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:
51241
Service:
DTV
Call Sign:
KALO
Channel:
18 (UHF)
File Number:
0000026151
FRN:
0019041623
Date Submitted:
09/06/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

KALO TV, INC.

Brent Keane

P.O. BOX 1256

HONOLULU, HI 96807

United States

+1 (808) 596-4417 Brent@KALOTV.COM Not-for-Profit

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

Anne Goodwin Crump

FCC Attorney

Fletcher, Heald & Hildreth, P.L.C.

Anne Goodwin Crump

1300 N 17th St.

11th Floor

Arlington, VA 22209

United States

+1 (703) 812-0426 crump@fhhlaw.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. Yes
Briefly describe transition plan Modified plan. KALO will move to nearby site. Will require new electrical and HVAC system, transmitter, and transmission system in existing building. Will share with KKAI the combiner, external transmission line, antenna, and new wooden support pole.

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 DXD-10U
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 2.0 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model TMU-9
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.2 kW
Justification for New Transmitter Existing Pineapple Technology Transmitter unsupported (company out-of-business) and cannot be retuned.

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 Yes
Size 1.5 inches
Length 60.0 feet
Other Electrical Service Yes
Description New service panel, small conduit, and electrical outlets.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 tons
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 150.0 square feet
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

Security and Fencing for Main Transmitter

A 50ft fence is for protection and security for access to the KALO room and associated equipment and is required by the site manager.

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use N/A
Change Type Purchase
Manufacturer
Model ACT-TRN-5X-U-28-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2.2 kW
Justification for New Transmitter Existing Pineapple Transmitter is no longer supported - company is out of business and there are no engineers to retune. This Interim transmitter is required to accommodate channel repack while permanent location undergoes construction and preparation.

Interim Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
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
Inside RF System Is an additional interior RF system required to support this interim transmitter? No

Interim Transmitter

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Other Transmitter Cost Not Listed

Name Description

Interim Transmitter Installation

Includes installation of interim transmitter and removal of existing 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? 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? Yes
Existing Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 2
Number of Panels 8
Design power capacity in use 67.0 %
Lower Limit 470.00 MHz
Upper Limit 800.00 MHz
Other Antenna Type N/A
ERP: 5.0 kW
Manufacturer
Model 955518
Year 2009

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

Facility ID Call Sign
3246 KAAH-TV

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Ownership Owned
Owner N/A
Is antenna shared? Yes
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Full Power
Mounting Side Mount
Antenna position in stack Top
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 2
Number of Panels/Bays 12
Lower Limit 470.00 MHz
Upper Limit 620.00 MHz
Design power capacity in use 4.0 %
Other Antenna Type N/A
ERP: 50.0 kW
Manufacturer
Model JUHD 10/2 (20 panel) Narrow Cardioid
Year 2018
Justification for New Antenna Current antenna is 18 years old, cannot accommodate new channel, and is not retunable. New antenna to be shared by two or more stations.

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? Yes
Type New
Number of channels supported 2
Frequencies of channels supported RF channel
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? No
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Broadband or Single Channel? N/A
Feed Line Size N/A
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? No

Enter a list of RF channel numbers.

RF Channel Number
29
18

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Interim Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Interim
Description of Use N/A
Change Type Purchase New
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Middle
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 4
Lower Limit 494.00 MHz
Upper Limit 500.00 MHz
Design power capacity in use 60.0 %
Other Antenna Type N/A
ERP: 74.0 kW
Manufacturer
Model K723147
Year 2018
Justification for New Antenna Interim antenna required while permanent location undergoes construction and preparation for transition.

Interim Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Broadband or Single Channel? N/A
Feed Line Size N/A
Side Mount Brackets Do you require the separate purchase of side mount brackets for an 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? No

Interim Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? Yes
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Flexible Foam
Diameter 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 105 feet per run

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

Facility ID Call Sign
3246 KAAH-TV

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 Flexible Air
Diameter 3 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 128 feet per run
Justification for New Transmission Line Moving to site shared with KKAI. Costs lower than existing site. Old transmission line is 12 - 14 years old, deteriorated from exposure to weather, can't be bent again, and is too short to reuse.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Interior Transmission Line

Line from KALO-TV transmitter room to KKAI-TV transmitter room combiner. Approximately 60' 1-5/8" hard line.

Interim Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Flexible Air
Diameter 7/8 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 200 feet per run
Justification for New Transmission Line Interim transmission line required while permanent location undergoes construction and preparation.

