TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
LeSEA Broadcasting of South Bend, Inc. Doing Business As: LeSEA Broadcasting of South Bend, Inc.	LeSEA Broadcasting of South Bend, Inc. 61300 IRONWOOD ROAD SOUTH BEND, IN 46614 United States	+1 (574) 291-8200	whylton@lesea.com	Not-for-Profit

Applicant

Address

Phone

Applicant Type

LeSEA Broadcasting of South Bend, Inc.

Doing Business As: LeSEA Broadcasting of South Bend, Inc.

LeSEA Broadcasting of South Bend, Inc.

61300 IRONWOOD ROAD

SOUTH BEND, IN 46614

United States

+1 (574) 291-8200

whylton@lesea.com

Not-for-Profit

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant	Address	Phone	Email
[Confidential]

Preparer Contact Information

Preparer Contact Name and Information

Applicant	Address	Phone	Email
Joseph C. Chautin III Hardy, Carey, Chautin & Balkin	1080 West Causeway Approach Mandeville, LA 70471 United States	+1 (985) 629-0777	jchautin@hardycarey.com

Applicant

Address

Phone

Joseph C. Chautin III

Hardy, Carey, Chautin & Balkin

1080 West Causeway Approach

Mandeville, LA 70471

United States

+1 (985) 629-0777

jchautin@hardycarey.com

Broadcaster Information and Transition Plan

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.	No
Briefly describe transition plan	Replace existing channel 48 system with Channel 36

Transmitters

Section	Question	Response
Transmitter Related Expenses	Do you have transmitter related expenses?	Yes

Primary Transmitter

Existing Transmitter Information

Section	Question	Response
Existing Transmitter Description	Type of change	Retune Existing
	Use	Primary (Main)
	Ownership	Owned
	Owner	N/A
	Is this transmitter currently shared with another station?	No
	Is this transmitter currently in operating condition?	Yes
Existing Transmitter Manufacturer and Type	Manufacturer	CoMark
	Model	Paragon
	Year	1995
	Type	Inductive Output Tube
	IOT Power Type	Two
	Power capacity	50 kW

Primary Transmitter

Retuning Transmitter Costs

Section	Question	Response
New IOT Tubes	Number of Tubes (including accessories) needed
New Mask Filter
	Power	60 kW
	Other Power	N/A
New Exciter	Is a new exciter needed?	Yes
New Exciter	Exciter Type	Dual exciter with changeover

Primary Transmitter

Other Transmitter Costs

Section	Question	Response
Electrical Service	Service Entrance (3 phases 800A 208V)	No
	Switchgear (industrial 800 amp)	No
	Transformer (480V)	No
	Power	N/A
	Rigid Conduit and Wiring	No
	Size	N/A
	Length	N/A
	Other Electrical Service	No
	Description	N/A
HVAC Service	Does the replacement transmitter require HVAC Service?	No
	Type	N/A
	Size	N/A
	Other Size	N/A
Transmitter Building Addition/Modification or Leasehold Improvement	Does the Transmitter Building require an addition, modification, other leashold improvement?	No
	Size	N/A
Channel 14 Costs	Is an RF Consulting Engineer needed?	N/A
	Is a channel 14 Mask Filer needed?	N/A
	Is additional field engineering time needed?	N/A
	Number of Days	N/A

Primary Transmitter

Other Transmitter Cost Not Listed

Name	Description
Retune Cost	Retune existing transmitter
Aux Transmitter	Purchase a 5KW Aux Transmitter

Primary Transmitter

Add Transmitter Information

Section	Question	Response
Existing Transmitter Description	Type of change	Purchase New
	Use	Primary (Main)
	Description of Use	N/A
	Ownership	Owned
	Owner	N/A
	Site	N/A
	Is this transmitter currently shared with another station?	No
	Is this transmitter currently in operating condition?	No
Existing Transmitter Manufacturer and Type	Manufacturer
	Model	Paralax channel 36
	Year	2018
	Type	Solid State
	Solid State Cooling	Liquid Cooled
	Solid State Power Capacity	27.5 kW

Primary Transmitter

New Transmitter Costs

Section	Question	Response
New Transmitter	Use	Primary (Main)
	Change Type	Purchase New
	Is this a request for upgraded equipment?	Yes
	Manufacturer
	Model	Paralax UHF
	Transmitter Type	Solid State
	Solid State Cooling	Liquid Cooled
	Solid State Power capacity	27.5 kW
	Justification for New Transmitter	Less expensive than the retune of existing Xtmr.

