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

FCC Form 399: Incentive Auction Relocation Reimbursement Fund System

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

(REFERENCE COPY - Not for submission)FCC Form 399: Incentive Auction Relocation Reimbursement Fund System

File Number:
0000025416
FRN:
0002629566
Facility ID:
35584
Repack Channel:
24 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
10/04/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

KSAX-TV, INC.

Doing Business As: KSAX-TV, INC.

David A. Jones

3415 UNIVERSITY AVE., WEST

ST. PAUL, MN 55114

United States

+1 (651) 642-4334 DJONES@HBI.COM Corporation

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

Charles R. Naftalin

LEGAL COUNSEL

HOLLAND & KNIGHT LLP

Charles Naftalin

Holland & Knight, 800 17th Street, NW

Suite 1100

Washington, DC 20006

United States

+1 (202) 955-3000 charles.naftalin@hklaw.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 The station will replace its owned antenna on its existing tower with a new antenna on a top-mounted omni-directional pylon on a supporting pole. The station also expects to require an interim antenna to avoid notable service disruptions. See Exhibit 1.

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  
Ownership Owned
Owner  
Site  
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model DHD-15P1
Year 2002
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 15 kw
Other Transmitter Type  

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Description of Use  
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model UAXTE-12R44
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 7.2 kw
Other Transmitter Type  
Justification for New Transmitter Current primary air-cooled solid state transmitter has been classified by manufacturer as unable to be re-tuned to new UHF channel. Price includes new exciters and mask filter. See Exhibit 1.

Primary Transmitter

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Other Transmitter Costs

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

Primary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use  
Change Type Purchase
Manufacturer
Model Maxiva UAXTE-12R44
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 7.2 kw
Other Transmitter Type  
Justification for New Transmitter Because the catalog doesn't list a 7-8 kW air-cooled solid state transmitter, a GatesAir quote has been provided. See Exhibit 1.

Interim Transmitter

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Other Transmitter Costs

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

Interim Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

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 Top-mount single
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: 80.00 kW
Manufacturer
Model TFU-25J
Year 1985

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? No
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 Type Class Full Power
Mounting Top-mount single
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: 55.30 kW
Manufacturer
Model TFU-12JTH/VP-R 04
Year 2017
Justification for New Antenna Existing antenna is unable to be re-tuned to new repacked channel. See Exhibit 1.

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? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 6 1/8 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
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

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Other Antenna Cost Not Listed

Information not provided.

Interim Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Interim
Description of Use N/A
Change Type Purchase New
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 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/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 55.30 kW
Manufacturer
Model TLP32A
Year 2017
Justification for New Antenna Interim antenna is necessary to avoid loss of broadcast service during transition to new (repacked) channel. See Exhibit 1.

Interim 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

Interim 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 Waveguide
Diameter
Segment Length N/A
Other Segment Length 11.95 feet
Number of parallel runs 1
Length 1250 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 Rigid
Diameter 6 1/8 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 1200 feet per run
Justification for New Transmission Line Current transmission line could not be used due to frequency change. See Exhibit 1.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Interim Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Rigid
Diameter 6 1/8 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 1100 feet per run
Justification for New Transmission Line Additional transmission line needed for interim facility to facilitate smooth transition to new channel. See Exhibit 1.

Interim 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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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? No
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1025694
Coordinates (NAD83) Latitude (NAD83) 45° 41' 59.0" N-
Longitude (NAD83) 095° 10' 36.0" W-
Overall Structure Height 1191.91 feet
Support Structure Height 1139.75 feet
Ground Elevation Above Mean Sea Level (AMSL) 1356.94 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner KSAX-TV, INC.
Date Constructed 09/01/1987


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: 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? 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 Yes
Quantity 1
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 Yes
Quantity 1
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

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Other Professional Services Expenses Not Listed

Name Description

Coverage Verification, Interim Antenna

Coverage verification (field study) for interim antenna operations. See Exhibit 1.

Internal Staff Work

See Exhibit 1.

RF exposure measurements, interim antenna

RF exposure measurements for interim antenna operations. See Exhibit 1.