Interim 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 Construct New
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1218023
Coordinates (NAD83) Latitude (NAD83) 21° 23' 33.6" N-
Longitude (NAD83) 158° 05' 48.1" W-
Overall Structure Height 198.82 feet
Support Structure Height 198.82 feet
Ground Elevation Above Mean Sea Level (AMSL) 2280.48 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Salem Media of Hawaii
Date Constructed 10/03/2000

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID Call Sign Service
81538 KLHT-FM FM
38244 KDDB FM
16745 KQMQ-FM FM
51241 KALO DTV
10950 KAIM-FM FM
36242 KORL-FM FM
3246 KAAH-TV DTV

Primary Tower

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Tower Construction Costs

Section Question Response
Construct New Tower Use Primary (Main)
Description of Use N/A
Is this a request for upgraded equipment? No
Height 100.00 feet
Justification for New Tower Existing pole is termite-ridden and unable to support new mounts and hanging of new transmission line.

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? Yes

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Pole Installation Expenses

Site preparation (clearing, hole drilling, concrete), rigging, shipping

Interim Tower

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Tower Construction Costs

Section Question Response
Construct New Tower Use Interim
Description of Use N/A
Height 198.82 feet
Justification for New Tower KALO-TV will renew lease with Salem Media on their existing tower for the duration of their interim period. The primary transmission location will not be completed in time for the Phase 2 cut over date . KALO-TV IS NOT CONSTRUCTING A NEW INTERIM TOWER.

Interim 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

Interim Tower

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Other Tower Expenses Not Listed

Name Description

Interim Tower Rigging

Cost to install and remove interim equipment. Please see attached OPM Services LLC Quote rev 5 and cover letter for KALO interim site

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 950
Explanation KALO does not have its own engineering staff. Consultants will provide filing, technical installation, and communication with MVPDs for permanent and interim sites. Involves travel from California. Involves new station owner and new shared use agreement.
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 Yes
RF exposure measurements Yes
Additional Field Engineering Service Yes
Number of Days 36
Justification Installation of the transmitter and supporting systems. 2 persons, one local, one traveling. Estimated 8 days for interim site alone.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

File for STL PCN and STL FCC License

Required for interim transmission site to function legally and without loss of market.

RF Upgrade Engineering and FCC Filing

Required for interim transmission site to function legally and without loss of market.

PJ Video Engineering Consulting

Engineering Consulting

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change Yes
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Name Description

ASI-to-IP converter, Dektec DTE-3120

Required to maintain interim transmission site without loss of market

Legal Work

Required to create Shared Use Agreement, assist with leases, utility agreements. New station ownership.

STL transmitter and receiver, SAF or equiv. 7 GHz

Required to maintain interim transmission site without loss of market

TRAVEL - GSA - Per Person Per Trip

Required to bring appropriately trained staff and support to interim transmission site in a timely manner - estimated at $4,750 per person per trip.

Accounting

Additional Accounting Services required as part of repack

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 $395,499.64 $350,667.35 N/A $307,432.64 N/A
Total for all systems $1,819,543.94 $1,987,049.11 N/A $956,482.29 N/A
Interim Transmitter ACT-TRN-5X-U-28-C $138,000.00 $67,802.80 $55,802.80
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $55,802.80 Please see attached OPM Services LLC Quote rev 3 and cover letter for KALO interim site; Justifying Quote 399-#TX-Freight-Quote (shipping) $55,802.80 N/A
Interim Transmitter Installation $12,000.00 $12,000.00 Please see attached OPM Services LLC Quote rev 3 and cover letter for KALO interim site N/A N/A
Primary Transmitter TMU-9 $257,499.64 $282,864.55 $251,629.84
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $138,000.00 OPM to provide quote. $111,315.29 N/A
Other -- Building Addition Size: 150.0 $71,126.54 $71,126.54 Modifying Pre-WWII building to construct transmitter room for KALO at shared primary transmission site. OPM to provide Quote; Justifying Quote - 399-RoomBuild-Quote $71,126.54 invoices
Security and Fencing for Main Transmitter $10,181.70 $10,181.70 Justification Letter - OPM Invoice for Primary Transmitter Site Security and Site Fencing $10,181.70 N/A
5 Ton system $20,250.00 $33,614.91 Redundant split-system, 5 ton. OPM to provide quote; Justifying Quote - KALO 399-HVAC-Quote $33,614.91 N/A
Other Electrical Service: New service panel, small conduit, and electrical outlets. $25,391.40 $25,391.40 Reusing room that had been stripped of electrical system. New 240 VAC single-phase system, breaker panel, conduit, six outlets. Very remote Hawaii location; Justifying Quote - KALO 399-RoomElectrical-Quote $25,391.40 N/A
1.5" Rigid Conduit and Wiring $4,550.00 $4,550.00 Electrical meter and service from main. N/A N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Freight charge to ship Anywave Tx from manufacturer to Hawaii docks
Amount:
$1,522.80