Primary Transmitter

Other Transmitter Costs

Section	Question	Response
Electrical Service	Service Entrance (3 phases 800A 208V)	Yes
	Switchgear (industrial 800 amp)	No
	Transformer (480V)	No
	Power	N/A
	Rigid Conduit and Wiring	No
	Size	N/A
	Length	N/A
	Other Electrical Service	No
	Description	N/A
HVAC Service	Does the replacement transmitter require HVAC Service?	Yes
	Type	Cooling Only
	Size	10 tons
	Other Size	N/A
Transmitter Building Addition/Modification or Leasehold Improvement	Does the Transmitter Building require an addition, modification, other leashold improvement?	No
	Size	N/A
Channel 14 Costs	Is an RF Consulting Engineer needed?	N/A
	Is a channel 14 Mask Filer needed?	N/A
	Is additional field engineering time needed?	N/A
	Number of Days	N/A

Primary Transmitter

Other Transmitter Cost Not Listed

Information not provided.

Antennas

Section	Question	Response
Antenna Related Expenses	Do you have antenna related expenses?	Yes

Primary Antenna

Add Antenna Information

Section	Question	Response
Existing Antenna Description	Type of change	Purchase New
	Antenna Use	Primary (Main)
	Description of Use	N/A
	Ownership	Owned
	Owner	N/A
	Site	N/A
	Is this antenna currently shared with any other stations?	No
	Is this antenna directional?	No
	Is antenna in operating condition?	No
	Is antenna located on or in close proximity to an antenna farm?	No
Existing Antenna Manufacturer and Type	Class	Full Power
	Mounting	Top Mount
	Antenna position in stack	Not in Stack
	Polarization	Elliptical
	Type	Slotted Coaxial
	Number of Stations Supported	N/A
	Number of Panels	N/A
	Design power capacity in use	N/A
	Lower Limit	N/A
	Upper Limit	N/A
	Other Antenna Type	N/A
	ERP:	236.0 kW
	Manufacturer
	Model	TFU 29JTH/VP-R-06
	Year	2018

Primary Antenna

New Antenna Costs

Section	Question	Response
New Antenna Description	Use	Primary (Main)
	Description of Use	N/A
	Change Type	Purchase New
	Is this a request for upgraded equipment?	Yes
	Ownership	Owned
	Owner	N/A
	Is antenna shared?	No
	Is antenna directional?	No
	Will antenna be located on or in close proximity to an antenna farm?	No
New Antenna Manufacturer and Types	Class	Full Power
	Mounting	Top Mount
	Antenna position in stack	Not in Stack
	Polarization	Elliptical
	Type	Slotted Coaxial
	Number of Stations Supported	N/A
	Number of Panels/Bays	N/A
	Lower Limit	N/A
	Upper Limit	N/A
	Design power capacity in use	N/A
	Other Antenna Type	N/A
	ERP:	236.0 kW
	Manufacturer
	Model	TFU 29JTH/VP-R-06
	Year	2018
	Justification for New Antenna	Upgrade for better coverage and to prepare for ATSC3.

Primary Antenna

Other Antenna Costs

Section	Question	Response
Combiner for Shared Antenna	Do you need a Combiner for a Shared Antenna?	No
	Type
	Number of channels supported	N/A
	Frequencies of channels supported	N/A
	Frequency	N/A
	Do you need a combiner output splitter/switcher for dual feed lines?	N/A
Elbow Complex	Do you require the separate purchase of the Elbow Complex?	Yes
	Broadband or Single Channel?	Single Channel
	Feed Line Size	4 1/16 inches inches
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

Other Antenna Cost Not Listed

Information not provided.

