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:
35277
Service:
DTV
Call Sign:
KNSD
Channel:
40 (UHF)
File Number:
0000028291
FRN:
0003593860
Date Submitted:
05/31/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

STATION VENTURE OPERATIONS, LP

Margaret L. Tobey

C/O NBCUNIVERSAL

300 NEW JERSEY AVENUE, N.W., SUITE 700

WASHINGTON, DC 20001

United States

+1 (202) 524-6401 MARGARET.TOBEY@NBCUNI.COM Limited Partnership

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

Margaret L Tobey

NBCUniversal, LLC

300 New Jersey Ave. NW

Suite 700

Washington, DC 20001

United States

+1 (202) 524-6401 Margaret.Tobey@nbcuni.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan Install new antenna in place of existing analog antenna and new transmitter for new channel. The old transmitter and antenna will remain in place for interim use until the cut-over.

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 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 CTT--U-DXCP-2
Year 2012
Type Inductive Output Tube
IOT Power Type Two
Power Capacity 53 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? Yes
Manufacturer
Model THU9-8
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 13.0 kW
Justification for New Transmitter Attached quote to retune DXCP-2 transmitter shows cost exceeds cost of new solid state transmitter Existing transmitter has 400% headroom. Solid state replacement is one level higher than that required to provide FCC allocated ERP.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service Yes
Description Electrical Design, Labor, Materials, and Equipment for transmitter room
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

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Other Transmitter Cost Not Listed

Name Description

Transmitter Installation

Installation of Transmitter

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? Yes
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 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: 370.0 kW
Manufacturer
Model ALP16M4-HSPX-40
Year 2017

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 Types Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Elliptical
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: 225.0 kW
Manufacturer
Model TFU-16ETT/VP-R C180
Year 2017
Justification for New Antenna Installation of new top mount antenna in location occupied by old analog antenna will allow use of existing pre-auction antenna during repack work and avoids cost for installation of an interim antenna, transmission line, and additional tower upgrades.

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 4 1/16 inches inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

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 6 1/8 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 171 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 4 1/16 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 185 feet per run
Justification for New Transmission Line Existing line is wrong segment length. Existing line will be required to maintain operation on existing channel during repack.

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 Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 32° 41' 48.2" N-
Longitude (NAD83) 116° 56' 09.1" W-
Overall Structure Height 187.00 feet
Support Structure Height 129.60 feet
Ground Elevation Above Mean Sea Level (AMSL) 2641.00 feet
Structure Type LTOWER - Lattice Tower
Tower Owner American Tower
Date Constructed 01/01/1977


Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 1200
Explanation Project oversight of transmitter install, electrical connectivity, tower work, and antenna installation. Additional time will be spent tracking financial and legal process and coordinating with other broadcasters.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development No
Prepare engineering section of Form FCC Construction Permit Application No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare engineering section of Form FCC License to Cover Application No
For Auxiliary Facility N/A
For Main Facility N/A
Prepare request for Special Temporary Authority No
Quantity N/A
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
NEPA Section 106 environmental review No
Environmental Assessment Yes
ASR Modification Yes
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 Yes
Additional Field Engineering Service Yes
Number of Days 20
Justification Ground Level RF System Design

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Site Coordination Meeting

Site Coordination Meeting

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 Yes
Non-zoning permits Yes
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)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? No
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

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 $633,931.00 $482,892.75 N/A $97,022.95 N/A
Total for all systems $1,656,641.05 $1,256,026.60 N/A $603,751.33 N/A
Primary Transmitter THU9-8 $633,931.00 $482,892.75 $97,022.95
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW $494,500.00 $343,461.75 Cost for transmitter, plus 7.75% tax added. N/A N/A
Other Electrical Service: Electrical Design, Labor, Materials, and Equipment for transmitter room $62,531.00 $62,531.00 N/A $39,962.95 N/A
Transmitter Installation $76,900.00 $76,900.00 See lines 3 & 4 of Electron Dynamics quote, plus charge for Electron Dynamics second visit quote $57,060.00 N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW Information not provided.
Other Electrical Service: Electrical Design, Labor, Materials, and Equipment for transmitter room

Component Description:
Electrical Design and Labor
Amount:
$39,962.95
Transmitter Installation

