TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
SARKES TARZIAN, INC. Doing Business As: SARKES TARZIAN, INC.	Station KTVN 205 NORTH COLLEGE AVENUE SUITE 800 BLOOMINGTON, IN 47402 United States	+1 (812) 332-7251	lfox@ktvn.com	Corporation

Applicant

Address

Phone

Applicant Type

SARKES TARZIAN, INC.

Doing Business As: SARKES TARZIAN, INC.

Station KTVN

205 NORTH COLLEGE AVENUE

SUITE 800

BLOOMINGTON, IN 47402

United States

+1 (812) 332-7251

lfox@ktvn.com

Corporation

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
Nancy Ory Attorney Lerman Senter PLLC	Nancy Ory Lerman Senter PLLC 2001 L Street, NW, Suite 400 Washington, DC 20036 United States	+1 (202) 416-6791	nory@lermansenter.com

Applicant

Address

Phone

Nancy Ory

Attorney

Lerman Senter PLLC

Nancy Ory

Lerman Senter PLLC

2001 L Street, NW, Suite 400

Washington, DC 20036

United States

+1 (202) 416-6791

nory@lermansenter.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.	Yes
Briefly describe transition plan	Retune existing primary transmitter to the new channel. Replace non retunable auxiliary transmitter on the new channel. Replace mask filter, low pass filter and combiner. Modify existing exhaust and electrical system for install. Proof

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	Gates Air
	Model	VAX 3D
	Year	2016
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	4.5 kW

Primary Transmitter

Retuning Transmitter Costs

Section	Question	Response
New IOT Tubes	Number of Tubes (including accessories) needed	N/A
New Mask Filter
	Power	10 kW
	Other Power	N/A
New Exciter	Is a new exciter needed?	No

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
combiner	new combiner tuned to the new channel designation
Combiner installation	Modify transmission line from existing 2 port combiner to new 4 port combiner

Auxiliary Transmitter

Add Transmitter Information

Section	Question	Response
Existing Transmitter Description	Type of change	Purchase New
	Use	Auxiliary (Backup)
	Description of Use	Auxiliary
	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	Platinum
	Year	2003
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power Capacity	20 kW

Auxiliary Transmitter

New Transmitter Costs

Section	Question	Response
New Transmitter	Use	Auxiliary (Backup)
	Change Type	Purchase New
	Is this a request for upgraded equipment?	No
	Manufacturer
	Model	VAX TE8
	Transmitter Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	6.4 kW
	Justification for New Transmitter	Existing Auxiliary transmitter is not re-tunable to the new designated channel.

Auxiliary 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	Yes
	Description	Reconnection using existing wiring from currently installed Auxiliary to new Auxiliary
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

Auxiliary Transmitter

Other Transmitter Cost Not Listed

Name	Description
Air Exhaust	modify existing exhaust ductwork from current Auxiliary's Harris Platinum configuration to new Auxiliary's Gates Air Vax TE 8 configuration

Antennas

Section	Question	Response
Antenna Related Expenses	Do you have antenna related expenses?	No

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?	Yes
	Number of Hours	100
	Explanation	The station's attorney will manage the reimbursement filings, review engineering applications, and engage in any additional coordination that is needed for KTVN to accomplish its repack transition over the three year period.
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	No
RF Field Engineering Services	Comprehensive coverage verification via field study	Yes
	RF exposure measurements	Yes
	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	Yes
	FCC Construction Permit Minor Change	Yes
	FCC License to Cover Application	Yes
	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?	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

