Go to the Federal Communications Commission homepage at www.fcc.gov

FCC Form 399: Reimbursement Request

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

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

Facility ID:
50044
Service:
DTV
Call Sign:
KPBT-TV
Channel:
28 (UHF)
File Number:
0000028613
FRN:
0014288831
Date Submitted:
03/20/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

PERMIAN BASIN PUBLIC TELECOMMUNICATIONS, INC.

Doing Business As: KPBT-TV

Jazmin Shotts

P.O. BOX 8940

MIDLAND, TX 79708

United States

+1 (432) 563-5728 jshotts@basinpbs.org Not-for-Profit

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

David Sanderford

Marsand, Inc.

David Sanderford

1957 Reynolds Dr

Azle, TX 76020

United States

+1 (817) 783-5566 david@marsand.com

Broadcaster Information and Transition Plan

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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 See attached Transition Plan Narrative.

Transmitters

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

Primary Transmitter

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Existing 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? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model DHD60P2
Year 2001
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 14 kW

Primary Transmitter

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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 THU9-12Evo
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 19 kW
Justification for New Transmitter Solid State Power Capacity is "pre-mask filter". See attached Transition Plan Narrative.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) Yes
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 180.0 feet
Other Electrical Service Yes
Description Build out electrical to accommodate the addition of the existing UPS and generator and then move the UPS and generator after the transition to comply with WARN act.
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? Yes
Size 800.0 square feet
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

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Other Transmitter Cost Not Listed

Name Description

Transmitter Installation

Installation, commissioning and proof of performance documentation.

Remove Existing Equipment

Remove pre-auction channel transmitter and interior RF system.

Antennas

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

Primary Antenna

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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? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
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: 220.0 kW
Manufacturer
Model ATL20H3-HSO-38
Year 2001

Primary Antenna

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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? No
New Antenna Manufacturer and Types Class Full Power
Mounting Side 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: 500.0 kW
Manufacturer
Model SAA28-ATW_P3-J300-ES6R-28
Year 2018
Justification for New Antenna See attached Transition Plan Narrative.

Primary Antenna

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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? No
Broadband or Single Channel? N/A
Feed Line Size N/A
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? Yes
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? Yes

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Air
Diameter 4 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 315 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Flexible Air
Diameter 4 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 900 feet per run
Justification for New Transmission Line See attached Transition Plan Narrative.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Add Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) No
Others Types of Users Yes
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1215312
Coordinates (NAD83) Latitude (NAD83) 31° 53' 50.3" N-
Longitude (NAD83) 102° 20' 15.5" W-
Overall Structure Height 367.78 feet
Support Structure Height 350.06 feet
Ground Elevation Above Mean Sea Level (AMSL) 2917.62 feet
Structure Type MAST - Mast
Tower Owner Gray Television Group, Inc.
Date Constructed 12/23/2000


Other Types of Users

Users
K238AZ FM Trans
KOSA-TV STL

Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: No reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Primary Tower

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Add Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1053361
Coordinates (NAD83) Latitude (NAD83) 32° 05' 11.0" N-
Longitude (NAD83) 102° 17' 12.0" W-
Overall Structure Height 1131.88 feet
Support Structure Height 1030.17 feet
Ground Elevation Above Mean Sea Level (AMSL) 2909.09 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner Subcarrier Communications Inc
Date Constructed 01/01/1963

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID Call Sign Service
41856 KMRK-FM FM
65306 KMCM FM
9667 KCRS-FM FM

Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 350
Explanation Please see attached Transition Plan Narrative.
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 Yes
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

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Other Professional Services Expenses Not Listed

Name Description

Site Survey

Required for specifying the final equipment needs and installation planning.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
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)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? No
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Name Description

Studio to Transmitter Link

Fiber or microwave radio connection from the studio to the transmitter site.

Cost Information

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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 $1,057,560.00 $795,630.11 N/A $97,985.75 N/A
Total for all systems $2,004,640.00 $1,622,985.11 N/A $184,743.98 N/A
Primary Transmitter THU9-12Evo $1,057,560.00 $795,630.11 $97,985.75
Remove Existing Equipment $15,000.00 $15,000.00 Dismantle and remove the transmitter and interior RF components. N/A N/A
Transmitter Installation $30,000.00 $30,000.00 Please see attached transmitter installation quotation. N/A N/A
Other -- Building Addition Size: 800.0 $96,875.00 $96,875.00 See attached Building Modification quote. N/A N/A
10 Ton system $38,900.00 $14,645.80 See attached HVAC quote (6 ton system). N/A N/A
Other Electrical Service: Build out electrical to accommodate the addition of the existing UPS and generator and then move the UPS and generator after the transition to comply with WARN act. $94,025.00 $94,025.00 Please see attached quotations for generator and UPS decommissioning, move and commissioning. N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $9,360.00 $8,820.00 N/A N/A N/A
Transformer 3 phase/480v - 300 KVA $36,800.00 $35,000.00 N/A N/A N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $13,700.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW $684,000.00 $451,264.31 See attached transmitter quotation. $97,985.75 N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A

Components

Actual Information Description File Name
Remove Existing Equipment Information not provided.
Transmitter Installation Information not provided.
Other -- Building Addition Size: 800.0 Information not provided.
10 Ton system Information not provided.
Other Electrical Service: Build out electrical to accommodate the addition of the existing UPS and generator and then move the UPS and generator after the transition to comply with WARN act. Information not provided.
3" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Transformer 3 phase/480v - 300 KVA Information not provided.
Service entrance 3 phase/800 amp/208 volt Information not provided.
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW

Component Description:
25% Downpayment Rohde & Schwarz Model THU9-12 Evo Quote: 802-0335601.4
Amount:
$97,985.75
Switchgear - industrial 800 amp Information not provided.