Component Description:
See lines 3 and 4 of invoice
Amount:
$38,040.00

Component Description:
See lines 3 and 4 of invoice
Amount:
$19,020.00

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 $305,800.00 $183,302.50 N/A $164,972.25 N/A
Total for all systems $1,656,641.05 $1,256,026.60 N/A $603,751.33 N/A
Primary Antenna TFU-16ETT/VP-R C180 $305,800.00 $183,302.50 $164,972.25
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed) $9,570.00 $8,055.00 N/A $7,249.50 N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $289,500.00 $165,247.50 See attached proposal, line 1. Vertical Polarization costs of $15,900 have been subtracted from the above estimate. $148,722.75 N/A
Sweep test of existing antenna $6,730.00 $10,000.00 Includes testing, commissioning, and supervision of antenna/line install. See Electron Dynamics quote $9,000.00 N/A

Components

Actual Information Description File Name
Elbow complex, single channel, at antenna input, per 4 1/16. feedline (if needed)

Component Description:
See line 3 of invoice
Amount:
$3,624.75

Component Description:
See line 3 of invoice.
Amount:
$3,624.75
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized

Component Description:
See line 1 of invoice. See attached "explanation of variance" for line 2
Amount:
$74,361.37

Component Description:
See line 1 of invoice. See attached "explanation of variance" for line 2.
Amount:
$74,361.38
Sweep test of existing antenna

Component Description:
See line 1 of invoice
Amount:
$6,000.00

Component Description:
See line 1 of invoice
Amount:
$3,000.00

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 $26,270.00 $30,806.30 N/A $27,725.68 N/A
Total for all systems $1,656,641.05 $1,256,026.60 N/A $603,751.33 N/A
Primary Transmission Line $26,270.00 $30,806.30 $27,725.68
Rigid Transmission Line - copper, 4 1/16" $26,270.00 $30,806.30 Price includes hangers, based on quote from Dielectric (attached) $27,725.68 N/A

Components

Actual Information Description File Name
Rigid Transmission Line - copper, 4 1/16"

Component Description:
See lines 4, 8, 9 of invoice
Amount:
$13,862.84

Component Description:
See lines 4, 8, 9 of invoice.
Amount:
$13,862.84

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 $268,500.00 $145,660.00 N/A $96,210.00 N/A
Total for all systems $1,656,641.05 $1,256,026.60 N/A $603,751.33 N/A
Primary Tower LTOWER $268,500.00 $145,660.00 $96,210.00
Short Tower (less than 500') $84,200.00 $88,900.00 Includes tower charge in WIS budget worksheet. Plus supervision, testing, and commissioning in Electron Dynamics Quote. $39,450.00 N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $16,435.00 See first line of proposal "KNSD ATC PO Request" $16,435.00 N/A
Minor tower reinforcement/modifications $158,000.00 $40,325.00 N/A $40,325.00 N/A

Components

Actual Information Description File Name
Short Tower (less than 500')

Component Description:
Tower equipment and rigging, see attachment "KNSD Repack budget worksheet WIS" for supporting documentation
Amount:
$39,450.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study

Component Description:
Tower mapping
Amount:
$16,435.00
Minor tower reinforcement/modifications

Component Description:
Broadcast Structural
Amount:
$10,475.00

Component Description:
See budget worksheet for breakdown of costs for this project. This corresponds to minor tower reinforcement/modifications
Amount:
$29,850.00

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 $349,570.00 $348,605.00 N/A $200,810.40 N/A
Total for all systems $1,656,641.05 $1,256,026.60 N/A $603,751.33 N/A
Outside Professional Services $349,570.00 $348,605.00 $200,810.40
Site Coordination Meeting $5,000.00 $5,000.00 See budget worksheet attached to invoice $5,000.00 N/A
Additional Field Engineering Service, 20 Days $20,000.00 $20,000.00 N/A $5,000.39 N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $91,855.00 Estimated cost if higher than predetermined cost. See quote attached to invoice to see how vendor came to the total cost for the field study $91,855.00 N/A
Project management of the transition $189,600.00 $180,000.00 $24480.00 / American Tower $250 Anthony Flores Other - undocumented $97,225.39 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $1,313.82 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $5,000.00 Cost quoted by ATC N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $415.80 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 - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 N/A N/A N/A
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet $10,520.00 $17,500.00 Migratory bird assessment per ATC quote N/A N/A
ASR modification (prepare FCC Form 854) $2,105.00 $500.00 N/A N/A N/A
RF Exposure Measurements $21,050.00 $15,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Site Coordination Meeting

Component Description:
See budget worksheet for breakdown of costs for this project.
Amount:
$5,000.00
Additional Field Engineering Service, 20 Days