Primary Antenna

Existing Antenna Information

Section	Question	Response
Existing Antenna Description	Type of change	Purchase New
	Antenna Use	Primary (Main)
	Description of Use	N/A
	Ownership	Owned
	Owner	N/A
	Site	N/A
	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?	Yes
Existing Antenna Manufacturer and Type	Class	Full Power
	Mounting	Side Mount
	Antenna position in stack	Top
	Polarization	Horizontal
	Type	Slotted Coaxial
	Number of Stations Supported	N/A
	Number of Panels	N/A
	Design power capacity in use	N/A
	Lower Limit	N/A
	Upper Limit	N/A
	Other Antenna Type	N/A
	ERP:	236.0 kW
	Manufacturer
	Model	TFU-18DSC T160
	Year	2005

Primary Antenna

New Antenna Costs

Section	Question	Response
New Antenna Description	Use	Primary (Main)
	Description of Use	N/A
	Change Type	Purchase New
	Is this a request for upgraded equipment?	Yes
	Ownership	Owned
	Owner	N/A
	Is antenna shared?	No
	Is antenna directional?	Yes
	Will antenna be located on or in close proximity to an antenna farm?	Yes
New Antenna Manufacturer and Types	Class	Full Power
	Mounting	Side Mount
	Antenna position in stack	Top
	Polarization	Horizontal
	Type	Slotted Coaxial
	Number of Stations Supported	N/A
	Number of Panels/Bays	N/A
	Lower Limit	N/A
	Upper Limit	N/A
	Design power capacity in use	N/A
	Other Antenna Type	N/A
	ERP:	236.0 kW
	Manufacturer
	Model	TFU-18DSC T160
	Year	2017
	Justification for New Antenna	Channel Change

Primary Antenna

Other Antenna Costs

Section	Question	Response
Combiner for Shared Antenna	Do you need a Combiner for a Shared Antenna?	No
	Type
	Number of channels supported	N/A
	Frequencies of channels supported	N/A
	Frequency	N/A
	Do you need a combiner output splitter/switcher for dual feed lines?	N/A
Elbow Complex	Do you require the separate purchase of the Elbow Complex?	Yes
	Broadband or Single Channel?	Single Channel
	Feed Line Size	4 1/16 inches inches
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

Other Antenna Cost Not Listed

Information not provided.

Transmission Line

Section	Question	Response
Transmission Line Related Expenses	Do you have transmission line related expenses?	No

Tower Equipment And Rigging Costs

Section	Question	Response
Tower Equipment or Rigging Costs Changes	Do you have tower equipment or rigging costs changes?	No

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	No
	Number of Hours	N/A
	Explanation	N/A
Outside RF consulting Engineering Services	Perform engineering study for new channel assignment and antenna development	Yes
	Prepare engineering section of Form FCC Construction Permit Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare engineering section of Form FCC License to Cover Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare request for Special Temporary Authority	No
	Quantity	N/A
	Do you have Distributed Transmission System engineering services?	N/A
	Critical Facility	N/A
	Terrain-Shielded Facility	N/A
Attorney and Other Outside Consulting Services	Prepare and file Form FCC Construction Permit Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare and file Form FCC License to Cover Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare request for Special Temporary Authority	No
	Quantity	N/A
	NEPA Section 106 environmental review	No
	Environmental Assessment	No
	ASR Modification	No
	FAA Consultation (including preparation of FAA Form 7460)	No
	Negotiation of Lease and other Matter for Shared Locations	No
	Prepare or Review FCC Form 399 for Reimbursement	Yes
	Address transition timing and coordination issues w/ other stations and wireless providers	Yes
RF Field Engineering Services	Comprehensive coverage verification via field study	No
	RF exposure measurements	No
	Additional Field Engineering Service	No
	Number of Days	N/A
	Justification	N/A

