TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
WVAH LICENSEE, LLC Doing Business As: WVAH LICENSEE, LLC	Lisa Asher 2000 W. 41ST. STREET BALTIMORE, MD 21211 United States	+1 (410) 662-9688	LAsher@cunninghambroadcasting.com	Limited Liability Company

Applicant

Address

Phone

Applicant Type

WVAH LICENSEE, LLC

Doing Business As: WVAH LICENSEE, LLC

Lisa Asher

2000 W. 41ST. STREET

BALTIMORE, MD 21211

United States

+1 (410) 662-9688

LAsher@cunninghambroadcasting.com

Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant	Address	Phone	Email
[Confidential]

Preparer Contact Information

Preparer Contact Name and Information

Applicant	Address	Phone	Email
Paul A. Cicelski , Esq . Lerman Senter PLLC	Paul A. Cicelski, Esq. 2001 L Street NW Suite 400 Washington, DC 20036 United States	+1 (202) 416-6756	pcicelski@lermansenter.com

Applicant

Address

Phone

Paul A. Cicelski , Esq .

Lerman Senter PLLC

Paul A. Cicelski, Esq.

2001 L Street NW

Suite 400

Washington, DC 20036

United States

+1 (202) 416-6756

pcicelski@lermansenter.com

Broadcaster Information and Transition Plan

Question	Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information.	Yes
Briefly describe transition plan	See Exhibit A.

Transmitters

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

Primary Transmitter

Existing Transmitter Information

Section	Question	Response
Existing Transmitter Description	Type of change	Purchase New
	Use	Primary (Main)
	Description of Use	N/A
	Ownership	Owned
	Owner	N/A
	Site	N/A
	Is this transmitter currently shared with another station?	No
	Is this transmitter currently in operating condition?	Yes
Existing Transmitter Manufacturer and Type	Manufacturer
	Model	Quantum QXV2
	Year	2002
	Type	Inductive Output Tube
	IOT Power Type	Two
	Power Capacity	60 kW

Primary Transmitter

New Transmitter Costs

Section	Question	Response
New Transmitter	Use	Primary (Main)
	Change Type	Purchase New
	Is this a request for upgraded equipment?	Yes
	Manufacturer
	Model	THU9evo-36
	Transmitter Type	Solid State
	Solid State Cooling	Liquid Cooled
	Solid State Power capacity	55 kW
	Justification for New Transmitter	Per the manufacturer, the current transmitter cannot be retuned. See Exhibit B.

Primary Transmitter

Other Transmitter Costs

Section	Question	Response
Electrical Service	Service Entrance (3 phases 800A 208V)	No
	Switchgear (industrial 800 amp)	Yes
	Transformer (480V)	Yes
	Power	300 kVA
	Rigid Conduit and Wiring	Yes
	Size	2 inches
	Length	800.0 feet
	Other Electrical Service	No
	Description	N/A
HVAC Service	Does the replacement transmitter require HVAC Service?	No
	Type	N/A
	Size	N/A
	Other Size	N/A
Transmitter Building Addition/Modification or Leasehold Improvement	Does the Transmitter Building require an addition, modification, other leashold improvement?	No
	Size	N/A
Channel 14 Costs	Is an RF Consulting Engineer needed?	N/A
	Is a channel 14 Mask Filer needed?	N/A
	Is additional field engineering time needed?	N/A
	Number of Days	N/A

Primary Transmitter

Other Transmitter Cost Not Listed

Information not provided.

Antennas

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

Primary Antenna

Existing Antenna Information

Section	Question	Response
Existing Antenna Description	Type of change	Retune Existing
	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?	Yes
	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	Top Mount
	Antenna position in stack	Bottom
	Polarization	Horizontal
	Type	Broadband Panel
	Number of Stations Supported	2
	Number of Panels	50
	Design power capacity in use	100.0 %
	Lower Limit	503.00 MHz
	Upper Limit	635.00 MHz
	Other Antenna Type	N/A
	ERP:	475.0 kW
	Manufacturer	DIELECTRIC
	Model	TUC-O5-10/50H-1-B
	Year	2003

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID	Call Sign
71280	WCHS-TV

Primary Antenna

Adjustment to Existing Antenna

Section	Question	Response
Sweep Test of Existing Antenna	Do you need a sweep test of existing antenna?	Yes

Primary Antenna

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	2
	Frequencies of channels supported	RF channel
	Frequency	N/A

Enter a list of RF channel numbers.

