Form FCC Form 2100, Sch FCC Form 2100, Sch TV Broadcaster Relocation Fund Reimbursement Form

OMB Control Number: 3060-1178

TV Broadcaster Relocation Fund Reimbursement Form

FCC Form 2100, Schedule 399

Automatically generates from LMS (based on Facility ID)/COALS (based on COALS ID):

Legal name of Entity

DBA (doing business as) name, if applicable

Address (Street, City, State, Zip)

Phone Number

(if incorrect, correct in LMS/COALS)

Section I – Application Type

1. Type of Entity (automatically determined based on point of entry to system)

• MVPD

  • Type of MVPD (Cable Operator / DBS/Other)

• Broadcaster

  

  • Facility ID {numeric entry}

2. Type of Submission (automatically determine based on questions answered)

• Estimated Costs
  
  

• Submission of Actual Costs with Documentation
  
  

• Final Allocation or Final Accounting

• Final Allocation (is construction complete?)

• Final Accounting (construction is complete)

Section II – Contact Information

1. Is the prefilled information correct? {yes / no->direct to correct in LMS/COALS}

2. Identify the CORES address to be used for reimbursement payments (select from CORES addresses) (all CORES addresses with valid banking information will appear)

3. Reimbursement Contact Information (all fields required)

Same as CORES address

New Contact

Contact Name {text}

Contact Title {text}

Street Address {text}

City, State Zip Code {text}

Contact Telephone Number {text}

Contact E-mail address {text}

4. FCC Registration Number (FRN) (filled from login)

5. Form Preparer Contact Information {complete all fields}

Same as CORES contact

Same as Reimbursement contact

New contact

Contact Name {text}

Contact Title {text}

Contact Company{text}

Street Address {text}

City, State Zip Code {text}

Contact Telephone Number {text}

Contact E-mail address {text}

(Broadcaster Proceed to Section III, MVPD Proceed to Section IV)

Section III.A – Broadcaster Information and Transition Plan

Automatically generates from LMS/Kidvid:

Call Sign

Type (Class A, Full Power)

Licensee Name

Status {Noncommercial Educational, Commercial}

Distributed Transmission System {Yes, No}

Community of License

City, State, County, Zip Code

Pre-auction RF Channel

Post-auction RF Channel

Neilsen DMA

Network Affiliation

(if incorrect, correct in appropriate DB)

Facility ID Number from above generates

1. Channel sharing {/es -> al) channel sharing:
   to transition schedule to Form 301Yes -> Sharee station facility ID number, No}
   
   

2. Briefly describe transition plan {text}

Section III.B – Broadcaster Estimated or Actual Transition Expenses

Section III.B.1. Transmitters

1. Type of Change(s) (select all that apply)

Option List:

• Retune Primary Transmitter

• Purchase New Primary Transmitter

• Lease Primary Transmitter

• Retune Auxiliary Transmitter

• Purchase New Auxiliary Transmitter

• Lease Auxiliary Transmitter

• Purchase Interim Transmitter

• Lease Interim Transmitter
  
  

• No Transmitter Related Expenses (Proceed to Section II.B.2)
  
  

2. For each current transmitter serving a licensed facility, answer:

Existing Transmitter(s) Description [Complete All]

1. Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

2. Ownership {Owned, Leased->Owner{Text}}

3. Shared {No; Yes->Sharing Station Facility ID’s}

4. Manufacturer {text}

5. Model {text}

6. Year {text}

7. Type {Inductive Output Tube (IOT), Solid State, Other}

   1. Inductive Output Tube

      1. IOT Power Type: {Single; Two ; Three Other {text}]

      2. Power capacity{kW}

   2. Solid State

      1. Solid State Cooling {Air; Liquid}

      2. Solid State Power Capacity {Number in kW}

   3. Other Type {Text}

8. Is transmitter in operating condition? {yes, no}

3. Transmitter Costs from Catalog of Costs

1. Retuning Costs (complete for each reuse or modification of existing transmitter)
   
   

