type Flexible Foam
Diameter 1 5/8 inches
Number of parallel runs 1
Length 350 feet per run New Transmission Line Primary TransmissionSection Question Response Line New Transmission Line Use Primary Costs (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 No Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators?
Other Transmission Line Expenses Not Listed Primary TransmissionName Description Line Transmission line taxes Sales tax for new line
Transmission line shipping Shipping fees for new line Tower Section Question Response Equipment Tower Equipment or Do you have tower equipment or rigging Yes And costs changes? Rigging Rigging Costs Changes Costs
Existing Tower Primary Tower Section Question Response
Existing Tower Type of change Move Description Equipment
Tower Use Primary (Main)
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other No stations?
Is tower documented for structural analysis? No
Is tower compliant with Rev G? Yes
Existing Tower Structure Do you have a tower registration number? Yes Registration ASR Number 1032494
Coordinates (NAD83 ( Latitude (NAD83) 39° 05' North American Datum of 32.0" N- 1983)) 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 999.99 feet (AMSL)
Structure Type TOWER - Free Standing or Guyed Structure Tower Owner Heartland Tower Inc.
Date Constructed 12/01/1964
Tower Rigging Costs Primary Tower Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Are helicopter services required? No Required
Other Tower Expenses Not Listed Primary Tower Information not provided. Outside Section Question Response Professional Outside Project Do you require outside project management Yes Services services? Costs Management Services
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 Perform engineering study for displacement Yes Engineering Services application
Prepare engineering section of Form FCC Yes Construction Permit Application
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC Yes License to Cover Application
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Yes Authority
Quantity 1
Prepare Form 601 No Attorney and Other Prepare and file Form FCC Construction Yes Outside Consulting Permit Application Services For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Yes Cover Application
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Yes Authority
Quantity 1
Negotiation of Lease and other Matter for Yes Shared Locations
Prepare or Review FCC Form 399 for Yes Reimbursement
Form 399 assistance or other program Yes management costs
RF Field Engineering Comprehensive coverage verification via Yes Services field study
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. Other Professional Services Expenses Not Listed Outside Professional Name Description Services Costs General Engineering Services Engineering services provided Other Section Question Response Expenses 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 Yes Application
Other Miscellaneous Does this relocation require paying Yes Expenses Disposal Costs (for equipment and other waste, net of any salvage value)?
Does this relocation require Equipment Yes Delivery or Handling Charges not otherwise included in individual item costs?
Does this relocation require Equipment Yes Storage?
Point to Point Microwave Frequency Coordination for Unidirection No (STL/ICR) System
Frequency Coordination for Bi-Direction No System
New Point to Point Microwave System No
Other Expenses Not Listed Other Expenses Information not provided. Transmitters Cost Information Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Estimated Predetermined Estimated Cost Actual Actual Cost Description Cost Estimate Cost Justification Cost Justification
Primary $143,800.00 $163,800.00 $0.00 Transmitter TRN- U-3000-FA
Transmitter $7,000.00 $7,000.00 Estimated N/A N/A Decommissioning costs of harvesting and removal of old transmitter from site. Revised upon Site Survey.
UHF - Air Cooled $106,300.00 $106,300.00 Cost N/A N/A Solid State determined Transmitter from order 2.501 - 3.999 kW invoice submitted on 4.2.20
Transmitter $10,000.00 $30,000.00 4/2/2020- N/A N/A Building Site Working to Survey obtain /Installation quote which may be delayed due to coronavirus pandemic. Site Prep $8,000.00 $8,000.00 4/2/2020- N/A N/A Working to obtain quote which may be delayed due to coronavirus pandemic.
Transmitter $10,000.00 $10,000.00 4/2/2020- N/A N/A Taxes Working to obtain quote which may be delayed due to coronavirus pandemic.
Transmitter $2,500.00 $2,500.00 Estimated N/A N/A Shipping fee shipping costs for transmitter. Actual costs to be determined.
Sub-total $143,800.00 $163,800.00 N/A $0.00 N/A
Total for all $413,911.00 $445,919.25 N/A $65,484.75 N/A systems
Components
Information not provided. Antennas Cost Information Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Estimated Predetermined Estimated Cost Actual Actual Cost Description Cost Estimate Cost Justification Cost Justification
Primary $43,955.00 $45,330.00 $29,900.00 Antenna ATC- BCC418M-V3- 19
Antenna $2,800.00 $2,800.00 Estimated N/A N/A Sales Tax sales tax collected by vendors as part of the repack. Actual costs to be determined.
Side Mount $4,625.00 $6,000.00 Cost $6,000.00 N/A antenna determined brackets by invoices.