RF Channel Number
29
24

Primary Antenna

Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Primary Transmission Line

Existing Transmission Line

Section	Question	Response
Existing Transmission Line Description	Type of change	Utilize Existing
	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?	Yes
	Is Transmission Line in operating condition?	Yes
Existing Transmission Line Manufacturer and Type	Manufacturer	Dielectric
	Type	Rigid
	Diameter	8 3/16 inches
	Other Diameter	N/A
	Segment Length	Broadband
	Other Segment Length	N/A
	Number of parallel runs	1
	Length	1570 feet per run

Facility ID's and Call Signs of all stations with whom the transmission line is shared.

Facility ID	Call Sign
71280	WCHS-TV

Primary Transmission Line

Other Transmission Line Expenses Not Listed

Information not provided.

Tower Equipment And Rigging Costs

Section	Question	Response
Tower Equipment or Rigging Costs Changes	Do you have tower equipment or rigging costs changes?	No

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	Yes
	Number of Hours	400
	Explanation	Outside consulting engineering, legal work, and accounting services, as well as project management for regional and comprehensive repack execution.
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	2
	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	2
	NEPA Section 106 environmental review	No
	Environmental Assessment	No
	ASR Modification	Yes
	FAA Consultation (including preparation of FAA Form 7460)	Yes
	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

Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

Section	Question	Response
AM Pattern Disturbance	Is an Impact Study needed?	No
AM Pattern Disturbance	Is Remediation needed?	No
Facility Expenses	Name	N/A
	Other Distributed Transmission System Expenses Not listed	N/A
	Name	N/A
	Is Notification of a Medical Facility required as a result of DTV broadcasting?	Yes
Permit and Filing Costs	Local Zoning	No
	Non-zoning permits	No
	BLM or NFS Coordination	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

Other Expenses Not Listed

Information not provided.

Cost Information

Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$1,883,800.00	$1,182,322.50	N/A	$272,755.62	N/A
Total for all systems	$2,797,686.00	$2,053,603.50	N/A	$296,097.84	N/A
Primary Transmitter THU9evo-36	$1,883,800.00	$1,182,322.50		$272,755.62
2" Rigid Conduit and Wiring (Cost per foot)	$20,800.00	$20,000.00	N/A	N/A	N/A
Transformer 3 phase/480v - 300 KVA	$36,800.00	$35,000.00	N/A	N/A	N/A
Switchgear - industrial 800 amp	$38,200.00	$36,300.00	N/A	N/A	N/A
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW	$1,788,000.00	$1,091,022.50	N/A	$272,755.62	N/A

Components

Actual Information Description	File Name
2" Rigid Conduit and Wiring (Cost per foot)	Information not provided.
Transformer 3 phase/480v - 300 KVA	Information not provided.
Switchgear - industrial 800 amp	Information not provided.
UHF - Liquid Cooled Solid State Transmitter 52 - 61 kW	Component Description: Transmitter cost, 25% down. #9500094443 Amount: $272,755.62

Cost Information

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	$637,930.00	$606,400.00	N/A	$0.00	N/A
Total for all systems	$2,797,686.00	$2,053,603.50	N/A	$296,097.84	N/A
Primary Antenna TUC-O5-10/50H-1-B	$637,930.00	$606,400.00		$0.00
New combiner, cost per channel (without antenna)	$84,200.00	$80,000.00	N/A	N/A	N/A
Sweep test of existing antenna	$6,730.00	$6,400.00	N/A	N/A	N/A
UHF - High Power Top Mount (200-1000 kW), Two Station broadband panel antenna, horizontally polarized	$547,000.00	$520,000.00	N/A	N/A	N/A

Components

Information not provided.