Component Description:
Repack Site Survey at transmitter site. See attached site survey report and purchase order for supporting documentation.
Amount:
$5,000.39
Comprehensive coverage verification via field study, if needed

Component Description:
Attached is both the quote and invoice for the field measurements at the KNSD site.
Amount:
$91,855.00
Project management of the transition

Component Description:
Point B Project Management Invoice
Amount:
$893.28

Component Description:
Attached invoice for project management.
Amount:
$9,900.00

Component Description:
Coordination with ATC on structural modification and antenna replacement plan and schedule
Amount:
$324.90

Component Description:
Coordination with ATC on structural modification and antenna replacement plan and schedule. Permitting review and conference calls. Tower elevation verification.
Amount:
$95.00

Component Description:
Point B Project Management Jan 2019
Amount:
$3,300.00

Component Description:
Repack and structural assesment project management - April-June 2017
Amount:
$475.00

Component Description:
Project Management Services
Amount:
$3,965.00

Component Description:
Coordination with ATC on structural modification and antenna replacement plan and schedule. Permitting review and conference calls
Amount:
$124.45

Component Description:
Project Management over permitting
Amount:
$9,400.00

Component Description:
Project Management Services
Amount:
$3,600.00

Component Description:
Project Management Services
Amount:
$2,470.00

Component Description:
Project Management Services
Amount:
$2,405.00

Component Description:
Coordination with ATC on structural modification and antenna replacement plan and schedule
Amount:
$524.40

Component Description:
July 2018 Project Management
Amount:
$3,890.00

Component Description:
This is for project management services from point B for the month of February. See line item.
Amount:
$4,950.00

Component Description:
Coordination with ATC on structural modification and antenna replacement plan and schedule
Amount:
$124.45

Component Description:
August 2018 Project Management
Amount:
$8,170.00

Component Description:
Project Management Services
Amount:
$348.95

Component Description:
Project Management Services
Amount:
$7,800.00

Component Description:
Project Management Services
Amount:
$1,072.50

Component Description:
Project Management Services
Amount:
$975.00

Component Description:
Project Management services, see attached receipts for travel expenses
Amount:
$6,867.46

Component Description:
June 2018 Project Management
Amount:
$4,460.00

Component Description:
Coordination with ATC on structural modification and antenna replacement plan and schedule. Permitting review and conference calls.
Amount:
$190.00

Component Description:
Jan 2018 Project Management
Amount:
$9,750.00

Component Description:
See budget worksheet for breakdown of costs for this project.
Amount:
$5,000.00

Component Description:
April 2018 Project Management
Amount:
$6,150.00
Prepare and or review reimbursement form

Component Description:
Review of Form 399.
Amount:
$43.65

Component Description:
See lines 3-5 on invoice, with 10% discount included.
Amount:
$310.86

Component Description:
Review and compilation of Form 399
Amount:
$915.66

Component Description:
Review of Form 399
Amount:
$43.65
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
See lines 1-2 on invoice, including 10% vendor discount.
Amount:
$226.80

Component Description:
Preparation of minor change application
Amount:
$189.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet Information not provided.
ASR modification (prepare FCC Form 854) Information not provided.
RF Exposure Measurements Information not provided.

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 $72,570.05 $64,760.05 N/A $17,010.05 N/A
Total for all systems $1,656,641.05 $1,256,026.60 N/A $603,751.33 N/A
Other Expenses $72,570.05 $64,760.05 $17,010.05
MVPD Notification of Channel Change $10,000.00 $10,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $0.00 $0.00 N/A $0.00 N/A
Equipment Delivery and Handling Charges $20,000.00 $20,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $20,785.05 $20,785.05 Disposal of old transmission line, antenna, and transmitter; cost to rent on-site dumpster $17,010.05 N/A
Non-zoning permits $5,200.00 $5,200.00 N/A N/A N/A
Local Zoning $4,700.00 $4,700.00 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 $3,750.00 N/A N/A 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.
Equipment Delivery and Handling Charges Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
See line 2 of invoice
Amount:
$10,650.00

Component Description:
On-site dumpster rental
Amount:
$26.25

Component Description:
On-site dumpster rental
Amount:
$1,008.80

Component Description:
See line 2 of invoice
Amount:
$5,325.00
Non-zoning permits Information not provided.
Local Zoning Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
DTV Medical Facility Notification Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,656,641.05 $1,256,026.60 $603,751.33

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.

Margaret L Tobey

Assistant Secretary


05/31/2019

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.

Margaret L Tobey

Assistant Secretary


05/31/2019

Attachments

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