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:
3661
Service:
DTV
Call Sign:
WTVW
Channel:
22 (UHF)
File Number:
0000028334
FRN:
0004284899
Date Submitted:
08/16/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

MISSION BROADCASTING, INC.

30400 DETROIT ROAD

SUITE 304

WESTLAKE, OH 44145

United States

+1 (440) 526-2227 missionbroadcasting@gmail.com Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Henry Gola

Wiley Rein LLP

1776 K Street, N.W.

Washington, DC 20006

United States

+1 (202) 719-7561 hgola@wileyrein.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 Replace transmitter, antenna and line. Acquire interim antenna and line for continued operation during construction and duration of the assigned phase. Map and analyze tower; design and implement modifications if required. See attached.

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 DCX Millennium
Year 2005
Type Inductive Output Tube
IOT Power Type Single
Power Capacity 30 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 THU9evo-24
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 19 kW
Justification for New Transmitter The manufacturer of the existing IOT transmitter advises that the transmitter cannot be re-tuned to the assigned channel. A new Comark Paragon MSDC IOT transmitter is the basis for a replacement as suggested by the FCC. See attachment.

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) Yes
Transformer (480V) Yes
Power 150 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 100.0 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

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Other Transmitter Cost Not Listed

Name Description

Additional Interior RF System

Interior RF System Existing Transmitter to Interim Transmission line

Transmitter Installation, Commissioning and Proof of Performance

Electrical installation, Commissioning, Drawings, Project Management and Proof of Transmitter Performance

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? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 1000.0 kW
Manufacturer
Model TFU-30DSC T170
Year 2005

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? No
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: 570.0 kW
Manufacturer
Model TFU-29ETT/VP-R 3T170
Year 2018
Justification for New Antenna The existing primary antenna is a single channel slotted coaxial which cannot accommodate the assigned channel.The new antenna is moving from side to top, new line needed for the new main antenna. The existing antenna and line will serve as interim

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 6 1/8 inches inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? 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

Feed Through Complex

Feed Through Complex

Wedding Cake Mounting Adapter

Wedding Cake Mounting Adapter

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 900 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? Yes
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 980 feet per run
Justification for New Transmission Line Antenna moving to top mount. New line needed to feed new top mount antenna.

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 Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
One or more FM, AM or TV radio broadcaster(s) N/A
Others Types of Users N/A
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1027511
Coordinates (NAD83) Latitude (NAD83) 38° 01' 26.8" N-
Longitude (NAD83) 087° 21' 43.3" W-
Overall Structure Height 890.08 feet
Support Structure Height 879.91 feet
Ground Elevation Above Mean Sea Level (AMSL) 476.04 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner American Tower, LLC
Date Constructed 09/01/1982


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: Major 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 283
Explanation Schedule and coordinate multiple vendors, complete progress reports, and update Schedule 399. Station does not have available personnel or personnel trained in project management for such complex projects. Internal accounting and Project management.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations 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 No
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 17
Justification It will be necessary to survey the site, plan the equipment, develop specifications for purchasing, and oversee multiple vendor RF projects. Station does not have available personnel or personnel trained in such services.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed 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 Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
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

Sales Tax

Sales and use tax for goods and services.

Cost Information

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Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $1,000,050.00 $730,750.00 N/A $471,700.00 N/A
Total for all systems $2,587,544.00 $2,168,044.70 N/A $886,193.70 N/A
Primary Transmitter THU9evo-24 $1,000,050.00 $730,750.00 $471,700.00
Transmitter Installation, Commissioning and Proof of Performance $107,100.00 $107,100.00 See Land Communications quote 1048 $53,550.00 N/A
Additional Interior RF System $140,000.00 $140,000.00 N/A N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $5,200.00 $4,900.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $24,300.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW $684,000.00 $418,150.00 See Rohde & Schwarz quote 192428.0 attached; total cost $729,100 less upgrade ($310,950) $418,150.00 N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A N/A N/A

Components

Actual Information Description File Name
Transmitter Installation, Commissioning and Proof of Performance

Component Description:
Transmitter installation and electrical, installment #1
Amount:
$53,550.00
Additional Interior RF System Information not provided.
3" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Transformer 3 phase/480v - 150 KVA Information not provided.
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW

Component Description:
Transmitter, installment #2
Amount:
$313,612.50

Component Description:
Transmitter, installment #1
Amount:
$104,537.50
Switchgear - industrial 800 amp Information not provided.

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $347,755.00 $284,498.00 N/A $250,288.20 N/A
Total for all systems $2,587,544.00 $2,168,044.70 N/A $886,193.70 N/A
Primary Antenna TFU-29ETT/VP-R 3T170 $347,755.00 $284,498.00 $250,288.20
Wedding Cake Mounting Adapter $30,825.00 $30,825.00 See Dielectric quote DMS140-4 $27,742.50 N/A
Feed Through Complex $8,400.00 $8,400.00 See Dielectric quote DMS140-4 $7,560.00 N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,300.00 $10,710.00 See Dielectric quote DMS140-4 $9,639.00 N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $289,500.00 $228,163.00 Total cost $258,388 less vpol ($30,225); see Dielectric quote DMS140-4 $205,346.70 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A

Components

Actual Information Description File Name
Wedding Cake Mounting Adapter

Component Description:
Wedding Cake Mounting Adapter, installment #1, line 3 of invoice
Amount:
$13,871.25

Component Description:
Wedding cake mounting adapter, installment #2
Amount:
$13,871.25
Feed Through Complex

Component Description:
Feed through complex, installment #1, line 4 of invoice
Amount:
$3,780.00

Component Description:
Feed through complex, installment #2
Amount:
$3,780.00
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
Elbow complex, installment #1, line 5 of invoice
Amount:
$4,819.50

Component Description:
Elbow complex, installment #2
Amount:
$4,819.50
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized

Component Description:
Antenna, installment #1, line 1 of invoice
Amount:
$102,673.35

Component Description:
Antenna, installment #2
Amount:
$102,673.35
Sweep test of existing antenna Information not provided.

