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:
0000027507
FRN:
0025026022
Facility ID:
66170
Repack Channel:
14 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
11/21/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

KTIV License, LLC

Doing Business As: KTIV License, LLC

Brady Dreasler

PO Box 909

Quincy, IL 62306

United States

+1 (217) 223-5100 bdreasler@quincymedia.com Limited Liability Company

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

Tony zumMallen

QCommunications

Tony zumMallen

705B SE Melody LN #314

Lees Summit, MO 64063

United States

+1 (816) 729-1177 tony@qcom1.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. Yes
Briefly describe transition plan The transition from channel 41 to channel 14 requires shared interim systems with KMEG and KPTH through a combiner. KTIV will require a new antenna, line and transmitter to complete the transition.

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 PowerCD
Year 2006
Type Inductive Output Tube
IOT Power Type Two
Description  
Power capacity 60 kw
Solid State Cooling  
Solid State Power Capacity  
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? Yes
Manufacturer
Model ULXTE-100
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 56.7 kw
Other Transmitter Type  
Justification for New Transmitter IOT Transmitter is not tunable per the manufacturer. Special Case- Channel 14 requirements. Per engineering consultant new TPO required is 56.7kw.

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 2 inches
Length 500.0 feet
Other Electrical Service No
Description  
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 25 tons
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? Yes
Is a channel 14 Mask Filer needed? Yes
Is additional field engineering time needed? Yes
Number of Days 10

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Site Survey - TX

Site survey and report are required to be performed before the new transmitter and components installation plan can be finalized.

Sales Tax - Non Exempt -IA

KTIV is not tax exempt from Iowa Sales tax -Gates calculates

Channel 14 remediation

After working with the NAB and our consulting engineer a LM remediation budget needs to be added to cover these estimated costs of operating in CH 14.

Freight - MFG

Freight- from MFG to staging area or station

Disconnect existing Transmitter

Disconnect transmitter and components from existing configuration and move within building to make way for new facilities.

Transmitter Site Preparation

Site prep for installation of the interim and main transmitters and RF components not part of Installation SOW.

Transmitter - Training

Transmitter training - offsite - 1 week in duration at mfg site.

RF Accessories-other

RF Accessories on Gates Q-62047 for transmitters not captured on existing line items

Securirty - Site

This site requires security once the new transmission line and equipment arrive on site to be installed. Estimated length of 4-6 weeks.

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use  
Change Type Purchase
Manufacturer
Model ULXTE-30
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 20 kw
Other Transmitter Type  
Justification for New Transmitter Interim facility is required to avoid prolonged period of station silence during transition, and station currently has no aux facility to use for interim operation. Extended silent period during transition to new channel is unreasonable.

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) Yes
Transformer (480V) No
Power
Rigid Conduit and Wiring Yes
Size 2 inches
Length 500.0 feet
Other Electrical Service No
Description  
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 25 tons
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? No
Is a channel 14 Mask Filer needed? No
Is additional field engineering time needed? No
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

Name Description

Sales Tax est

IA sales tax est per mfg

Transmitter Site Preparation

Site prep for installation of the interim and main transmitters and RF components not part of Installation SOW.

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? Yes
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: 873.00 kW
Manufacturer
Model TFU-30JTH-R-04
Year 2006

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Type Class Full Power
Mounting Top-mount single
Antenna position in stack Not in Stack
Polarization Elliptical
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 24
Lower Limit 470.00 MHz
Upper Limit 698.00 MHz
Design power capacity in use 100.0 %
Other Antenna Type N/A
ERP: 873.00 kW
Manufacturer
Model TFU-24GTH
Year 2017
Justification for New Antenna Required to operate on the new channel assignment. Ch14 special case. FAA height restrictions.

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? Broadband
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

Name Description

FREIGHT EQUIPMENT

FREIGHT FOR THE ANTENNA AND LINE FROM MFG TO STORAGE OR STAGING AREA.