1. Existing Transmitter Issue [Complete all and Pre-fill row in table based on data entry]

Inductive Output Tube Banding Issues {Major, Minor}

Prefill IOT retune cost

For each Solid State transmitter, prefill retune cost

2. New Mask Filter [Complete all and Pre-fill row in table based on data entry]

• Power [select: 1.5 kW; 3 kW; 7 kW; 10 kW; 30 kW; 60 kW; 90 kW; Other {text}]

3. New Exciter [Complete all and Pre-fill row in table based on data entry]

• Yes

  • Type [select: single frequency agile; dual exciter with changeover]

• No

2. New Transmitter Costs (complete for each new transmitter indicated above)

1. New Transmitter [Complete all and Pre-fill row in table based on data entry]

• Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

• Manufacturer {text}

• Model {text}

• Select Type (pick one)

  • UHF-inductive output tube (IOT)

    • Type [ Single ; Two; Three; Other {text}]

    • Power capacity{kW}

  • Solid State

    • Band [UHF; High VHF; Low VHF]

    • Cooling {Air; Liquid}

  • Other Type {Text}

• Justification for New Transmitter {Text}

3. Other Transmitter Costs (each service optional for all applicants)

1. Electrical Service [Select all that apply and pre-fill row(s) in table based on data entry]

• Service Entrance (3 phase 800A 208V)

• Switchgear (industrial 800 amp)

• Transformer (480V)

  • Power [150 kVA ; 300 kVA; 500 kVA]

• Rigid Conduit

  • Size (in inches)

  • Length (in feet)

• Other Electrical Service [text]

2. HVAC Service [Select 1 and pre-fill row based on data entry]

• Yes

  • Type [ Cooling Only; Heating and Cooling]

  • Size [5 tons; 10 tons; 15 tons; 25 tons; 50 tons; Other]

• No

3. Transmitter Building Addition /Modification or Leasehold Improvement [Select 1 and pre-fill row based on data entry]

• Yes

  • Size in square feet [number]

• No

4. Channel 14 Costs [To be completed only by stations relocating to channel 14]

• RF Consulting Engineer {Yes, No}

• Channel 14 Mask Filter {Yes, No}

• Additional Field Engineering Time {Yes, No}

  • Number of Days {Number}

5. Inside RF System [Complete and Pre-fill row in table based on data entry]

• {Yes, No}

6. Other Transmitter Cost Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

4. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section III.B.2. Antenna Changes

1. Type of Change(s) (select all that apply)

• Utilize Existing Primary Antenna

• Purchase New Primary Antenna

• Lease Primary Antenna

• Utilize Existing Auxiliary Antenna

• Purchase New Auxiliary Antenna

• Lease Auxiliary Antenna

• Purchase Interim Antenna

• Lease Interim Antenna
  
  

• No Antenna Related Costs

2. For each existing antenna:

Existing Antenna Description [Repeat below for each antenna]

1. Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

2. Ownership {Leased->Owner{Text},Owned by station}Shared {No, Yes->enter facility ID numbers}

3. Manufacturer {text}

4. Model {text}

5. Year {text}

6. Mounting {select: top-mount single, top-mount stacked, side-mount}

7. Antenna position in stack {not in stack, top, middle, bottom}

8. Polarization {Horizontal, Elliptical, Circular}

9. Broadband Panel{no, yes->give frequency range of antenna}

10. Is antenna in operating condition? {yes, no}

11. Is antenna located on or in close proximity to an antenna farm?

3. Antenna Costs from Catalog of Costs

1. Retune Existing Antenna (complete for each “utilize existing” indicated above)

Field Testing and Adjustment [Complete All and Pre-fill row in table based on data entry]

• Antenna Use {Primary (Main); Auxiliary (Backup) ->Name; DTS->Site Number}

  • Sweep Test of Existing Antenna {yes,no}

2. New Antenna Costs (complete for each “purchase” indicated above)

New Antenna Description [Complete All for each new antenna and Pre-fill row in table based on data entry]

• Antenna Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

• Shared {No, Yes->facility id of sharing stations}

• Mounting [ Top-mount single, top-mount stacked, Side-mount]

• Polarization [Horizontal, Elliptical, Circular]