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

Section	Question	Response
AM Pattern Disturbance	Is an Impact Study needed?	No
AM Pattern Disturbance	Is Remediation needed?	No
Facility Expenses	Name	N/A
	Other Distributed Transmission System Expenses Not listed	N/A
	Name	N/A
	Is Notification of a Medical Facility required as a result of DTV broadcasting?	Yes
Permit and Filing Costs	Local Zoning	No
	Non-zoning permits	No
	BLM or NFS Coordination	No
	FCC Construction Permit Minor Change	No
	FCC License to Cover Application	No
	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)?	No
	Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs?	No
	Does this relocation require Equipment Storage?	No
	Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change?	No
	Does this relocation require MVPD Notification of a Channel Change?	No

Other Expenses

Other Expenses Not Listed

Information not provided.

Cost Information

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	$1,493,550.00	$866,935.00	N/A	$280,785.75	N/A
Total for all systems	$2,087,980.00	$1,196,686.25	N/A	$563,287.00	N/A
Primary Transmitter Paralax UHF	$1,000,300.00	$866,935.00		$280,785.75
10 Ton system	$38,900.00	$37,000.00	N/A	N/A	N/A
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW	$947,000.00	$816,235.00	N/A	$280,785.75	N/A
Service entrance 3 phase/800 amp/208 volt	$14,400.00	$13,700.00	N/A	N/A	N/A
Primary Transmitter Paragon	$493,250.00	$0.00		$0.00
60 kW mask filter	$89,400.00	$0.00	Price includes RF system and all transmitter components and proof, shipping etc. Cancelled	$0.00	N/A
Aux Transmitter	$0.00	$0.00	Cancelled	$0.00	N/A
Retune Cost	$0.00	$0.00	Included in RF system and services.	N/A	N/A
Dual exciter system with change over	$47,350.00	$0.00	CoMark Quote. Cancelled	N/A	N/A
Two IOT system (50 kW)	$356,500.00	$0.00	Transmitter components needed to retune xtmr Cancelled	N/A	N/A

Components

Actual Information Description	File Name
10 Ton system	Information not provided.
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW	Component Description: Down payment that has been paid Amount: $280,785.75
Service entrance 3 phase/800 amp/208 volt	Information not provided.
60 kW mask filter	Information not provided.
Aux Transmitter	Information not provided.
Retune Cost	Information not provided.
Dual exciter system with change over	Information not provided.
Two IOT system (50 kW)	Information not provided.

Cost Information

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	$557,900.00	$302,501.25	N/A	$282,501.25	N/A
Total for all systems	$2,087,980.00	$1,196,686.25	N/A	$563,287.00	N/A
Primary Antenna TFU 29JTH/VP-R-06	$328,950.00	$296,101.25		$282,501.25
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized	$289,500.00	$289,701.25	This is for an upgrade we realize we must pay the difference.	$282,501.25	N/A
Side mount brackets for high power antennas (if not included in antenna base cost)	$23,150.00	$0.00	N/A	N/A	N/A
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed)	$9,570.00	$0.00	N/A	N/A	N/A
Sweep test of existing antenna	$6,730.00	$6,400.00	N/A	N/A	N/A
Primary Antenna TFU-18DSC T160	$228,950.00	$6,400.00		$0.00
Side mount brackets for high power antennas (if not included in antenna base cost)	$23,150.00	$0.00	N/A	N/A	N/A
UHF - Lower Power Side Mount, One station - 200-500 kW, horizontally polarized	$189,500.00	$0.00	N/A	N/A	N/A
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed)	$9,570.00	$0.00	N/A	N/A	N/A
Sweep test of existing antenna	$6,730.00	$6,400.00	N/A	$0.00	N/A

Components

Actual Information Description	File Name
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized	Component Description: second payment due on antenna Amount: $152,135.69 Component Description: down payment on antenna Amount: $130,365.56
Side mount brackets for high power antennas (if not included in antenna base cost)	Information not provided.
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed)	Information not provided.
Sweep test of existing antenna	Information not provided.
Side mount brackets for high power antennas (if not included in antenna base cost)	Information not provided.
UHF - Lower Power Side Mount, One station - 200-500 kW, horizontally polarized	Information not provided.
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed)	Information not provided.
Sweep test of existing antenna	Information not provided.