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? Yes
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Type Class Full Power
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Broadband Slot
Number of Stations Supported 3
Number of Panels/Bays 24
Lower Limit 470.00 MHz
Upper Limit 698.00 MHz
Design power capacity in use 50.0 %
Other Antenna Type N/A
ERP: 300.00 kW
Manufacturer
Model TFU-24WB-1-R
Year 2017
Justification for New Antenna Interim facility is required to avoid prolonged period of station silence during transition, and station currently has no aux facility to use for interim operation. Shared with KPTH and KMEG. Paid from the KPTH deal.

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? Yes
Type New
Number of channels supported 3
Frequencies of channels supported RF channel
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? No
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Broadband
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

Enter a list of RF channel numbers.

RF Channel Number
30
32
14

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 Rigid
Diameter 7 3/16 inches
Segment Length 19 ½ '
Other Segment Length
Number of parallel runs 1
Length 2298 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 7 3/16 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 2140 feet per run
Justification for New Transmission Line Required to make the channel assignment relocation from CH41 to CH14

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Disconnect existing Interior RF components

Disconnect interior RF transmission line and filters from existing configuration and move within the building to make way for new facilities.

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 Leased
Is this tower consider Complex? Candelabra
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 1057963
Coordinates (NAD83) Latitude (NAD83) 42° 35' 12.0" N-
Longitude (NAD83) 096° 13' 19.0" W-
Overall Structure Height 1987.84 feet
Support Structure Height 1847.09 feet
Ground Elevation Above Mean Sea Level (AMSL) 1332.99 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Heartland Tower Company, L.L.C.
Date Constructed 02/22/2007

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
77451 KPTH DTV
39665 KMEG DTV

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 tower with candelabra
Tower Reinforcements Please select whether tower reinforcements are needed: Major Reinforcements needed

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 1401
Explanation Scope & significance of project (QMI has multiple stations repacked) require outside management services to augment existing internal personnel to assist turnkey management of and ensure timely and safe execution of channel relocation.
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 4
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 4
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements No
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

General Repack Legal Services

See attached memo-QMI Repack Invoice Memo for Shared Legal Expenses (Matter 104411 00054) for Form 399

Quarterly reporting

Preparation and submittal of the FCC required quarterly report 387 by PM and attorney.

Vendor Travel Expenses

Reimbursable Vendor Travel expenses for working in the field on behalf of the station for the Repack project - see quote for estimated expenses.

Plumbing work for TX cooling systems

New TX Interim and Main required new plumbing systems to be installed

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? Yes
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

SITE SAFETY AND CLEARING PREP

CLEAR THE CONTROLLED AREA AROUND THE TOWER OF BRUSH AND APPLY INSECTICIDE TO PREVENT ACCIDENTS AND PROMOTE A SAFE SITE AND MINIMIZING RISK.

