Form FCC Form 399 FCC Form 399 Request for Reimbursement of Repacking Expenses

Federal Communications Commission Not Approved by OMB

Washington, DC 20554 3060-XXXX

FCC FORM 399

Request for Reimbursement of Repacking Expenses

Instructions

This form must be filed by eligible broadcasters and multichannel video programming distributors subject to the requirements of 47 C.F.R. § 73.3700. It should be used to request reimbursement of expenses incurred as a result of the repacking of channels following completion of the incentive auction proceeding. See 47 C.F.R. 73.3700. This form must be filed using the Broadcast Radio and

Television Consolidated DataBase System (CDBS), and placed in the station’s Public Inspection File and public website, if

such exists. For more information on filing via CDBS, please visit: http://www.fcc.gov/mb/cdbs.html.

Requesting Entity Information

Station ______ (Full Power) ______ (Class A) __________________ (Licensee) _________(Call Sign)_ ______________________ (Community of License) _____________________________ (DMA/Television Market)

Multichannel Video Programming Distributor ______________________ (Name) __ _______ (City) ___ (State)

Type of Request

_______ A - Initial Request For Reimbursement _______ B - Follow-Up Certification

________ C - Request for Advance Reimbursement Based on Estimated Expenses

_________ D - Request for Reimbursement Based on Actual Expenses

If you selected D above, attach, as exhibit D-1, a break down of all expenses for which you are claiming reimbursement.

If you selected B above, complete the following certification: _______ I hereby certify that all funds advanced were expended properly for the reimbursement of expenses incurred as a result of the repacking of channels following the completion of the incentive auction proceeding.

STATION/MVPD CERTIFICATION

I certify that the statements in this document are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT

We have estimated that each response to this collection of information will take 1- 2 hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Paperwork Reduction Project (3060-XXXX), Washington, D. C. 20554. We will also accept your comments via the Internet if you send them to [email protected]. Remember - you are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-XXXX.

THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1, 1995,44 U.S.C. 3507.

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE,

TITLE 18, SECTION 1001), AND/CR 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). Draft