UHF-Low $21,900.00 $21,900.00 Per $21,900.00 N/A Power, Side attached Mount, Alive Slotted invoice. Coaxial, 15.0 kW input, Circular
Sweep test of $5,730.00 $5,730.00 N/A N/A N/A transmission line and antenna
Elbow $6,900.00 $6,900.00 N/A N/A N/A complex, single channel, 1 5 /8” input (if needed) Antenna $2,000.00 $2,000.00 Estimated $2,000.00 N/A Shipping fee shipping costs for antenna. Actual costs to be determined.
Sub-total $43,955.00 $45,330.00 N/A $29,900.00 N/A
Total for all $413,911.00 $445,919.25 N/A $65,484.75 N/A systems
Components
Actual Information Description File Name
Antenna Sales Tax Information not provided.
Side Mount antenna brackets
Component Description: Cost of mount brackets. Amount: $6,000.00
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0 Component Description: Payment for kW input, Circular antenna minus v- pol upgrade. Amount: $5,475.00
Component Description: Antenna Payment minus V-pol upgrade. Amount: $5,475.00
Component Description: Antenna payment minus V-pol upgrade. Amount: $10,950.00
Sweep test of transmission Information not provided. line and antenna Elbow complex, single Information not provided. channel, 1 5/8” input (if needed)
Antenna Shipping fee
Component Description: Cost of shipping Amount: $2,000.00 Transmission Line Cost Information Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Estimated Predetermined Estimated Cost Actual Actual Cost Description Cost Estimate Cost Justification Cost Justification
Primary $10,400.00 $10,400.00 $0.00 Transmission Line
Transmission $1,000.00 $1,000.00 Estimated N/A N/A line taxes sales tax collected by vendors as part of the repack. Actual costs to be determined.
Transmission $1,000.00 $1,000.00 Estimated N/A N/A line shipping shipping costs for new line. Actual costs to be determined.
Flexible $8,400.00 $8,400.00 N/A N/A N/A Foam Transmission Line - dielectric, 1 5 /8"
Sub-total $10,400.00 $10,400.00 N/A $0.00 N/A
Total for all $413,911.00 $445,919.25 N/A $65,484.75 N/A systems
Components
Information not provided. Tower Equipment and Rigging Costs Cost Information Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Estimated Predetermined Estimated Cost Actual Actual Cost Description Cost Estimate Cost Justification Cost Justification
Primary $56,190.00 $56,190.00 $0.00 Tower TOWER
Tower $56,190.00 $56,190.00 N/A N/A N/A Rigging Short Tower (less than 500')
Sub-total $56,190.00 $56,190.00 N/A $0.00 N/A
Total for all $413,911.00 $445,919.25 N/A $65,484.75 N/A systems
Components
Information not provided. Outside Professional Services Cost Information Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Predetermined Estimated Estimated Cost Actual Actual Cost Description Cost Estimate Cost Justification Cost Justification
Outside $146,356.00 $156,989.25 $35,584.75 Professional Services
Form 399 $17,517.00 $17,517.00 Cost determined $17,517.00 N/A assistance or by invoices other Program Management costs
Perform $1,800.00 $3,098.75 Cost determined $3,098.75 N/A engineering from submitted study for invoice displacement application
Project $36,925.00 $53,900.00 Estimated 350 N/A N/A management of hours at $154/hr the transition
Prepare/ $1,710.00 $2,500.00 Per attached $2,500.00 N/A Review 399 QCommunications reimbursement quote. form
Prepare $1,280.00 $1,280.00 N/A N/A N/A request for Special Temporary Authorization
Prepare $2,102.50 $2,102.50 N/A N/A N/A engineering section of FCC Form 2100 (main), Construction Permit Application Prepare $1,052.50 $1,052.50 N/A N/A N/A engineering section of FCC Form 2100 (main), License to Cover Application
Attorney Fees - $3,025.00 $3,025.00 N/A N/A N/A Prepare and File FCC Form 2100 (main), Construction Permit Application
Attorney Fees - $1,577.50 $1,577.50 N/A N/A N/A Prepare and File FCC Form 2100 (main), License to Cover Application
Attorney Fees - $3,262.50 $3,700.00 Cost determined $3,700.00 N/A Negotiation of from submitted lease and other invoice. matters for shared locations
Attorney Fees - $2,235.00 $2,235.00 N/A N/A N/A Prepare and File request for Special Temporary Authorization
Comprehensive $52,600.00 $43,732.00 Per-attached N/A N/A coverage quote number 712- verification via R for Coverage field study, if Verification needed
Additional Field $12,500.00 $12,500.00 Estimated field N/A N/A Engineering engineering Service, 5 Days services during transition activities. Actual costs to be determined. General $8,769.00 $8,769.00 Engineering $8,769.00 N/A Engineering services provided Services for LPTV Repack.