Component Description:
Anywave Transmitter INTERIM SITE - ACT-TRN-5X-U-28-C 2.2KW ACT-EXC-OPT-TSoIP
Amount:
$54,280.00
Interim Transmitter Installation Information not provided.
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
Running approximately 140 feet of conduit and wire
Amount:
$47,889.38

Component Description:
KALO-110-Primary Transmitter
Amount:
$375.00

Component Description:
Pour raised concrete generator pad at KALO permanent site includes tax
Amount:
$6,240.00

Component Description:
20KW 3 Phase diesel generator
Amount:
$56,810.91
Other -- Building Addition Size: 150.0

Component Description:
Replace Gyupsum-ceiling, walls, door, flooring and kick plate
Amount:
$35,185.92

Component Description:
Renovate 2nd floor room in WWII Building
Amount:
$19,359.65

Component Description:
"Outdoor meter, meter sockets, weatherhead, grounding and main breaker Includes local tax"
Amount:
$35,940.62
Security and Fencing for Main Transmitter

Component Description:
KALO-110-Primary Transmitter - Fencing and Security
Amount:
$10,181.70
5 Ton system

Component Description:
Mitsubishi Split Systems (single zone 2EA)
Amount:
$33,614.91
Other Electrical Service: New service panel, small conduit, and electrical outlets.

Component Description:
KALO-110-Primary Transmitter - Other Electrical
Amount:
$25,391.40
1.5" Rigid Conduit and Wiring Information not provided.

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $384,750.00 $371,774.00 N/A $10,774.00 N/A
Total for all systems $1,819,543.94 $1,987,049.11 N/A $956,482.29 N/A
Interim Antenna K723147 $89,400.00 $10,274.00 $10,274.00
UHF - Lower Power Side Mount, One station antenna - medium power (50-200 kW), horizontally polarized $89,400.00 $10,274.00 Used Kathrein antenna - Please see attached OPM Services LLC Quote rev 3 and cover letter for KALO interim site; Justifying quote - 399-#16-02192019-shipping-quote $10,274.00 N/A
UHF – Broadband Panel, Side Mount Auxiliary/Interim, 74 horizontally polarized $0.00 $0.00 PHANTOM ANTENNA, PLEASE IGNORE/DELETE N/A N/A
Primary Antenna JUHD 10/2 (20 panel) Narrow Cardioid $295,350.00 $361,500.00 $500.00
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $29,500.00 KKAI to provide quote. This will be a 50% shared cost plus shipping and install and commissioning. KALO cost will be $14,750.00 plus shipping and install and commissioning N/A N/A
New combiner, cost per channel (without antenna) $84,200.00 $144,000.00 KKAI to provide quote. This will be a 50% shared cost plus shipping and install and commissioning. KALO cost will be $72,000.00 plus shipping and install and commissioning N/A N/A
UHF - High Power, Side Mount, broadband panel, 12 bay,, 50 kW input, directional,, horizontally polarized $188,000.00 $188,000.00 KKAI to provide quote. This will be a 50% shared cost plus shipping and install and commissioning. KALO cost will be $94,000.00 plus shipping and install and commissioning $500.00 N/A

Components

Actual Information Description File Name
UHF - Lower Power Side Mount, One station antenna - medium power (50-200 kW), horizontally polarized

Component Description:
KALO-280-Interim Antenna - Kathrein K723147
Amount:
$8,500.00

Component Description:
Shipping Antenna for Interim Site - delivery to dock and then transport to mountain site
Amount:
$1,774.00
UHF – Broadband Panel, Side Mount Auxiliary/Interim, 74 horizontally polarized Information not provided.
Side mount brackets for high power antennas (if not included in antenna base cost) Information not provided.
New combiner, cost per channel (without antenna) Information not provided.
UHF - High Power, Side Mount, broadband panel, 12 bay,, 50 kW input, directional,, horizontally polarized