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 $3,998,146.98 $3,975,667.72 N/A $2,013,569.96 N/A
Total for all systems $6,451,813.59 $6,378,042.33 N/A $2,649,052.48 N/A
Interim Transmitter ULXTE-30 $995,487.90 $972,537.90 $416,416.42
Transmitter Site Preparation $5,000.00 $5,000.00 Site prep for installation of the interim and main transmitters and RF components not part of Installation SOW. $5,000.00 N/A
Sales Tax est $41,737.90 $41,737.90 as determined by GatesAir in the invoice $13,912.64 N/A
UHF inside RF system including switching $143,500.00 $140,000.00 N/A $21,843.62 N/A
25 Ton system $89,100.00 $87,000.00 N/A N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $13,000.00 $12,500.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW $666,000.00 $650,000.00 N/A $372,328.50 N/A
Switchgear - industrial 800 amp $37,150.00 $36,300.00 N/A $3,331.66 N/A
Primary Transmitter ULXTE-100 $3,002,659.08 $3,003,129.82 $1,597,153.54
Sales Tax - Non Exempt -IA $133,564.18 $133,564.18 KTIV is not exempt from IOWA state sales tax. Gates calculates sales tax for invoices. see Q62047 and INV TE10004376 $101,177.09 N/A
Securirty - Site $17,500.00 $17,500.00 This site requires security once the new transmission line and equipment arrive on site to be installed. Estimated length of 4-6 weeks. $15,654.10 N/A
RF Accessories-other $89,324.90 $89,324.90 RF Accessories per GatesAir Q-62047 Items C. RF Accessories. Captures required equipment not identified in existing 399 line items. - USE THE LINE C FROM THE ULXTE -72 QUOTE Q-74824 $89,324.90 N/A
Transmitter - Training $3,300.00 $3,300.00 Transmitter training - offsite - 1 week in duration at mfg site. N/A N/A
Transmitter Site Preparation $10,500.00 $10,500.00 Site prep for installation of the interim and main transmitters and RF components not part of Installation SOW. $10,500.00 N/A
Disconnect existing Transmitter $25,000.00 $25,000.00 Disconnect transmitter and components from existing configuration and move within building to make way for new facilities. N/A N/A
Freight - MFG $17,300.00 $17,300.00 Freight- from MFG to staging area or station $0.00 N/A
Channel 14 remediation $500,000.00 $500,000.00 After consulting further with The NAB and the consulting engineer it has been determined that a land-mobile receivers remediation budget needs to be added to cover these estimated remediation costs of transitioning to CH 14 found in a Land Mobile notice. $10,000.00 N/A
Site Survey - TX $25,000.00 $25,000.00 Site survey and report are required to be performed before the new transmitter and components installation plan can be finalized. $18,500.00 N/A
Additional field engineering time, 10-30 days $61,400.00 $60,000.00 N/A N/A N/A
Channel 14 Mask Filter $184,500.00 $180,000.00 N/A N/A N/A
RF Consulting Engineer $5,120.00 $5,000.00 N/A $0.00 N/A
25 Ton system $89,100.00 $87,000.00 We reviewed the transmitter transition plans and with an additional 25 tons of HVAC installed in the new section of the transmitter room it is estimated that the required environmental conditions to operate the new transmitter config can be obtained. N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $13,000.00 $12,500.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW $1,741,000.00 $1,700,000.00 N/A $1,312,291.83 N/A
Service entrance 3 phase/800 amp/208 volt $14,050.00 $13,700.00 N/A N/A N/A
Switchgear - industrial 800 amp $37,150.00 $83,440.74 PER Q-62047 - THE RF ACCESSORIES QUOTE LINE C IS MORE THAN THE PREDETERMINED SWITCHGEAR EST COST. $0.00 Q-62047 - RF ACCESSORIES - moved to Line Item-RF Accessories-other- Do not know how to remove invoice so we ZEROED the transaction in Switch gear.
Transformer 3 phase/480v - 300 KVA $35,850.00 $40,000.00 GATES EQ QUOTE AND LOCAL ELECTRIC INSTALL AND EQUIPMENT QUOTE $39,705.62 N/A

Components

Actual Information Description File Name
Transmitter Site Preparation

Component Description:
KTIV-PREP-INTERIM - INV-QC18-057
Amount:
$5,000.00
Sales Tax est

Component Description:
KTIV- INTERIM TX - EST sales tax as shown on inv TE10004377-2 and QUOTE - Q-62042 uploaded - added the rounding error 1 cent. 3-8-18
Amount:
$13,912.64
UHF inside RF system including switching

Component Description:
Gates- INT TX - RF - KTIV - Line C
Amount:
$10,921.81

Component Description:
Gates- INT TX - RF - KTIV - Line C - for 2nd inv from Quote - Q-62042 uploaded
Amount:
$10,921.81
25 Ton system Information not provided.
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW

Component Description:
Gates-INT TX - KTIV - 1/3 dep lines A, B and E - see revised INV and Q-62042
Amount:
$186,164.25

Component Description:
Gates-INT TX - KTIV - 2nd payment- LINES lines A, B and E - of quote Q-62042 uploaded- see for details.
Amount:
$186,164.25
Switchgear - industrial 800 amp

Component Description:
Gates - INT TX- KTIV - ELEC line D see Quote Q-62042 -2nd invoice uploaded
Amount:
$1,665.83