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	$418,510.00	$305,000.00	N/A	$97,809.02	N/A
Total for all systems	$577,405.00	$364,750.00	N/A	$116,174.02	N/A
Primary Transmitter VAX 3D	$243,510.00	$130,000.00		$48,026.75
combiner	$120,000.00	$120,000.00	N/A	$48,026.75	Dielectric Invoice MAN002243. The previous submission for the combiner was corrected by the new submission. The former request should be deleted from the cost spreadsheet. Total requested amount should be $48,026.75.
UHF and VHF - minor banding issues	$105,200.00	$0.00	N/A	N/A	N/A
10 kW mask filter	$8,310.00	$0.00	Mask filter built into combiner. No need for an external filter.	N/A	N/A
Combiner installation	$10,000.00	$10,000.00	N/A	N/A	N/A
Auxiliary Transmitter VAX TE8	$175,000.00	$175,000.00		$49,782.27
High VHF - Air Cooled Solid State Transmitter 6.4 kW	$165,000.00	$165,000.00	estimate from Gates Air	$49,782.27	Gates Air VAXTE-6R44. The previous submission for the transmitter was corrected by the new submission. The former request should be deleted from the cost spreadsheet. Total requested amount should be $49,782.27.
Air Exhaust	$5,000.00	$5,000.00	N/A	N/A	N/A
Other Electrical Service: Reconnection using existing wiring from currently installed Auxiliary to new Auxiliary	$5,000.00	$5,000.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
combiner	Component Description: Invoice with purchase order and quote backup provided Amount: $48,026.75 Component Description: 45% of Dielectric Invoice for combiner Amount: $48,026.75
UHF and VHF - minor banding issues	Information not provided.
10 kW mask filter	Information not provided.
Combiner installation	Information not provided.
High VHF - Air Cooled Solid State Transmitter 6.4 kW	Component Description: 1/3 down payment for transmitter Amount: $49,782.27 Component Description: transmitter Amount: $49,782.27
Air Exhaust	Information not provided.
Other Electrical Service: Reconnection using existing wiring from currently installed Auxiliary to new Auxiliary	Information not provided.

Cost Information

Antennas

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	$143,400.00	$53,250.00	N/A	$18,365.00	N/A
Total for all systems	$577,405.00	$364,750.00	N/A	$116,174.02	N/A
Outside Professional Services	$143,400.00	$53,250.00		$18,365.00
Project management of the transition	$15,800.00	$15,000.00	N/A	$11,386.25	N/A
Prepare and or review reimbursement form	$2,630.00	$2,500.00	N/A	$2,891.25	Actual cost exceeded Widelity Report estimate.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$3,155.00	$2,000.00	N/A	$1,837.50	Subtotal invoice includes other line items.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,580.00	$500.00	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
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
Comprehensive coverage verification via field study, if needed	$84,200.00	$15,000.00	N/A	N/A	N/A
Perform engineering study for new channel assignment and antenna development	$7,360.00	$3,000.00	N/A	$2,250.00	N/A
RF Exposure Measurements	$21,050.00	$8,000.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Project management of the transition	Component Description: Project management involving FRN association and banking information. Amount: $1,050.00 Component Description: Project management - advice and counsel regarding repack and reimbursement process Amount: $4,036.25 Component Description: Work includes FCC Forms 1876, 2100 and 399. Amount: $6,300.00
Prepare and or review reimbursement form	Component Description: Work was primarily FCC Forms 2100 and 399. Amount: $2,891.25
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	Component Description: Remainder of invoice ($625) is separate line item for review of repacked channel assignment. Amount: $1,837.50
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Information not provided.
Comprehensive coverage verification via field study, if needed	Information not provided.
Perform engineering study for new channel assignment and antenna development	Component Description: Engineering study for new channel assignment Amount: $1,625.00 Component Description: $625.00 of invoice for engineering study for new channel assignment. $1,837.50 of invoice for CP application - separate line item. Amount: $625.00
RF Exposure Measurements	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	$15,495.00	$6,500.00	N/A	$0.00	N/A
Total for all systems	$577,405.00	$364,750.00	N/A	$116,174.02	N/A
Other Expenses	$15,495.00	$6,500.00		$0.00
FCC Filing Fees - Form 2100 minor change CP application	$1,110.00	$0.00	N/A	N/A	N/A
MVPD Notification of Channel Change	$0.00	$0.00	N/A	N/A	N/A
Develop and air announcement of upcoming channel change	$0.00	$0.00	N/A	N/A	N/A
Equipment Delivery and Handling Charges	$1,500.00	$1,500.00	N/A	N/A	N/A
FCC Filing Fees - Form 2100 license to cover application	$335.00	$0.00	N/A	N/A	N/A
BLM or NFS Coordination	$1,000.00	$1,000.00	N/A	N/A	N/A
DTV Medical Facility Notification	$11,550.00	$4,000.00	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	$577,405.00	$364,750.00	$116,174.02

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.	Lawson Fox Vice President 04/23/2018

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.

Lawson Fox

Vice President

04/23/2018

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.	Lawson Fox Vice President 04/23/2018

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.

Lawson Fox

Vice President

04/23/2018

(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

Auxiliary Transmitter

Add Transmitter Information

Auxiliary Transmitter

New Transmitter Costs

Auxiliary Transmitter

Other Transmitter Costs

Auxiliary Transmitter

Other Transmitter Cost Not Listed

Antennas

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

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