Sub-total $146,356.00 $156,989.25 N/A $35,584.75 N/A
Total for all $413,911.00 $445,919.25 N/A $65,484.75 N/A systems
Components
Actual Information Description File Name
Form 399 assistance or other Program Management Component Description: PM Paperwork costs Amount: $1,740.20
Component Description: PM Paperwork Amount: $1,001.00
Component Description: PM Paperwork Amount: $862.40
Component Description: PM of the Repack transition Amount: $1,016.40
Component Description: PM Paperwork Amount: $1,139.60
Component Description: Form 399 Assistance and PM Costs Amount: $800.80
Component Description: PM Paperwork Amount: $1,786.40 Component Description: Project management of the Repack transition period. Amount: $369.60
Component Description: Paperwork PM Amount: $916.30
Component Description: Paperwork PM Amount: $646.80
Component Description: Paperwork PM Amount: $977.90
Component Description: Prepare and Process Form 399 Amount: $500.00
Component Description: Paperwork PM Amount: $924.00
Component Description: Paperwork PM Amount: $492.80
Component Description: PM Paperwork Amount: $1,293.60
Component Description: Paperwork PM Amount: $754.60
Component Description: PM Paperwork Amount: $1,432.20 Component Description: Paperwork PM Amount: $862.40
Perform engineering study for displacement application Component Description: Displacement study Amount: $3,098.75
Component Description: Displacement study Amount: $3,098.75
Project management of the Information not provided. transition
Prepare/ Review 399 reimbursement form Component Description: Form 399 Submission Amount: $2,500.00
Prepare request for Special Information not provided. Temporary Authorization
Prepare engineering section Information not provided. of FCC Form 2100 (main), Construction Permit Application
Prepare engineering section Information not provided. of FCC Form 2100 (main), License to Cover Application
Attorney Fees - Prepare Information not provided. and File FCC Form 2100 (main), Construction Permit Application
Attorney Fees -Prepare and Information not provided. File FCC Form 2100 (main), License to Cover Application Attorney Fees - Negotiation of lease and other matters Component Description: Lease agreement for shared locations Amount: $3,700.00
Component Description: Lease negotiation Amount: $3,700.00
Component Description: N/A Amount: N/A
Attorney Fees - Prepare Information not provided. and File request for Special Temporary Authorization
Comprehensive coverage Information not provided. verification via field study, if needed
Additional Field Engineering Information not provided. Service, 5 Days
General Engineering Services Component Description: General Engineer Service Amount: $7,862.50
Component Description: General Engineer Services. Amount: $906.50
Component Description: General Engineering Services Amount: $7,862.50
Component Description: Engineering consulting. Amount: $906.50 Other Expenses Cost Information Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Estimated Predetermined Estimated Cost Actual Actual Cost Description Cost Estimate Cost Justification Cost Justification
Other $13,210.00 $13,210.00 $0.00 Expenses
FCC Filing $1,110.00 $1,110.00 N/A N/A N/A Fees - Form 2100 minor change CP application
FCC Filing $335.00 $335.00 N/A N/A N/A Fees - Form 2100 license to cover application
FCC Filing $4,960.00 $4,960.00 4/2/2020- N/A N/A Fees - Form Working to 2100 Major obtain change CP quote application which may be delayed due to coronavirus pandemic.
FCC Filing $305.00 $305.00 N/A N/A N/A Fees - Special Temporary Authorization request Disposal $2,500.00 $2,500.00 Estimated N/A N/A Costs (for 4-6 yard equipment disposal and other bin on site waste, net of to capture any salvage all waste value) from on site system integration and tower vendors. Actual costs to be determined.
Equipment $2,000.00 $2,000.00 Estimated N/A N/A Delivery and transport, Handling forklift Charges rental and handling fees from staging area to transmitter site. Actuals to be determined.
Equipment $2,000.00 $2,000.00 Expecting N/A N/A Storage multiple staggered equipment deliveries from different vendors and need to store and stage new equipment prior to installation date.
Sub-total $13,210.00 $13,210.00 N/A $0.00 N/A
Total for all $413,911.00 $445,919.25 N/A $65,484.75 N/A systems Components
Information not provided. Grand Total Cost Information Predetermined Cost Estimate Estimated Cost Actual Cost
Total for all systems $413,911.00 $445,919.25 $65,484.75
ReimbursementQuestion Response Status The facility has ceased operating on its pre- No auction channel.
Construction of final facilities or all No necessary modifications are complete.
All receipts for reimbursement have been No 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. Certification Section Question Response
Submission of Estimated WILLFUL FALSE STATEMENTS ON THIS Expenses Statements 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 Robert an authorized representative of the above- Nall named applicant for the Authorization(s) President specified above. 08/18/2021 Certification Section Question Response
Submission of Actual WILLFUL FALSE, FRAUDULENT, OR Cost Documentation FICTITIOUS STATEMENTS ON THIS Statements 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 Robert an authorized representative of the above- Nall named applicant for the Authorization(s) President specified above. 08/18/2021
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