Component Description:
KALO-210-New Primary Antenna
Amount:
$500.00

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 $27,872.00 $57,720.00 N/A $5,000.00 N/A
Total for all systems $1,819,543.94 $1,987,049.11 N/A $956,482.29 N/A
Interim Transmission Line $3,600.00 $5,000.00 $5,000.00
Flexible Air Transmission Line - dielectric, 7/8" $3,600.00 $5,000.00 Please see attached OPM Services LLC Quote rev 3 and cover letter for KALO interim site $5,000.00 N/A
Primary Transmission Line $24,272.00 $52,720.00 $0.00
Flexible Air Transmission Line - dielectric, 3" $7,552.00 $36,000.00 KKAI to provide quote. This will be a 50% shared cost plus shipping and install. KALO cost will be $18,000.00 plus shipping and install. N/A N/A
Interior Transmission Line $16,720.00 $16,720.00 Please see attached OPM Quote KALO09211A - 60 feet 1-5/8" EIA line between transmitter and combiner, includes connectors and support. N/A N/A

Components

Actual Information Description File Name
Flexible Air Transmission Line - dielectric, 7/8"

Component Description:
KALO-380-Interim Transmission Line - 7/8" Flexible Air
Amount:
$5,000.00
Flexible Air Transmission Line - dielectric, 3" Information not provided.
Interior Transmission Line Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $424,400.00 $352,900.00 N/A $0.00 N/A
Total for all systems $1,819,543.94 $1,987,049.11 N/A $956,482.29 N/A
Primary Tower TOWER $0.00 $0.00 $0.00
Interim Tower $100,200.00 $31,000.00 $0.00
New tower $0.00 $0.00 KALO-TV will not be constructing a new interim tower. This category is a limitation of LMS. PLEASE IGNORE. N/A N/A
Short Tower (less than 500') $84,200.00 $15,000.00 KALO-TV will extend the lease on their existing tower. They are not constructing a new tower. Please see attached OPM Services LLC Quote rev 5 and cover letter for interim site N/A N/A
Interim Tower Rigging $16,000.00 $16,000.00 Rigging costs for interim equipment on existing tower. Please see attached OPM Services LLC Quote rev 5 and cover letter for interim site N/A N/A
Primary Tower $324,200.00 $321,900.00 $0.00
Pole Installation Expenses $29,000.00 $29,000.00 KKAI to provide quote. This will be a 50% shared cost plus shipping and install. KALO cost will be $14,500.00 plus shipping and install. N/A N/A
Tower Helicopter Lift $23,000.00 $23,000.00 KKAI to provide quote. This will be a 50% shared cost. KALO cost will be $11,500.00. N/A N/A
Short Tower (less than 500') $84,200.00 $81,900.00 KKAI to provide quote. This will be a 50% shared cost plus shipping and install. KALO cost will be $40,950.00 plus shipping and install. N/A N/A
New tower $188,000.00 $188,000.00 KKAI to provide quote. This will be a 50% shared cost plus shipping and install. KALO cost will be $94,000.00 plus shipping and install. N/A N/A

Components

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 $435,521.30 $710,210.16 N/A $579,794.05 N/A
Total for all systems $1,819,543.94 $1,987,049.11 N/A $956,482.29 N/A
Outside Professional Services $435,521.30 $710,210.16 $579,794.05
Project management of the transition $150,100.00 $455,518.86 see Estimated Cost Justification KALO-510-Outside Project Management of the Transition v0 $442,822.75 N/A
PJ Video Engineering Consulting $68,750.00 $68,750.00 Per PJ Video Engineering Contract ($2,500 per month for 24 months); See KALO-510-Outside Project Management of the Transition - PJ Video Engineering Consulting Estimated Cost Justification v.0 $68,750.00
File for STL PCN and STL FCC License $11,251.30 $11,251.30 May be required for interim site. Please see attached OPM Services LLC Quote rev 3 and cover letter for KALO interim site; invoices Starn O'Toole Marcus & Fisher, 53629-FCC Repack $11,251.30 N/A
Additional Field Engineering Service, 36 Days $61,000.00 $61,000.00 Please see attached quote from OPM Services LLC regarding interim transmission site costs. KALO anticipates 8 days of work for interim site alone. KALO has no Operations and Engineering staff. All field services will be performed by third party. $27,150.00 N/A
RF Exposure Measurements $21,050.00 $13,200.00 Please see attached proposal from Smith and Fisher - Power Density Survey of Constructed KALO-DT on Channel 18 N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,200.00 N/A $1,305.00 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $12,000.00 OPM to provide quote for three trips to the location to coordinate with other stations. KALO has no on-site Operations and Engineering staff. N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $8,400.00 OPM to provide quote. Please see Smith and Fisher Proposal for Preparation of the Engineering Portion of the FCC Application for Interim Facility for additional 1,750.00 budget increase; Justifying Invoice - KALO OPM 399-#17-04012019 $8,400.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $5,750.00 Required revision due to shared use agreement and new station ownership. Please see attached proposal from Smith & Fisher for additional $750 budget increase from previously approved amount. N/A N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,200.00 Required revisions due to new ownership and shared use agreement. $1,980.00 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,300.00 N/A $0.00 N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $35,000.00 OPM to provide quote. KALO has no Operations and Engineering staff. All field coverage pre/post signal survey will be performed by third party. N/A N/A
Prepare and or review reimbursement form $2,630.00 $4,050.00 Estimated Cost Justification KALO-550-Reimbursement form v0 $2,295.00 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $15,840.00 KALO-550-Attorney Fees Lease and Other Matters Budget Increase Justification Cover Letter V.3 $15,840.00 N/A
RF Upgrade Engineering and FCC Filing $4,250.00 $4,250.00 Please see attached quote from OPM Services LLC regarding interim transmission site costs. N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Preparation of Interim site for HVAC and electrical
Amount:
$17,587.50

