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:
166319
Service:
DTS
Call Sign:
KRBK
Channel:
22 (UHF)
File Number:
0000028042
FRN:
0009961889
Date Submitted:
03/08/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

Nexstar Broadcasting, Inc.

Doing Business As: Nexstar Broadcasting, Inc.

Elizabeth Ryder

545 E. John Carpenter Freeway

Suite 700

Irving, TX 75062

United States

+1 (972) 373-8000 eryder@nexstar.tv 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

Elizabeth Ryder

General Counsel

Nexstar Broadcasting, Inc.

Elizabeth Ryder

545 E. John Carpenter Freeway

Suite 700

Irving, TX 75062

United States

+1 (972) 373-8800 eryder@nexstar.tv

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 We have a DTS system on channel 49 and are being repacked to channel 22. While this plan shows a DTS plan, we are replacing the system with a single-tower DTV system. This is documented outside of the 399.

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 1
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model DXD-PRO3
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 3 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? No
Manufacturer
Model ULXTE-80
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 47.5 kW
Justification for New Transmitter Old transmitter can't be retuned. Also, we are converting from DTS system to standard single-tower DTV system.

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 6 inches
Length 50.0 feet
Other Electrical Service Yes
Description General Hookup expenses
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 tons
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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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 1
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? 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: 92.3 kW
Manufacturer
Model JA/LS-24/49 SHBP-S
Year 2009

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? 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 Middle
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: 1000.0 kW
Manufacturer
Model TFU-28DSC/VP-R W
Year 2018
Justification for New Antenna Old antennas can't be retuned to new frequency. Also, we are converting from DTS to a single tower DTV system.

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 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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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 1
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 821 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
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1950 feet per run
Justification for New Transmission Line Old Line must remain in use during the transition. And, changing from SFN system to DTV single tower system on a tall towerl.

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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Existing Tower

Section Question Response
Existing Tower Description Type of change Move Equipment
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? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1003484
Coordinates (NAD83) Latitude (NAD83) 37° 49' 09.6" N-
Longitude (NAD83) 092° 44' 52.1" W-
Overall Structure Height 897.95 feet
Support Structure Height 890.08 feet
Ground Elevation Above Mean Sea Level (AMSL) 1185.02 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner Crown Castle South LLC
Date Constructed 09/01/1988

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
51094 KJEL FM

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 Move Equipment
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? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1028721
Coordinates (NAD83) Latitude (NAD83) 37° 13' 09.4" N-
Longitude (NAD83) 092° 56' 57.4" W-
Overall Structure Height 1996.04 feet
Support Structure Height 1982.92 feet
Ground Elevation Above Mean Sea Level (AMSL) 1575.11 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner American Towers, LLC.
Date Constructed 01/01/1973

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
28496 KOLR DTV
3659 KOZL-TV DTV

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

Name Description

American Tower

Installation of Feedline and Antenna

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 100
Explanation Installation. Engineering services
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? No
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations No
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study 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

Information not provided.

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 No
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 No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? No
Does this relocation require Equipment Storage? No
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Information not provided.

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 $1,592,650.00 $1,527,649.87 N/A $1,489,714.87 N/A
Total for all systems $3,459,372.25 $3,116,768.24 N/A $2,683,853.37 N/A
Primary Transmitter ULXTE-80 $1,592,650.00 $1,527,649.87 $1,489,714.87
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,473,000.00 $1,435,376.87 Quote from GatesAir; additional parts needed at installation. $1,435,376.87 Sub-total is not greater than the estimated cost.
5 Ton system $20,250.00 $20,785.00 Revised to include 2 5 ton systems as required by transmitter manufacturer. Please see attachment "Revised HVAC Estimate". $20,785.00 Estimate was based on one 5 ton unit but we discovered it is necessary to have 2 5 ton units
Other Electrical Service: General Hookup expenses $5,000.00 $5,000.00 N/A $0.00 N/A
Transformer 3 phase/480v - 300 KVA $36,800.00 $11,488.00 Quote from GatesAir N/A N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $13,700.00 N/A $1,000.00 N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A $32,553.00 N/A
6" Rigid Conduit and Wiring $5,000.00 $5,000.00 N/A N/A N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW

Component Description:
Balance due on transmitter
Amount:
$95,637.82

Component Description:
Transmitter installation and misc installation items.
Amount:
$95,637.82

Component Description:
1/3 down payment for transmitter
Amount:
$455,391.37

Component Description:
Final payment for transmitter.
Amount:
$427,970.34

Component Description:
Credit for duplicate payment for transmitter.
Amount:
($455,391.37)

Component Description:
Second 1/3 payment for transmitter
Amount:
$455,391.37

Component Description:
Second of three payments for transmitter.
Amount:
$455,391.37

Component Description:
Additional parts required for installations.
Amount:
$985.97
5 Ton system

Component Description:
Additional costs incurred for A/C installation and equipment. Includes the cover letter that was requested by the reviewer.
Amount:
$3,325.00

Component Description:
Second payment for air conditioning installation. Includes the cover letter that was requested by the reviewer
Amount:
$8,492.13

Component Description:
Air conditioning for transmitter
Amount:
$8,967.87
Other Electrical Service: General Hookup expenses Information not provided.
Transformer 3 phase/480v - 300 KVA Information not provided.
Service entrance 3 phase/800 amp/208 volt

Component Description:
Electrical equipment required for transmitter installation (purchased second-hand)
Amount:
$1,000.00
Switchgear - industrial 800 amp

Component Description:
Final 3/3 payment for electrical services at transmitter site.
Amount:
$10,851.00

Component Description:
Second 1/3 payment for air conditioning and electric
Amount:
$10,851.00

Component Description:
First 1/3 payment for electrical services at transmitter site.
Amount:
$10,851.00
6" Rigid Conduit and Wiring 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 $470,907.25 $467,861.25 N/A $462,337.50 N/A
Total for all systems $3,459,372.25 $3,116,768.24 N/A $2,683,853.37 N/A
Primary Antenna TFU-28DSC/VP-R W $470,907.25 $467,861.25 $462,337.50
UHF - High Power, Side Mount, basic slot antenna, 1000 kW input, directional,, horizontally polarized $428,727.25 $428,727.25 Quote From Dielectric, antenna and transmission line $423,203.50 Invoice includes antenna, elbow mount, feed line and accessories. These items had a total cost estimate of $491,541.25. This invoice is for the first 34%.
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,300.00 $10,984.00 Quote from Dielectric $10,984.00 N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $21,750.00 quote from Dielectric $21,750.00 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $6,400.00 N/A

Components

Actual Information Description File Name
UHF - High Power, Side Mount, basic slot antenna, 1000 kW input, directional,, horizontally polarized

Component Description:
Antenna, installment #3
Amount:
$109,736.46

Component Description:
First 34% payment (per contract terms) for antenna (non-VPOL), bracket, transmission line, field service.
Amount:
$159,072.83

Component Description:
Second of three payments for antenna, feedline and accessories. V-pole removed.
Amount:
$154,394.21
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
Elbow complex
Amount:
$10,984.00
Side mount brackets for high power antennas (if not included in antenna base cost)

Component Description:
Side mount brackets
Amount:
$21,750.00
Sweep test of existing antenna