Cost Information

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	$0.00	$0.00	N/A	$0.00	N/A
Total for all systems	$2,797,686.00	$2,053,603.50	N/A	$296,097.84	N/A
Primary Transmission Line	$0.00	$0.00		$0.00

Components

Information not provided.

Cost Information

Tower Equipment and Rigging Costs

Information not provided.

Cost Information

Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$192,260.00	$181,750.00	N/A	$23,342.22	N/A
Total for all systems	$2,797,686.00	$2,053,603.50	N/A	$296,097.84	N/A
Outside Professional Services	$192,260.00	$181,750.00		$23,342.22
Project management of the transition	$63,200.00	$60,000.00	N/A	$17,425.01	N/A
Comprehensive coverage verification via field study, if needed	$84,200.00	$80,000.00	N/A	N/A	N/A
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase	$2,105.00	$2,000.00	N/A	N/A	N/A
ASR modification (prepare FCC Form 854)	$2,105.00	$2,000.00	N/A	N/A	N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization	$7,360.00	$7,000.00	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	$5,000.00	N/A	$221.92	N/A
Prepare request for Special Temporary Authorization	$4,100.00	$3,000.00	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,580.00	$1,500.00	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$3,155.00	$3,000.00	N/A	$1,642.50	N/A
Perform engineering study for new channel assignment and antenna development	$7,360.00	$7,000.00	N/A	$1,605.00	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
Prepare and or review reimbursement form	$2,630.00	$2,500.00	N/A	$2,447.79	N/A
Attorney Fees - Negotiation of lease and other matters for shared locations	$4,210.00	$4,000.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Project management of the transition	Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #463567 Amount: $566.48 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. Amount: $836.44 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1055 Amount: $243.38 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1063 Amount: $262.29 Component Description: Legal services cost. #460954 Amount: $310.00 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1123 Amount: $342.14 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1114 Amount: $242.25 Component Description: Portion of general repack matter invoice attributable to this station - divided by 99 stations. #468718 Amount: $349.51 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1117 Amount: $282.68 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1111 Amount: $159.58 Component Description: Portion of general repack matter invoice attributable to this station - divided by 99 stations. #469573 Amount: $377.14 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1105 Amount: $216.88 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #470923 Amount: $406.65 Component Description: Legal services cost. #470267 Amount: $292.50 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1093 Amount: $265.72 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1099 Amount: $266.93 Component Description: Legal services cost. #471567 Amount: $221.25 Component Description: Legal services cost. #472621 Amount: $157.50 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1130 Amount: $281.49 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1098 Amount: $238.07 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1090 Amount: $176.70 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #464321 Amount: $683.07 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1072 Amount: $237.64 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #467378 Amount: $576.96 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #467861 Amount: $470.30 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. Amount: $30.47 Component Description: Legal services cost. #464345 Amount: $57.50 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #463026 Amount: $801.57 Component Description: Legal Service Cost. #467911 Amount: $112.50 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. Amount: $86.88 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. Amount: $43.71 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1058 Amount: $187.24 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. Amount: $185.10 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. Amount: $20.64 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1078 Amount: $215.68 Component Description: Legal Service Cost. #465221 Amount: $177.50 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #466690 Amount: $446.87 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. Amount: $32.35 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #465173 Amount: $654.26 Component Description: Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1090 Amount: $176.70 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. #461289 Amount: $91.50 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. Amount: $999.04 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. Amount: $818.59 Component Description: Legal services cost. #461823 Amount: $133.60 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. Amount: $716.28 Component Description: Legal services cost. #464687 Amount: $120.00 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #465001 Amount: $596.30 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. Amount: $20.91 Component Description: Legal services cost. #457861 Amount: $571.40 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #461759 Amount: $29.98 Component Description: Portion of general repack matter invoice attributable to this station - divided by 99 stations. #1086 Amount: $275.35 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. Amount: $943.95 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1069 Amount: $246.68 Component Description: Legal Service Cost. #466736 Amount: $62.50 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. Amount: $105.97 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1079 Amount: $177.14
Comprehensive coverage verification via field study, if needed	Information not provided.
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase	Information not provided.
ASR modification (prepare FCC Form 854)	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 general repack matter invoice attributable to this station - divided by 93 stations. #461289 Amount: $122.00 Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #461759 Amount: $99.92
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: Consulting engineering cost. Amount: $1,642.50
Perform engineering study for new channel assignment and antenna development	Component Description: Consulting engineering cost. Amount: $1,605.00
Address transition timing and coordination issues w/ other stations and wireless	Information not provided.
Prepare and or review reimbursement form	Component Description: Portion of general repack matter invoice attributable to this station - divided by 98 stations. #461759 Amount: $869.30 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. Amount: $152.01 Component Description: Portion of general repack matter invoice attributable to this station - divided by 93 stations. #461289 Amount: $1,311.48 Component Description: Legal services cost. Amount: $115.00
Attorney Fees - Negotiation of lease and other matters for shared locations	Information not provided.