Outside Legal Analysis and Advice

Analysis and guidance provided by outside legal counsel with respect to repacking deadlines and other FCC requirements. See Exhibit 2 (Jan 2018).

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 Yes
FCC Special Temporary Authority Application Yes
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

Transmitter control

Remote control needed to comply with FCC requirements for main studio control of transmitters.

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 $642,124.78 $638,624.78 N/A $0.00 N/A
Total for all systems $2,173,470.78 $2,031,667.82 N/A $25,194.05 N/A
Interim Transmitter Maxiva UAXTE-12R44 $392,812.39 $389,312.39 $0.00
UHF inside RF system including switching $143,500.00 $140,000.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 7.2 kW $249,312.39 $249,312.39 See Exhibit 1 (and including estimated state sales tax). $0.00 N/A
Primary Transmitter UAXTE-12R44 $249,312.39 $249,312.39 $0.00
UHF - Air Cooled Solid State Transmitter 7.2 kW $249,312.39 $249,312.39 See Exhibit 1 (and including estimated state sales tax). N/A N/A

Components

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 $380,270.00 $315,140.54 N/A $0.00 N/A
Total for all systems $2,173,470.78 $2,031,667.82 N/A $25,194.05 N/A
Interim Antenna TLP32A $121,220.00 $91,377.54 $0.00
UHF - Lower Power Side Mount, One station antenna - medium power (50-200 kW), horizontally polarized $87,000.00 $67,500.54 N/A N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $22,550.00 $14,977.00 N/A N/A N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,120.00 $2,500.00 N/A N/A N/A
Primary Antenna TFU-12JTH/VP-R 04 $259,050.00 $223,763.00 $0.00
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,000.00 $9,183.00 N/A N/A N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized $240,500.00 $208,180.00 N/A N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 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 $453,100.00 $380,271.00 N/A $0.00 N/A
Total for all systems $2,173,470.78 $2,031,667.82 N/A $25,194.05 N/A
Interim Transmission Line $216,700.00 $177,998.00 $0.00
Rigid Transmission Line - copper, 6 1/8" $216,700.00 $177,998.00 N/A N/A N/A
Primary Transmission Line $236,400.00 $202,273.00 $0.00
Rigid Transmission Line - copper, 6 1/8" $236,400.00 $202,273.00 N/A 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 $384,100.00 $375,000.00 N/A $0.00 N/A
Total for all systems $2,173,470.78 $2,031,667.82 N/A $25,194.05 N/A
Primary Tower TOWER $384,100.00 $375,000.00 $0.00
Tall Tower (greater than 500') $205,000.00 $200,000.00 N/A N/A N/A
Minor tower reinforcement/modifications $153,500.00 $150,000.00 N/A N/A N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $25,600.00 $25,000.00 N/A N/A N/A

Components

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 $250,072.00 $259,090.50 N/A $25,194.05 N/A
Total for all systems $2,173,470.78 $2,031,667.82 N/A $25,194.05 N/A
Outside Professional Services $250,072.00 $259,090.50 $25,194.05
Internal Staff Work $20,674.00 $20,674.00 See Exhibit 1. $4,027.55 Although subtotal is not greater than approved estimates, additional explanation is provided in Exhibit 2 and 2a. Exhibit 2a links travel expenses with the correct Internal Labor Invoice (355841).
Outside Legal Analysis and Advice $118.00 $118.00 These costs were incurred in obtaining advice from outside counsel regarding the FCC requirements other than the Form 2100 or reimbursement, including periodic progress reports, repacking deadlines and other FCC requirements. See Exhibit 2. $118.00 See Exhibit 2.
RF exposure measurements, interim antenna $20,000.00 $20,000.00 See Exhibit 1. N/A N/A
Coverage Verification, Interim Antenna $80,000.00 $80,000.00 See Exhibit 1. N/A N/A
RF Exposure Measurements $20,500.00 $20,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $81,900.00 $80,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,585.00 $3,500.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,305.00 $2,250.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $6,956.25 See Exhibit 2. Unexpected additional costs resulted from necessary changes in repacked facility and post-filing follow-up with the FCC to address issues in online database. $6,956.25 See Exhibit 2. Necessary changes included revisions to initial repacked facility as well as follow-up regarding appearance of application in FCC system, among other matters.
Prepare request for Special Temporary Authorization $1,535.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $1,500.00 N/A $0.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A $500.00 N/A
Prepare and or review reimbursement form $2,560.00 $12,592.25 See Exhibit 2 (January 2018). $12,592.25 See Exhibit 2. Costs included significant revisions to reimbursement form due to changes in repacked facility design and responding to FCC requests (and changing contact information).
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A $1,000.00 N/A