Component Description:
Gates - INT TX- KTIV - ELEC line D see inv and quote Q-62042
Amount:
$1,665.83
Sales Tax - Non Exempt -IA

Component Description:
KTIV - GATES - MAIN - SALES TAX AT 7 PERCENT WAS DUE AND PAID.
Amount:
$101,177.09

Component Description:
KTIV-GATES-MAIN-TX-SALES TAX 1ST INV -TE10004376 - -6-13-PER 5-21-RFAS-REMOVED EST TAX
Amount:
N/A

Component Description:
KTIV-GATES-MAIN-TX-SALES TAX 2ND INV -TE10004376-2- 6-13- ZEROED OUT PER RFAS 5-21
Amount:
N/A

Component Description:
Gates - Main Tx - KTIV - INV for Sales tax est see Q-62047. We can true up on final invoice for TX if preferred.
Amount:
$44,521.39
Securirty - Site

Component Description:
KTIV- SECURITY -INV 23976- 111-20 THIS 1 OF 4 INV. 2 AND 3 PAID 4TH UPLOADED 11-20
Amount:
$6,779.52

Component Description:
KTIV-SECURITY-5/31-6/9 ON SITE INV23792
Amount:
$2,942.50

Component Description:
KTIV- LAST OF 4 INVOICES FOR SITE SECURITY KTIV-KMEG KPTH
Amount:
$1,412.40

Component Description:
KTIV-SECURITY-6/10-6/23-ON SITE-INV-23878
Amount:
$4,519.68
RF Accessories-other

Component Description:
KTIV- GATES MAIN - 3RD INV TE10004376-3 LINE C UPGRADE ONLY - ROUNDING DOWN ERROR OF 1 CENT FOR LINE C DUE TO ONE THIRD CALCULATION
Amount:
$29,774.96

Component Description:
KTIV-Gates-INV TE10004376-2- LINE C. RF Accessories per Q-62047 - 2nd 1/3 payment OF -72
Amount:
$29,774.97

Component Description:
KTIV-GATES-RF ACCESS-INV TE10004376 - LINE C - RESUBMITTED 7-27
Amount:
$29,774.97
Transmitter - Training Information not provided.
Transmitter Site Preparation

Component Description:
KTIV-PREP- MAIN- INV- QC18-057
Amount:
$10,500.00
Disconnect existing Transmitter Information not provided.
Freight - MFG

Component Description:
7-26-18 - ELIMINATING THE EST TAX FOR THIS SUBMITTAL.
Amount:
N/A
Channel 14 remediation

Component Description:
KTIV-RF NOTIF - LAND MOBILE INV 1005
Amount:
$5,000.00

Component Description:
KTIV- RF NOTIF - LAND MOBILE - INV 1015
Amount:
$5,000.00
Site Survey - TX

Component Description:
KTIV - SURVEY - INV-QC18-025
Amount:
$18,500.00
Additional field engineering time, 10-30 days Information not provided.
Channel 14 Mask Filter Information not provided.
RF Consulting Engineer Information not provided.
25 Ton system Information not provided.
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW

Component Description:
KTIV- GATES MAIN- 3RD INV- SEE MATRIX - LINE A AND B- UPGRADE ONLY
Amount:
$416,916.32

Component Description:
KTIV-GATES-MAIN TX -1ST- INVOICE TE10004376-per Q-62047 lines A, B and E RESUBMITTED 7-27
Amount:
$447,687.75

Component Description:
MAIN TX DEPOSIT INVOICE KTIV per Q-62047 lines A, B and E
Amount:
$603,873.41

Component Description:
KTIV-GATES-MAIN TX -2ND- INVOICE TE10004376-2 per Q-62047 lines A, B and E- PER 7-20-18 RFAS- ROUNDED UP 1 CENT.
Amount:
$447,687.76
Service entrance 3 phase/800 amp/208 volt Information not provided.
Switchgear - industrial 800 amp

Component Description:
KTIV-Gates- MAIN TX 1ST INV TE10004376-- RF - Q-62047 line C.- 6-13 ZEROED OUT AND MOVED TO RF COMP LINE ITEM
Amount:
N/A