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $197,960.00 $148,806.70 N/A $133,925.50 N/A
Total for all systems $2,587,544.00 $2,168,044.70 N/A $886,193.70 N/A
Primary Transmission Line $197,960.00 $148,806.70 $133,925.50
Rigid Transmission Line - copper, 6 1/8" $197,960.00 $148,806.70 See Dielectric quote DMS140-4 $133,925.50 N/A

Components

Actual Information Description File Name
Rigid Transmission Line - copper, 6 1/8"

Component Description:
Transmission line, installment #1, line 6 of invoice
Amount:
$66,962.75

Component Description:
Transmission line, installment #2
Amount:
$66,962.75

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 $657,800.00 $625,000.00 N/A $2,900.00 N/A
Total for all systems $2,587,544.00 $2,168,044.70 N/A $886,193.70 N/A
Primary Tower GTOWER $657,800.00 $625,000.00 $2,900.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $25,000.00 N/A $2,900.00 N/A
Tall Tower (greater than 500') $210,500.00 $200,000.00 N/A N/A N/A
Major tower reinforcement/modifications $421,000.00 $400,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study

Component Description:
Tower mapping
Amount:
$2,900.00
Tall Tower (greater than 500') 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 $113,634.00 $109,200.00 N/A $25,380.00 N/A
Total for all systems $2,587,544.00 $2,168,044.70 N/A $886,193.70 N/A
Outside Professional Services $113,634.00 $109,200.00 $25,380.00
Additional Field Engineering Service, 17 Days $34,000.00 $34,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 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
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 N/A N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 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 $3,000.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $2,500.00 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
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $7,000.00 N/A
Project management of the transition $44,714.00 $42,450.00 N/A $12,880.00 N/A

Components

Actual Information Description File Name
Additional Field Engineering Service, 17 Days 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 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 Information not provided.
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:
See cover letter item 4 - Prepare engineering section of FCC form 2100, Construction Permit Application services provided by consultant Kessler and Gehman Associates.
Amount:
$3,000.00
Prepare and or review reimbursement form

Component Description:
See cover letter item 2 - Prepare and or review reimbursement form services provided by consultant Kessler and Gehman Associates.
Amount:
$2,500.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
See cover letter item 3 - Perform engineering study for new channel assignment and antenna development provided by consultant Kessler and Gehman Associates.
Amount:
$7,000.00
Project management of the transition

Component Description:
Project management services March 2019
Amount:
$32.50

Component Description:
Project management services April 2019
Amount:
$115.00

Component Description:
Project management services 6.1.19 through 6.28.19
Amount:
$450.00

Component Description:
Project management services February 2019
Amount:
$123.50

Component Description:
Project management services 3.30.19 through 4.26.19
Amount:
$600.00

Component Description:
Project Management for Structural Analysis and Tower Modifications for dates May 26, 2018 through June 29, 2018 including consultants Kessler and Gehman Associates.
Amount:
$450.00

Component Description:
Project Management for Structural Analysis and Tower Modifications. Services from December 1, 2018 through December 31, 2018.
Amount:
$300.00

Component Description:
Project Management for Structural Analysis and Tower Modifications for dates September 29, 2018 through October 26, 2018 including consultants Kessler and Gehman Associates.
Amount:
$375.00

Component Description:
Project management services 3.2.19 through 3.29.19
Amount:
$225.00

Component Description:
Project management services 2.1.19 through 3.1.19
Amount:
$1,800.00

Component Description:
See lines 1, 5-8 on cover letter - Project Management for Structural Analysis and Tower Modifications services and reporting preparation including services from consultants Kessler and Gehman Associates.
Amount:
$4,309.00

Component Description:
Project Management for Structural Analysis and Tower Modifications for dates January 1, 2019 through January 31, 2019 including consultants Kessler and Gehman Associates.
Amount:
$825.00

Component Description:
Project Management for Structural Analysis and Tower Modifications. Services from July 28, 2018 through September 28, 2018.
Amount:
$75.00

Component Description:
Project Management for Structural Analysis and Tower Modifications for dates October 27, 2018 through November 30, 2018 including consultants Kessler and Gehman Associates.
Amount:
$3,200.00

Cost Information

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Other Expenses

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $270,345.00 $269,790.00 N/A $2,000.00 N/A
Total for all systems $2,587,544.00 $2,168,044.70 N/A $886,193.70 N/A
Other Expenses $270,345.00 $269,790.00 $2,000.00
Sales Tax $149,600.00 $149,600.00 Sales and use tax for good and services based on IN state rates. N/A N/A
Equipment Storage $16,000.00 $16,000.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
Non-zoning permits $40,000.00 $40,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $16,000.00 $16,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $30,000.00 $30,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $3,500.00 $3,500.00 Costs to develop and produce spots and crawls for viewer notification. N/A N/A
MVPD Notification of Channel Change $3,500.00 $3,500.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $2,000.00 N/A

Components

Actual Information Description File Name
Sales Tax Information not provided.
Equipment Storage Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
Non-zoning permits Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
MVPD Notification of Channel Change Information not provided.
DTV Medical Facility Notification

Component Description:
Notification of medical facilities
Amount:
$2,000.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $2,587,544.00 $2,168,044.70 $886,193.70

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.

Dennis P. Thatcher

President


08/16/2019

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.

Dennis P. Thatcher

President


08/16/2019

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