Component Description:
Sweep test
Amount:
$6,400.00

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 $393,900.00 $271,473.12 N/A $0.00 N/A
Total for all systems $3,459,372.25 $3,116,768.24 N/A $2,683,853.37 N/A
Primary Transmission Line $393,900.00 $271,473.12 $0.00
Rigid Transmission Line - copper, 6 1/8" $393,900.00 $271,473.12 Quotation from Dielectric $0.00 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 $842,000.00 $686,209.00 N/A $686,208.00 N/A
Total for all systems $3,459,372.25 $3,116,768.24 N/A $2,683,853.37 N/A
Primary Tower GTOWER $631,500.00 $26,796.00 $26,795.00
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $421,000.00 $26,795.00 ***System Notice: Estimate adjusted and locked because line has been superseded.***Quotes attached from American Tower $26,795.00 N/A
Tall Tower (greater than 500') $210,500.00 $1.00 Moving from Crown Castle tower to American listed separately. $1 shown so 399 will work properly. $0.00 N/A
Primary Tower GTOWER $210,500.00 $659,413.00 $659,413.00
Tall Tower (greater than 500') $210,500.00 $659,413.00 See "ATC Cost Estimation" and "Stainless_P18_235517_002.Service.Proposal_KRBK Signed". This includes all required structural modification and rigging work. $659,413.00 N/A

Components

Actual Information Description File Name
Complex Tower (includes, for example, those with candelabras and/or stacked antennas)

Component Description:
Broadcast tower structural study
Amount:
$10,450.00

Component Description:
Broadcast tower mapping
Amount:
$16,345.00
Tall Tower (greater than 500')

Component Description:
N/A
Amount:
N/A
Tall Tower (greater than 500')

Component Description:
Antenna and line installation, balance due on completion.
Amount:
$51,831.50

Component Description:
See corrected invoice 460199825
Amount:
($138,937.50)

Component Description:
First capital contribution for tower structural modification (25%).
Amount:
$138,937.50

Component Description:
Tower work, installment #3
Amount:
$138,937.50

Component Description:
Tower work, installment #1
Amount:
$138,937.50

Component Description:
Tower modification work (second milestone).
Amount:
$277,875.00

Component Description:
Broadcast Structural American Tower Site
Amount:
$10,450.00

Component Description:
50% down payment for tower rigging services
Amount:
$51,831.50

Component Description:
Broadcast Tower Mapping- Fordland Site American Tower
Amount:
$16,345.00

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 $146,030.00 $150,250.00 N/A $41,343.00 N/A
Total for all systems $3,459,372.25 $3,116,768.24 N/A $2,683,853.37 N/A
Outside Professional Services $146,030.00 $150,250.00 $41,343.00
RF Exposure Measurements $21,050.00 $20,000.00 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
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $6,000.00 Based on actual amounts charged by attorneys $5,973.00 Complexities relating to DTS required additional steps/explanation
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 and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
Project management of the transition $15,800.00 $25,500.00 Various engineering services that will not be allocated to other engineering components. $25,370.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $7,000.00 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
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $3,000.00 N/A

Components

Actual Information Description File Name
RF Exposure Measurements 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:
Legal Services: Form 2100
Amount:
$1,005.00

Component Description:
Legal services: prepare 2100
Amount:
$1,587.00

Component Description:
Legal services for Form 399
Amount:
$1,688.50

Component Description:
Advise on reimbursement and Form 399 as it relates to DTS
Amount:
$1,192.50

Component Description:
Legal advice on lease terms and negotiation to ensure transition date is met.
Amount:
$500.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare and or review reimbursement form Information not provided.
Project management of the transition

Component Description:
Project management and engineering services
Amount:
$9,717.50

Component Description:
Various engineering services
Amount:
$15,652.50
Perform engineering study for new channel assignment and antenna development

Component Description:
Perform engineering study for new channel assignment and antenna development
Amount:
$7,000.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Prepare engineering section of Form 2100
Amount:
$3,000.00

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 $13,885.00 $13,325.00 N/A $4,250.00 N/A
Total for all systems $3,459,372.25 $3,116,768.24 N/A $2,683,853.37 N/A
Other Expenses $13,885.00 $13,325.00 $4,250.00
MVPD Notification of Channel Change $1,000.00 $1,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $1,000.00 $1,000.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $4,250.00 N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
DTV Medical Facility Notification

Component Description:
Create and send out notifications to area health care facilities of frequency change.
Amount:
$4,250.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $3,459,372.25 $3,116,768.24 $2,683,853.37

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.

Elizabeth Ryder

General Counsel


03/08/2019

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.

Elizabeth Ryder

General Counsel


03/08/2019

Attachments

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