• Directional {yes/no}

• Type {Slotted coaxial, Broadband Panel, Other}

  • If Broadband Panel, Frequency range of panel {lower in MHz, upper in MHz}

  • If Broadband Panel, Percent of total power capacity planned to be used {%}

• Effective radiated Power {Number}

• Manufacturer {Text}

  • Model

  • Year

• Justification for New Antenna{Text}

3. Other Antenna Costs

1. Combiner for Shared Antenna [Select 1 and Pre-fill row in table based on data entry]

• Yes

  • Type [New; Additional Module]

  • Number of channels supported {number}

  • Frequencies of channels supported {list of RF channel numbers or upper and lower frequency in MHz}

• No

2. Other Antenna Expenses Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

4. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section III.B.3. Transmission Line Changes

1. Type of Change(s) (select all that apply)

• Utilize Existing Transmission Line for Primary Facility

• Purchase New Transmission Line for Primary Facility

• Lease Transmission Line for Primary Facility

• Utilize Existing Transmission Line for Auxiliary Facility

• Purchase New Transmission Line for Auxiliary Facility

• Lease Transmission Line for Auxiliary Facility

• Purchase New Transmission Line for Interim Facility

• Lease Transmission Line for Interim Facility
  
  

• No Transmission Line Changes

2. Existing Transmission Line(s) (complete for each existing transmission line)

Existing Transmission Line Description

1. Ownership {Leased->Owner{Text},Owned by station}

2. Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

3. Shared {No, Yes->enter facility ID numbers}

4. Manufacturer {text}

5. Type {select: Flexible Foam, Flexible Air, Rigid, Waveguide}

i. For Rigid, Segment Length {19 ½’, 19 ¾’, 20’, Broadband}

6. Diameter (in inches) {text}

7. Number of parallel runs {number}

8. Length (in feet, per run) {number}

9. Is transmission line in operating condition {yes, no}

3. Transmission Line Costs from Catalog of Costs

1. New Transmission Line Costs (complete for each transmission line indicated above)

Transmission Line Description [Complete All and Pre-fill row in table based on data entry]

• Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

• Type {select one}

  • Flexible Foam

    • Diameter {select: 7/8", 1 5/8", 2 1/4", other}

  • Flexible Air

    • Diameter {select: 7/8", 1 5/8", 2 1/4", 3", 4", 5", other}

  • Rigid

    • Diameter {select: 3 1/8", 4 1/16", 6 1/8", 7 3/16", 8 3/16", other}

    • Segment Length {select: 20', 19 3/4', 19 1/2', broadbanded}

  • Waveguide

• Number of parallel runs {number}

• Length (in feet, per run) {number}

• Justification for New Transmission Line {text}

2. Other Expenses

Other Transmission Line Expenses Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

4. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section III.B.4. Tower Equipment and Rigging Costs

1. Type of Change(s) (select all that apply)

• Modify Primary Tower

• Move Equipment to New Tower for Primary Facility

• Construct New Primary Tower

• Modify Auxiliary Tower

• Move Equipment to New Tower for Auxiliary Facility

• Construct New Auxiliary Tower
  
  

• No Tower Equipment or Rigging Costs

2. Existing Tower Information

Existing Tower Description (complete for each tower currently in use)

1. Tower Registration Number {No, Yes}

2. If YES: ASR {Numeric->Is the below information correct {yes, no}}

3. If NO: enter tower coordinates and Height AGL {lat/long, number in feet or meters}

4. Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

5. Ownership {Leased->Owner{Text},Owned by station}Shared {No, Yes- Other users on tower (select all that apply or none)

• One or more FM radio broadcaster(s)

• One or more AM radio broadcaster(s)

• One or more TV broadcaster(s)

• Others Types of Users {List}

>enter facility ID numbers of other broadcast stations on tower}

6. Complex tower {select: no, Candelabra, Located on Building, Terrain Constrained }

7. Year tower built (if known) {text}

8. Is tower documented for structural analysis?{yes, no, unknown}

9. Is the tower compliant with Rev G?{yes/no/don’t know}

Automatically generates from ASR:

Tower Height (AGL, HAAT, AMSL)

Tower Coordinates

Tower Owner

Date Constructed

3. Tower cost descriptions from Catalog of Costs

1. Tower Modification Costs (complete for each tower modification indicated above)

1. Engineering Study [Select 1 and Pre-fill row in table based on data entry]

• No study needed

• Study needed for undocumented/poorly documented tower

• Study needed for documented tower

• Study needed for tower with candelabra

2. Tower Reinforcements [select 1 and pre-fill row in table based on data entry

• No reinforcements needed

• Minor Reinforcements needed

• Major Reinforcements need

• Serious Reinforcements needed

2. Tower Construction Costs (complete for each tower construction indicated above)

1. New Tower [Complete and Pre-fill row in table based on data entry]

• Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

• Height (in feet)

• Justification for New Tower {text}

c. Tower Rigging Costs (complete for each tower move, modification, or construction above)

1. Tower Rigging [Select 1 and Pre-fill row in table based on data entry]

• Tall Tower {yes - greater than 500', no - less than 500'}

• Complex Tower {select reason below}:

  • Candelabra

  • Located on Building

  • Terrain constrained

  • Other

2. Helicopter Services Required [select 1 and pre-fill row in table based on data entry]

• Yes

• No

4. Other Expenses

1. Other Tower Expenses Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

4. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section III.B.5. Outside Professional Services

1. Professional Services Costs

1. Professional Services Costs

1. Outside Project Management Services [Select 1 and Pre-fill row in table based on data entry]

• Yes [complete all below]

  • Number of hours {numeric}

  • Explanation of necessity and inability to perform internally {text box}

• No

2. Outside RF consulting Engineering Services [select all that apply]

• Perform engineering study for new channel assignment and antenna development

• Prepare engineering section of Form 301or 340 FCC Construction Permit Application (Main, Auxiliary) (you may be filing both forms (main and auxiliary))

• Prepare engineering section of Form 302 FCC License to Cover Application (Main, Auxiliary) (you may be filing both forms (main and auxiliary))

• Prepare request for Special Temporary Authority (quantity)

• Distributed Transmission System engineering services (no, complete below)

  • Critical Facility (enter number of sites)

  • Terrain-Shielded Facility (enter number of sites)

3. Attorney and Other Outside Consultant Costs [select all that apply]

• Prepare and file Form 301 or 340 (Main, Auxiliary)

• Prepare and file Form 302 (Main, Auxiliary)

• Prepare and file request for Special Temporary Authority (quantity)

• NEPA Section 106 environmental review

• Environmental Assessment

• ASR Modification

• FAA Consultation (including preparation of FAA Form 7460)

4. RF Field Engineering Services [select all that apply and pre-fill row in table based on data entry]

• Comprehensive coverage verification via field study

• RF exposure measurements

• Additional Field Engineering Service

  • Number of Days {Number}

  • Justification {Text}

2. Other Expenses Not Listed (list)

1. Other Professional Service Expenses Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

2. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section III.B.6. Other Expenses

1. Miscellaneous Expense Costs
   
   

   1. Miscellaneous costs from Catalog of Costs

1. AM Pattern Disturbance

• Impact Study (yes, no)

[Pre-fill Predetermined Cost Estimate from Appendix]

• Remediation (yes, no)

[Pre-fill Predetermined Cost Estimate from Appendix]

2. Facility Expenses

• Other Interim Facility Expenses {Name, Amount}

• Other Distributed Transmission System Expenses {Name, Amount}

• DTV Medical Facility Notification {Yes, No}

3. Permit Costs (Complete all that apply)

• Local Zoning

• Non-zoning permits

• BLM or NFS Coordination

4. Other Miscellaneous Expenses [Complete all that apply]

• Disposal Costs (for equipment and other waste, net of any salvage value) {Yes, No}

• Equipment Delivery and Handling Charges {Yes, No}

• Equipment Storage {Yes, No}

• Develop and air announcement of upcoming channel change {Yes, No}

• MVPD Notification of Channel Change {Yes, No}

2. Other expenses not listed

1. Other Miscellaneous Expenses Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

2. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section IV.A – MVPD Information and Transition Plan