Component Description:
Gates- MAIN TX - RF KTIV - Q-62047 line C.
Amount:
$27,813.58

Component Description:
KTIV-Gates- MAIN TX - RF - Q-62047 line C. 5-1 - ZEROED out and added to Line Item - RF Accessories-other
Amount:
N/A
Transformer 3 phase/480v - 300 KVA

Component Description:
KTIV - GATES MAIN - LINE D ELECTRIC - OPEN PER QUOTE
Amount:
$4,069.74

Component Description:
KTIV- Gates- Main Tx -Q-62047 - Line D - FOR -72 COST
Amount:
$4,332.94

Component Description:
Gates- Main Tx - KTIV - Q-62047 - Line D
Amount:
$4,332.94

Component Description:
KTIV- Gates- Main Tx -Q-62047 - INV TE10004376-Line D RESUBMITTED 7-27
Amount:
$4,332.94

Component Description:
KTIV-SCHRAMM-ELEC- TRANSFORMER-INV2739
Amount:
$26,970.00

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 $426,200.00 $419,100.00 N/A $139,799.28 N/A
Total for all systems $6,451,813.59 $6,378,042.33 N/A $2,649,052.48 N/A
Interim Antenna TFU-24WB-1-R $99,850.00 $99,700.00 $2,141.56
New combiner, cost per channel (without antenna) $80,000.00 $80,000.00 each station requires a combiner to make the interim shared line and antenna work. N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A $0.00 N/A
UHF - High Power, Side Mount, basic slot antenna, 24 bay,, 300 kW input, directional,, elliptically or circularly polarized $0.00 $0.00 Cost of antenna is included in the KPTH deal. Shared with KTIV, KPTH and KMEG. N/A N/A
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed) $13,300.00 $13,300.00 This cost will be shared with KPTH and KTIV, and KPTH is purchasing this equipment. $2,141.56 N/A
Primary Antenna TFU-24GTH $326,350.00 $319,400.00 $137,657.72
FREIGHT EQUIPMENT $25,000.00 $25,000.00 FREIGHT FOR ANTENNA AND LINE FOR THE INTERIM AND MAIN NEW SYSTEM FROM MFG TO STORAGE OR STAGING AREA. $11,378.83 N/A
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed) $13,300.00 $13,000.00 N/A $9,000.45 N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $281,500.00 $275,000.00 N/A $111,518.44 N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A $5,760.00 N/A

Components

Actual Information Description File Name
New combiner, cost per channel (without antenna) Information not provided.
Sweep test of existing antenna Information not provided.
UHF - High Power, Side Mount, basic slot antenna, 24 bay,, 300 kW input, directional,, elliptically or circularly polarized Information not provided.
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
KTIV- INTERIM ANT LINE REDUCER CONNECTION - PART PLUS FREIGHT - NOT QUOTED.
Amount:
$2,141.56
FREIGHT EQUIPMENT

Component Description:
KTIV-MAIN ANT - FREIGHT- INV-162009
Amount:
$11,378.83
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
KTIV-DIE-ELBOW - 2ND 45% - LINE 4. 3-29-uploaded Order Conf. 402001 - Line 26 is V-POL upgrade not billed to FCC
Amount:
$4,835.70

Component Description:
ELBOW - DEPOSIT 10% - LINE 4
Amount:
$925.50

Component Description:
ELBOW - 35% - LINE 4.
Amount:
$3,239.25
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized

Component Description:
MAIN ANTENNA - DEPOSIT 10%LINES 1,2 AND 3.
Amount:
$24,781.88

Component Description:
MAIN-ANTENNA-35% 11/1- LINES 1,2 AND 3.
Amount:
$86,736.56

Component Description:
KTIV-DIE-MAIN-2ND 45PERCENT - INV MAN00247 LINES 1,2 AND 3. 3-29-Uploaded Order Conf - 40200. V-POL upgrade is line not billed to FCC.
Amount:
$111,518.44
Sweep test of existing antenna

