Appendix A: Public Interest Programming and Community Service Certification Form

PUBLIC INTEREST PROGRAMMING AND COMMUNITY SERVICE CERTIFICATION FORM

LICENSEE -- NETWORK AFFILIATION -- NIELSEN DMA -- HOME PAGE ADDRESS (IF ANY) CALL SIGN -- CHANNEL NO. -- COMMUNITY OF LICENSE -- STATE -- COUNTY -- ZIP CODE

NEWCASTS

1. The licensee typically airs ____ hours of newscasts per week.

2. Of these hours, _________ are typically devoted to local newscasts.

PUBLIC AFFAIRS

3. The licensee has aired at least [ ] hours* per week of programming addressing national or local public affairs during the past three months. q YES q NO

4. The licensee has aired programming addressing national or local public affairs during the past three months that exceeds (by at least one hour) the weekly minimum listed in question 3. q YES q NO

5. List in Exhibit A a representative sample of programs and/or segments aired during the past three months that addressed national or local public affairs, the day and time each aired, and what issue(s) each addressed.

POLITICAL/CIVIC DISCOURSE

6. The licensee has provided at least five (5) minutes per day, at no charge, for federal, state, or local candidate-centered discourse ( e.g., debates, interviews, candidate "uses" as defined in 47 U.S.C. §315(a)) in the 30 days before a general election. q YES q NO q NOT APPLICABLE THIS QUARTER

7. The licensee has aired at least __________ (minutes/hours) of programming during the past three months (not including candidate-centered discourse in question 6 or paid advertising) addressing election- or ballot referendum-related matters in the 30 days before a general election.

8. List in Exhibit B a representative sample of programs and/or segments that aired during the past three months (not including paid advertising) that addressed candidates, elections and/or ballot referendums, the day and time each aired, and what candidates/elections or ballot referendums each addressed.

9. As a matter of policy, the licensee does not sell advertising to state or local candidates in the 30 days before a general election. q YES q NO

UNDERSERVED COMMUNITIES

10. The licensee has aired at least ________(minutes/hours) of programming during the past three months to meet the needs of underserved communities, i.e., demographic segments of the community of license to whom little or no programming is directed, for example, people of color, the elderly, gays, and lesbians.

11. List in Exhibit C a representative sample of programs and/or segments that aired during the past three months that met the needs of an underserved community, the day and time each aired, and the underserved audience segment each addressed.

LOCAL PROGRAMMING (NOT LISTED ELSEWHERE IN THIS REPORT)

12. The licensee has aired at least _______ (minutes/hours) of locally originated or locally oriented programming, programming primarily devoted to coverage of local issues and/or programming providing opportunity for local self-expression (not listed elsewhere in this report) during the past three months.

13. List in Exhibit D a representative sample of programs and/or segments aired during the past three months that were locally originated or locally oriented, addressed local issues, and/or provided opportunity for local self-expression (not listed elsewhere in this report), the program length, the day and time each aired, and what local issue(s) each addressed.

PUBLIC SERVICE ANNOUNCEMENTS

14. The licensee airs at least [ ]* locally originated public service announcements during a three-month period. q YES q NO

15. At least [ ]* of these public service announcements are aired between 6 a.m. and midnight. q YES q NO

16. The licensee airs at least [ ]* other public service announcements during a three-month period. q YES q NO

17. At least [ ]* of these public service announcements are aired between 6 a.m. and midnight. q YES q NO

18. List in Exhibit E a representative sample of no fewer than five local and five national issues addressed by public service announcements during the past three months.

ASCERTAINMENT

19. The licensee undertakes efforts to ascertain the programming needs of various segments of their communities. q YES q NO

20. List in Exhibit F a representative sample of these efforts.

COMMUNITY SERVICE

21. List in Exhibit G any community service programs, community outreach, or other similar non-broadcast activities directed to serving the community of license undertaken during the past three months.

LOCAL MARKETING AGREEMENTS AND EXTENDED TIME BROKERAGE AGREEMENTS

22. The licensee leases or sells three hours or more per day to an entity other than the licensee pursuant to a local marketing agreement or time brokerage agreement. q YES q NO

23. The licensee retains editorial control over all political programming which dies not constitute candidate "uses" as defined in 47 U.S.C. §315(a), retains control over the station's political broadcasting files, and has taken steps to ensure that no political programming decisions are made by entities other than the licensee. q YES q NO

24. If the answer to any part of question 22 is no, please explain in Exhibit H.

CERTIFICATION

WILLFUL FALSE STATEMENTS MADE 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).

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

Name of Licensee

Signature

Date

*Minimums as determined by the Federal Communications Commission.

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