1. Type of MVPD {prefill cable operator, DBS/Other MVPD}

2. Broadcast Station List (for each station requiring modification complete chart)

Facility ID

Call sign

Nature of Change (channel reassigned, new station resulting from sharing)

PSID(s) or Receive Site at which channel is received

Example Broadcast Station List Chart

Facility ID	Call Sign	Nature of Change	PSID(s)/Receive Site
000001	WAAA	Reassigned	PSID1, PSID2, PSID3, …
000002	WBBB	Reassigned	PSID1, PSID2, …
000003	WCCC	Sharing	PSID2, PSID3, …
…	…	…	…

Section IV.B – MVPD Estimated or Actual Transition Expenses

1. For each channel on each PSID or Receive Site, complete as applicable:
   
   

1. PSID or Receive Site (identifier)
   
   

1. Channel Specific Costs

• Channel(s) Affected

• Coaxial Cable[{length in feet or meters}

• Antenna {Make, Model, Frequency Range, Gain}

• Structural or Capacity Augments for Tower

• Tower Rigging Expenses

• RF Processing Equipment {Pre-amp, Receiver, Decoder, Other-> Describe}

  • Identification {Make, Model}

• Other channel-specific costs {Describe}

2. Outside Professional Services

• Structural Study of Tower Capacity

• Engineering Study

• Other Professional Service Costs Not Listed {Describe}

Example PSID/Receive Site Chart

PSID	Channels	Costs	Appendix A Cost Chart
PSID1
	WAAA	Antenna	[continue to chart]
	WBBB	Pre-Amp	[continue to chart]
	…	…	[continue to chart]
PSID2
	WBBB, WCCC	…	[continue to chart]
…	…	…

2. Other Expenses Not Listed (list)

1. Other Miscellaneous Expenses Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

2. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide justification {text box}

Section V: Certifications

Certify to the following sections as appropriate (as determined automatically based on user input):

Section V.A: WITH SUBMISSION OF ESTIMATED EXPENSES:

WILLFUL FALSE 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 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 certifies that the statements in this form 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 (broadcasters) 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 it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement 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 pre-requisite for obtaining the payments herein requested.

Print Name of Authorized Person	Print Title of Authorized Person
Signature	Date

Section V.B: WITH SUBMISSION OF ACTUAL COST DOCUMENTATION:

WILLFUL FALSE 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 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 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).

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 certifies that the cost information/documents submitted reflect costs actually incurred.

6. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

7. 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.

Print Name of Authorized Person	Print Title of Authorized Person
Signature	Date

Section V.C: WITH SUBMISSION OF FINAL ALLOCATION OR ACCOUNTING INFORMATION:

WILLFUL FALSE 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 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 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.

Print Name of Authorized Person	Print Title of Authorized Person
Signature	Date

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT

We have estimated that each response to this collection of information will take 1 – 4

hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the 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 (3060-1178), Washington, DC 20554. We will also accept your comments via the Internet if your send them to [email protected]. Please DO NOT SEND COMPLETED APPLICATIONS TO THIS ADDRESS. 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 3060-1178.

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

(A) Description	(B) Predetermined Cost Estimate (if available)	(C) Estimated Cost	Actual Cost Information
			(D) Component Description	(E) Component Amount	Documentation
					(F) Vendor Name/EIN/TIN (if available)	(G) Invoice Number	(H) Invoice Date/ Due Date	(I) Total Invoice Amount	(J) File Upload	(K) Invoice Type	(L) Payment Date
[Pre-fill from above]	[Pre-fill from Catalog of Potential Expenses and Estimated Costs]	[Provide amount]	[Describe]	[Provide Amount]	[Name of vendor]		[Date]	[total]	[select]		[Date]
			…	…	…
			Subtotal	[Calculated Sum]
…	…	…	…	…	…
	[Calculated Sum]	[Calculated Sum]	Total	[Calculated Sum]				[total]

APPENDIX A – COST CHART

19 Draft

Not Yet Approved By OMB