Component Description:
MAIN ANTENNA SWEEP- 35%-LINE 25.
Amount:
$2,240.00

Component Description:
KTIV-MAIN SWEEP- 2ND 45%-LINE 25. MAN00247
Amount:
$2,880.00

Component Description:
MAIN ANTENNA - SWEEP TEST - DEPOSIT 10% -LINE 25
Amount:
$640.00

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 $620,620.00 $605,640.00 N/A $210,382.65 N/A
Total for all systems $6,451,813.59 $6,378,042.33 N/A $2,649,052.48 N/A
Primary Transmission Line $620,620.00 $605,640.00 $210,382.65
Rigid Transmission Line - copper, 7 3/16" $605,620.00 $590,640.00 N/A $210,382.65 N/A
Disconnect existing Interior RF components $15,000.00 $15,000.00 Disconnect interior RF transmission line and filters from existing configuration and move within the building to make way for new facilities. N/A N/A

Components

Actual Information Description File Name
Rigid Transmission Line - copper, 7 3/16"

Component Description:
MAIN-TX LINE-10% LINE 5.
Amount:
$46,751.70

Component Description:
TX LINE - MAIN - 35% -11/1 LINE 5.
Amount:
$163,630.95

Component Description:
KTIV-DIE-ANT LINE - 2ND 45% INV MAN00247 - LINES 5,30 AND 31
Amount:
$213,570.34
Disconnect existing Interior RF 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 $838,450.00 $819,000.00 N/A $53,917.30 N/A
Total for all systems $6,451,813.59 $6,378,042.33 N/A $2,649,052.48 N/A
Primary Tower TOWER $838,450.00 $819,000.00 $53,917.30
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $409,500.00 $400,000.00 N/A $53,917.30 N/A
Structural engineering tower load study for a documented tower with candelabra $19,450.00 $19,000.00 N/A $0.00 N/A
Major tower reinforcement/modifications $409,500.00 $400,000.00 N/A N/A N/A

Components

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

Component Description:
KTIV-TOWER CREW ARRIVAL 5-2-18- AT SITE INV. 7241
Amount:
$53,917.30
Structural engineering tower load study for a documented tower with candelabra Information not provided.
Major tower reinforcement/modifications 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 $455,168.61 $446,519.61 N/A $217,956.49 N/A
Total for all systems $6,451,813.59 $6,378,042.33 N/A $2,649,052.48 N/A
Outside Professional Services $455,168.61 $446,519.61 $217,956.49
Plumbing work for TX cooling systems $33,384.00 $33,384.00 KTIV- Plumbing for cooling systems fro new transmitters both Interim and Main. per local contractor Quote attached to inv. $9,850.00 N/A
Vendor Travel Expenses $21,965.00 $21,965.00 Reimbursable Vendor Travel expenses for working in the field on behalf of the station for the Repack project - see quote for estimated expenses. Q-17002 $2,418.61 4-2-uploaded revised invoice, QC17-144 with correct airfare.
Quarterly reporting $5,000.00 $5,000.00 Preparation and submittal of the FCC required quarterly report 387 by PM and attorney. N/A N/A
General Repack Legal Services $10,000.00 $10,000.00 See attached memo-QMI Repack Invoice Memo for Shared Legal Expenses (Matter 104411 00054) for Form 399- $9,173.77 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 $14,340.00 $14,000.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,095.00 $4,000.00 N/A $1,895.00 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 $5,000.00 N/A $4,901.00 N/A
Prepare request for Special Temporary Authorization $6,140.00 $6,000.00 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 N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,560.00 $2,500.00 N/A N/A N/A
Project management of the transition $215,754.00 $210,150.00 N/A $151,447.50 N/A
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A $0.00 NEW CHANNEL 14 ANALYSIS AND CP MOD APPLICATION REQUIRED MORE THAN THE NORMAL AMOUNT OF ATTENTION DUE TO LAND MOBILE INTERFERENCE ISSUES.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A $0.00 N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A N/A N/A
Electric work and materials for Interim and Main $38,270.61 $38,270.61 ***System Notice: Estimate adjusted and locked because line has been superseded.***ELECTRICAL MATERIALS AND WORK FOR BOT INTERIM AND MAIN TRANSFORMER PER SCHRAMM QUOTE AND PO 20224. $38,270.61 N/A