Cost Information

Transmission Line

Information not provided.

Cost Information

Tower Equipment and Rigging Costs

Information not provided.

Cost Information

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	$24,980.00	$23,750.00	N/A	$0.00	N/A
Total for all systems	$2,087,980.00	$1,196,686.25	N/A	$563,287.00	N/A
Outside Professional Services	$24,980.00	$23,750.00		$0.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$2,365.00	$2,250.00	N/A	N/A	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$5,260.00	$5,000.00	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$3,155.00	$3,000.00	N/A	N/A	N/A
Perform engineering study for new channel assignment and antenna development	$7,360.00	$7,000.00	N/A	N/A	N/A
Address transition timing and coordination issues w/ other stations and wireless	$2,630.00	$2,500.00	N/A	N/A	N/A
Prepare and or review reimbursement form	$2,630.00	$2,500.00	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,580.00	$1,500.00	N/A	N/A	N/A

Components

Information not provided.

Cost Information

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	$11,550.00	$3,500.00	N/A	$0.00	N/A
Total for all systems	$2,087,980.00	$1,196,686.25	N/A	$563,287.00	N/A
Other Expenses	$11,550.00	$3,500.00		$0.00
DTV Medical Facility Notification	$11,550.00	$3,500.00	N/A	N/A	N/A

Components

Information not provided.

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$2,087,980.00	$1,196,686.25	$563,287.00

Reimbursement Status

Question	Response
The facility has ceased operating on its pre-auction channel.	No
Construction of final facilities or all necessary modifications are complete.	No
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.	No

Certification

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.
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. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. 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). 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. 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. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. 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.	Tony Agostino CFO 01/26/2018

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.

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.
The above-named entity acknowledges that all certifications and attached documentation are considered material representations.
The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.
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).
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.
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.
The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.
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.

Tony Agostino

CFO

01/26/2018

Certification

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).
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 certifies that the statements in this form and attached documentation are true, complete, and correct. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. 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) . 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. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. 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.	Tony Agostino CFO 01/26/2018

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).

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 certifies that the statements in this form and attached documentation are true, complete, and correct.
The above-named entity acknowledges that all certifications and attached documentation are considered material representations.
The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.
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) .
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.
The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.
The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.
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.

Tony Agostino

CFO

01/26/2018

(REFERENCE COPY - Not for submission) FCC Form 399: Reimbursement Request

Applicant Information

Applicant Name, Type, and Contact Information

Reimbursement Contact Information

Reimbursement Contact Name and Information

Preparer Contact Information

Preparer Contact Name and Information

Broadcaster Information and Transition Plan

Transmitters

Primary Transmitter

Existing Transmitter Information

Primary Transmitter

Retuning Transmitter Costs

Primary Transmitter

Other Transmitter Costs

Primary Transmitter

Other Transmitter Cost Not Listed

Primary Transmitter

Add Transmitter Information

Primary Transmitter

New Transmitter Costs

Primary Transmitter

Other Transmitter Costs

Primary Transmitter

Other Transmitter Cost Not Listed

Antennas

Primary Antenna

Add Antenna Information

Primary Antenna

New Antenna Costs

Primary Antenna

Other Antenna Costs

Primary Antenna

Other Antenna Cost Not Listed

Primary Antenna

Existing Antenna Information

Primary Antenna

New Antenna Costs

Primary Antenna

Other Antenna Costs

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Tower Equipment And Rigging Costs

Outside Professional Services Costs

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Other Expenses

Other Expenses

Other Expenses Not Listed

Cost Information

Transmitters

Components

Cost Information

Antennas

Components

Cost Information

Transmission Line

Cost Information

Tower Equipment and Rigging Costs

Cost Information

Outside Professional Services

Components

Cost Information

Other Expenses

Components

Cost Information

Grand Total

Reimbursement Status

Certification

Certification

Attachments