Cost Information

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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 $177,640.00 $172,350.00 N/A $0.00 N/A
Total for all systems $2,004,640.00 $1,622,985.11 N/A $184,743.98 N/A
Primary Antenna SAA28-ATW_P3-J300-ES6R-28 $177,640.00 $172,350.00 $0.00
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A
UHF - High Power, Side Mount, basic slot antenna, 500 kW input, directional,, elliptically or circularly polarized $142,500.00 $142,500.00 See attached antenna quotation (cost for comparable Hpol only antenna). N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $18,450.00 See attached antenna quotation. N/A N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,260.00 $5,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Transmission Line

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 $66,600.00 $30,000.00 N/A $0.00 N/A
Total for all systems $2,004,640.00 $1,622,985.11 N/A $184,743.98 N/A
Primary Transmission Line $66,600.00 $30,000.00 $0.00
Flexible Air Transmission Line - dielectric, 4" $66,600.00 $30,000.00 See attached antenna quotation. N/A N/A

Components

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

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 $491,600.00 $418,555.00 N/A $75,598.23 N/A
Total for all systems $2,004,640.00 $1,622,985.11 N/A $184,743.98 N/A
Primary Tower GTOWER $381,100.00 $362,000.00 $61,798.23
Tall Tower (greater than 500') $210,500.00 $200,000.00 Installation of antenna and transmission line. $47,097.48 N/A
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A $10,700.75 N/A
Structural engineering tower load study for well documented tower $12,600.00 $12,000.00 N/A $4,000.00 N/A
Primary Tower MAST $110,500.00 $56,555.00 $13,800.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $16,555.00 See attached series of invoices labeled Initial Tower Studies $13,800.00 N/A
Short Tower (less than 500') $84,200.00 $40,000.00 This tower is not able to be brought into conformance with the TIA-222-G specification. Existing antenna and transmission line removal only post-transition. N/A N/A

Components

Actual Information Description File Name
Tall Tower (greater than 500')

Component Description:
30% down payment for all tower modifications and services - ASR# 1053361. Less the amounts for the Application Fee ($3,000.00), Design Drawing Package ($10,700.75) and Tower Study 1 ($1500.00) and 2 ($2500.00).
Amount:
$47,097.48
Minor tower reinforcement/modifications

Component Description:
Tower Modification Design Drawing Package
Amount:
$10,700.75
Structural engineering tower load study for well documented tower

Component Description:
Tower loading study for initial antenna (PEP8A) and subsequent loading study for final antenna. (SAA28-ATW_P3-J300-ES6R-28)
Amount:
$4,000.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study

Component Description:
KPBT - Tower Mapping
Amount:
$3,500.00

Component Description:
KOSA - Remobilization Fee
Amount:
$2,755.00

Component Description:
KPBT - Geotechnical Investigation
Amount:
$3,300.00

Component Description:
KPBT - Remobilization Fee
Amount:
$1,600.00

Component Description:
KPBT - Structural Analysis
Amount:
$1,500.00

Component Description:
KPBT - Foundation Mapping
Amount:
$3,900.00
Short Tower (less than 500') Information not provided.

Cost Information

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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 $94,490.00 $90,250.00 N/A $11,160.00 N/A
Total for all systems $2,004,640.00 $1,622,985.11 N/A $184,743.98 N/A
Outside Professional Services $94,490.00 $90,250.00 $11,160.00
Site Survey $10,000.00 $10,000.00 Please see attached Site Survey quotation. $3,000.00 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A $1,620.00 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
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 $5,850.00 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
Project management of the transition $55,300.00 $52,500.00 Please see attached Project Management quotation. N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $690.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Site Survey

Component Description:
Non refundable application fee to initiate lease negotiations - ASR# 1053361.
Amount:
$3,000.00
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Repack Services
Amount:
$120.00

Component Description:
Attorney Fees Form 2100 Form 399 STA
Amount:
$1,500.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
Engineering services
Amount:
$1,631.25

Component Description:
Initial RF Coverage Scenarios
Amount:
$4,218.75
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Project management of the transition Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Television Repacking Services
Amount:
$690.00

Component Description:
Television Repacking Services- Billed Thru October 31, 2017
Amount:
$359.25
Prepare and or review reimbursement form Information not provided.

Cost Information

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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 $116,750.00 $116,200.00 N/A $0.00 N/A
Total for all systems $2,004,640.00 $1,622,985.11 N/A $184,743.98 N/A
Other Expenses $116,750.00 $116,200.00 $0.00
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $15,000.00 $15,000.00 Disposal of old transmitter, antenna, line and misc. electrical. N/A N/A
MVPD Notification of Channel Change $1,200.00 $1,200.00 N/A N/A N/A
Equipment Delivery and Handling Charges $23,000.00 $23,000.00 Freight for antenna and transmission line. Offloading equipment rental and labor. N/A N/A
Develop and air announcement of upcoming channel change $6,000.00 $6,000.00 N/A N/A N/A
Studio to Transmitter Link $60,000.00 $60,000.00 Construct fiber "last mile" connection for STL link (preferred). Microwave radio link is more expensive. N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $2,004,640.00 $1,622,985.11 $184,743.98

Reimbursement Status

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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

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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.

  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 an authorized representative of the above-named applicant for the Authorization(s) specified above.

Jazmin Shotts

Interim GM


03/20/2018

Certification

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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).

  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 an authorized representative of the above-named applicant for the Authorization(s) specified above.

Jazmin Shotts

Interim GM


03/20/2018

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