Components

Actual Information Description File Name
Plumbing work for TX cooling systems

Component Description:
KTIV- FOULK - PLUMBING INV 381368 - 2ND INV FOR PROGRESS PAYMENT
Amount:
$3,850.00

Component Description:
KTIV- FOULK - PLUMBING INV 3802866 - PROGRESS PAYMENT
Amount:
$6,000.00
Vendor Travel Expenses

Component Description:
KTIV-QCOMM-PM-Travel expenses INV -QC17-144-QUOTE QC17002 - RFAS DOES NOT AFFECT THIS ITEM
Amount:
$2,418.61
Quarterly reporting Information not provided.
General Repack Legal Services

Component Description:
Brooks General -JUNE 17 -inv-1/7th
Amount:
$266.44

Component Description:
KTIV - BROOKS - APRIL18-INV3952577
Amount:
$330.00

Component Description:
Brooks-General Fee May-17-1/7th
Amount:
$190.85

Component Description:
Brooks-General-July 17 - inv 1/7th
Amount:
$275.00

Component Description:
KTIV - LEGAL fees - FEB18 - INV 3950146 4-16- changed inv date
Amount:
$49.50

Component Description:
Brooks-General- OCT17- inv 1/7th
Amount:
$322.28

Component Description:
Brooks-General - Sept-17-INV 1/7th
Amount:
$80.57

Component Description:
Brooks-General -AUG 17 - inv 1/7th
Amount:
$117.85

Component Description:
KTIV-BROOKS-LEGAL AUG18 - INV 3957117
Amount:
$2,161.50

Component Description:
KTIV- BROOKS - MAR18- INV3951194
Amount:
$148.50

Component Description:
KTIV-BROOKS- JUNE18-INV 3954662
Amount:
$99.00

Component Description:
KTIV- BROOKS - MAY18 - INV 3953757
Amount:
$396.00

Component Description:
KTIV- BROOKS JULY18-LEGAL INV 3955730
Amount:
$1,386.00

Component Description:
KTIV-BROOKS-LEGAL INV 3949052 - JAN18
Amount:
$49.50

Component Description:
Brooks-General-NOV17-inv 1/7th
Amount:
$221.57

Component Description:
KTIV - BROOKS LEGAL SEPT18 - INV 3958277
Amount:
$3,811.50
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 - Negotiation of lease and other matters for shared locations

Component Description:
CH 14 NEW FACILITY SHARED WITH KPTH AND KMEG
Amount:
$1,895.00
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:
Brooks- Legal- KTIV-NOV17-inv
Amount:
$329.00

Component Description:
Brooks-KTIV-NOV17-legal-inv
Amount:
$47.00

Component Description:
ATTY FEES CP - KTIV MAY17
Amount:
$752.00

Component Description:
ATTY FEES - KTIV - JUNE 17 CP
Amount:
$359.00

Component Description:
ATTY - CP SEPT 17 FEES
Amount:
$141.00

Component Description:
ATY FEES MAY 17 CP
Amount:
$453.00

Component Description:
ATTY FEES CP - AUG 17 KTIV
Amount:
$2,820.00
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Project management of the transition

Component Description:
KTIV-QCOMM-PM-INV QC17-144 -MAR THRU AUG17- QTE QC17002-RFAS INFO UPLOADED
Amount:
$24,187.50

Component Description:
KTIV- QCOMM-PM-APRIL-JULY18 -INV QC18-063 PO 19807-20391
Amount:
$78,577.50

Component Description:
KTIV- PM- 1 THRU 3-18 INV QC18-047
Amount:
$25,387.50

Component Description:
KTIV-QCOMM-PM 8-18-17- INV QC18-018
Amount:
$23,295.00
Perform engineering study for new channel assignment and antenna development