Cost Information

Other Expenses

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$83,696.00	$83,131.00	N/A	$0.00	N/A
Total for all systems	$2,797,686.00	$2,053,603.50	N/A	$296,097.84	N/A
Other Expenses	$83,696.00	$83,131.00		$0.00
MVPD Notification of Channel Change	$5,000.00	$5,000.00	See Exhibit J.	N/A	N/A
Develop and air announcement of upcoming channel change	$28,050.00	$28,050.00	See Response to August 22 Inquiry.	N/A	N/A
Equipment Delivery and Handling Charges	$10,000.00	$10,000.00	See Exhibit J.	N/A	N/A
Disposal Costs (for equipment and other waste, net of any salvage value)	$28,566.00	$28,566.00	See Response to August 22 Inquiry.	N/A	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	$335.00	$325.00	N/A	N/A	N/A
DTV Medical Facility Notification	$11,550.00	$11,000.00	N/A	N/A	N/A

Components

Information not provided.

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$2,797,686.00	$2,053,603.50	$296,097.84

Reimbursement Status

Question	Response
The facility has ceased operating on its pre-auction channel.	No
Construction of final facilities or all necessary modifications are complete.	No
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator.	No

Certification

Section	Question	Response
Submission of Actual Cost Documentation Statements	WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).
The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) . The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Lisa Asher Secretary 07/08/2019

Section

Question

Response

Submission of Actual Cost Documentation Statements

WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).

The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.
The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.
The above-named entity acknowledges that all certifications and attached documentation are considered material representations.
The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.
The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .
The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.
The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.
The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.
The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.

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

Lisa Asher

Secretary

07/08/2019

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

Applicant Information

Applicant Name, Type, and Contact Information

Reimbursement Contact Information

Reimbursement Contact Name and Information

Preparer Contact Information

Preparer Contact Name and Information

Broadcaster Information and Transition Plan

Transmitters

Primary Transmitter

Existing Transmitter Information

Primary Transmitter

New Transmitter Costs

Primary Transmitter

Other Transmitter Costs

Primary Transmitter

Other Transmitter Cost Not Listed

Antennas

Primary Antenna

Existing Antenna Information

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Primary Antenna

Adjustment to Existing Antenna

Primary Antenna

Other Antenna Costs

Enter a list of RF channel numbers.

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Primary Transmission Line

Existing Transmission Line

Facility ID's and Call Signs of all stations with whom the transmission line is shared.

Primary Transmission Line

Other Transmission Line Expenses Not Listed

Tower Equipment And Rigging Costs

Outside Professional Services Costs

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Other Expenses

Other Expenses

Other Expenses Not Listed

Cost Information

Transmitters

Components

Cost Information

Antennas

Components

Cost Information

Transmission Line

Components

Cost Information

Tower Equipment and Rigging Costs

Cost Information

Outside Professional Services

Components

Cost Information

Other Expenses

Components

Cost Information

Grand Total

Reimbursement Status

Certification

Attachments