Components

Actual Information Description File Name
Internal Staff Work

Component Description:
Including pay stubs from an entity that is commonly owned with the licensee KSAX-TV, Inc.
Amount:
$1,098.12

Component Description:
Cannot delete cost component section. Please disregard.
Amount:
N/A

Component Description:
Including pay stubs from an entity that is commonly owned with the licensee of KSAX-TV, Inc.
Amount:
$1,777.57

Component Description:
This material document summarizes costs, as reimbursed by licensee parent, for travel expenses for trip to KSAX antenna site. Supporting documentation for all expenses reimbursed is also attached. See also Exhibit 2a per staff request.
Amount:
$222.91

Component Description:
Including pay stubs from an entity that is commonly owned with the licensee of KSAX-TV, Inc.
Amount:
$923.95

Component Description:
Copy and document expenses for blueprint creation and transmission for new KSAX facility.
Amount:
$5.00
Outside Legal Analysis and Advice

Component Description:
Fee for attorney work regarding FCC repacking requirements, including transition progress reports
Amount:
$118.00
RF exposure measurements, interim antenna Information not provided.
Coverage Verification, Interim Antenna Information not provided.
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Portion of invoice (as appropriately allocated on invoice) relevant to construction permit work.
Amount:
$447.00

Component Description:
Portion of invoice (as appropriately allocated and marked on invoice) relevant to construction permit work.
Amount:
$513.50

Component Description:
Portion of invoice relevant to construction permit work.
Amount:
$1,356.25

Component Description:
Portion of invoice (including allocations as marked on invoice) relevant to construction permit work.
Amount:
$4,639.50
Prepare request for Special Temporary Authorization Information not provided.
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

Component Description:
Portion allocable to relevant line item. The selected attachment has requested detail. Please ignore other versions of Invoice 240733.
Amount:
$500.00
Prepare and or review reimbursement form

Component Description:
Portion of invoice relevant to preparation of reimbursement request
Amount:
$7,757.50

Component Description:
Portion of invoice relevant to review and preparation of reimbursement information, including responses to FCC requests.
Amount:
$4,338.00

Component Description:
Portion of invoice relevant to preparation of reimbursement forms
Amount:
$244.25

Component Description:
Portion of invoice relevant to preparation and review of reimbursement forms, including responding to further FCC requests.
Amount:
$252.50
Perform engineering study for new channel assignment and antenna development

Component Description:
Portion allocable to relevant line item. The selected attachment also has requested detail. Please ignore other versions of Invoice 240733.
Amount:
$1,000.00

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 $63,804.00 $63,541.00 N/A $0.00 N/A
Total for all systems $2,173,470.78 $2,031,667.82 N/A $25,194.05 N/A
Other Expenses $63,804.00 $63,541.00 $0.00
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $333.00 $325.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $7,146.00 $7,146.00 See Exhibit 1. N/A N/A
Equipment Delivery and Handling Charges $35,200.00 $35,200.00 See Exhibit 1. N/A N/A
Develop and air announcement of upcoming channel change $4,100.00 $4,100.00 See Exhibit 1. N/A N/A
Transmitter control $4,580.00 $4,580.00 See Exhibit 1. N/A N/A
MVPD Notification of Channel Change $1,000.00 $1,000.00 See Exhibit 1. 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 $2,173,470.78 $2,031,667.82 $25,194.05

Construction Status

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Question Response
Is construction complete? 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.

David A. Jones

Vice President


10/04/2018

Certification

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Section Question Response
Submission of Actual Cost Documentation 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 and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material.

  2. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  3. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).

  4. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  5. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

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

  7. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

David A. Jones

Vice President


10/04/2018

Attachments

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