Component Description:
CP ALT CH ANALYSIS
Amount:
$5,210.00

Component Description:
ENGR - NEW CHANNEL AND 399
Amount:
$2,850.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
ENGR - CP -
Amount:
$1,885.00
Prepare and or review reimbursement form Information not provided.
Electric work and materials for Interim and Main

Component Description:
KTIV-SCHRAMM-ELEC-INV 2781 6-13-corrected $
Amount:
$21,613.38

Component Description:
KTIV-SCHRAMM ELEC-INV2759
Amount:
$16,657.23

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 $63,278.00 $63,015.00 N/A $13,426.80 N/A
Total for all systems $6,451,813.59 $6,378,042.33 N/A $2,649,052.48 N/A
Other Expenses $63,278.00 $63,015.00 $13,426.80
SITE SAFETY AND CLEARING PREP $3,500.00 $3,500.00 CLEAR THE CONTROLLED AREA AROUND THE TOWER OF BRUSH AND APPLY INSECTICIDE TO PREVENT ACCIDENTS AND PROMOTE A SAFE SITE AND MINIMIZING RISK. $2,006.25 N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 Required FCC notifications. N/A N/A
Develop and air announcement of upcoming channel change $15,000.00 $15,000.00 Required FCC announcements and good will public relations must we upheld. The production airing and disseminating of these announcements are fundamental to our operations. N/A N/A
Equipment Storage $10,000.00 $10,000.00 Expecting multiple staggered equipment deliveries from different vendors and need to store and stage new equipment prior to installation date. Anticipate from 6-24 months of storage time. $0.00 N/A
Equipment Delivery and Handling Charges $8,000.00 $8,000.00 Transport and handling fees from staging area to transmitter site. $6,835.00 N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 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
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A $2,950.00 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $10,000.00 $10,000.00 Rent 40 yard dumpster with multiple pickups. Estimated 6- months on site. Potential hazardous waste management issues. $1,635.55 N/A

Components

Actual Information Description File Name
SITE SAFETY AND CLEARING PREP

Component Description:
KTIV- SITE CLEARING-PEST- JAY LAN - INV NONE GIVEN - USING ACCOUNT NO. 5961
Amount:
$2,006.25
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage

Component Description:
KTIV-Storage inv-part of INV1002
Amount:
$3,600.00
Equipment Delivery and Handling Charges

Component Description:
KTIV- CASEYS DELIVERY OF ADDITIONAL TX LINE FROM STORAGE STAGING FACILITY.
Amount:
$1,200.00

Component Description:
KTIV-BIG S - OFFLOAD TX LINE AND EQUIPMENT FROM DELIVERY TRUCK INV 12
Amount:
$840.00

Component Description:
KTIV- CASEYS- DELIVERY OF EQ FROM STORAGE STAGING FACILITY. INV 1020
Amount:
$2,500.00

Component Description:
KTIV- BARHHART- LIFTING AND SETTING NEW CIF FILTER - PART OF MATERIAL HANDLING OF TX INSTALLATION COVERED UNDER GATES INSTALL. INV 46410
Amount:
$2,295.00
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
DTV Medical Facility Notification

Component Description:
KTIV-RF Notification-inv-1005
Amount:
$5,000.00

Component Description:
KTIV-RF NOTIF- MED - INV 1029
Amount:
$2,950.00
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
KTIV- BIG S DISPOSAL AND MATERIAL HANDLING - INV 8
Amount:
$1,165.00

Component Description:
KTIV-LINDBLOM-ROLLOFF - MAY18 - INV 83469 -11-20-this is standard rate roll-off and no quote available
Amount:
$374.25

Component Description:
KTIV- LINDBLOM - ROLLOFF MAY18 - INV 84872- 11-20 stand roll off price no quote.
Amount:
$96.30

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $6,451,813.59 $6,378,042.33 $2,649,052.48

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.

BRADY DREASLER

CORPORATE DIRECTOR OF ENGINEERING


11/21/2018

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.

BRADY DREASLER

CORPORATE DIRECTOR OF ENGINEERING


11/21/2018

Attachments

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