Component Description:
Prepare Tx revised site Rack Elevations, update BOM, dataflow dwg and local site infrastrcutre - both Interim and Final site
Amount:
$17,025.00

Component Description:
Engineering design, oversight and project management
Amount:
$4,500.00

Component Description:
Repack Project meetings
Amount:
$5,062.50

Component Description:
Repacking Monthly hours for soliciting, reviewing and consolidating 399 quotes AND 3rd party invoices
Amount:
$6,262.50

Component Description:
Repacking Monthly hours for soliciting, reviewing and consolidating 399 quotes AND 3rd party invoices
Amount:
$3,900.00

Component Description:
Working with KKAI on tower purchase and install planning
Amount:
$6,262.50

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Please deny this invoice
Amount:
N/A

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Project Management
Amount:
$9,998.60

Component Description:
Project Management
Amount:
$15,702.55

Component Description:
Please deny this invoice
Amount:
N/A

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Please deny this invoice
Amount:
N/A

Component Description:
Please deny this invoice
Amount:
N/A

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
3rd party transportation of transmitter from Hawaii dock to transmitter site- fixed price
Amount:
$16,762.50

Component Description:
Working with KKAI on tower purchase and install planning
Amount:
$5,212.50

Component Description:
Repack Project meetings
Amount:
$4,800.00

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Please deny this invoice
Amount:
N/A

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Working with KKAI on tower purchase and install planning
Amount:
$6,450.00

Component Description:
Project Manage. Oversight, Quality control
Amount:
$2,700.00

Component Description:
Engineering design, oversight and project management
Amount:
$450.00

Component Description:
Project management, oversight, quality control
Amount:
$1,050.00

Component Description:
Working with KKAI on tower purchase and install planning
Amount:
$19,837.50

Component Description:
Project Manage FCC Repacking - local coordination, RF Tx and current and new site coordination and legal coordination
Amount:
$13,500.00

Component Description:
Project Manage FCC Repacking - local coordination, RF Tx and microwave frequenies (STL/TSL) current and new site coordination and legal coordination
Amount:
$14,212.50

Component Description:
Repack Project meetings
Amount:
$3,975.00

Component Description:
Project Management
Amount:
$8,619.35

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Project management
Amount:
$2,404.85

Component Description:
Prepare Tx revised site Rack Elevations, update BOM, dataflow dwg - both Interim and Final site
Amount:
$14,475.00

Component Description:
Project Management
Amount:
$1,024.00

Component Description:
Project Management
Amount:
$3,657.35

Component Description:
Write KALO RF Upgrade report
Amount:
$10,612.50

Component Description:
Project Manage FCC Repacking - local coordination, RF Tx, FCC reports
Amount:
$14,700.00

Component Description:
Project Management
Amount:
$6,955.70

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
KALO-510-Outside Project Management of the Transition - includes Widelity and OPM
Amount:
$450.00

Component Description:
Project Management
Amount:
$4,031.75

Component Description:
KALO-510-Outside Project Management of the Transition - includes Widelity and OPM
Amount:
$3,000.00

Component Description:
Flight to / From Hawaii, Per Diem /Incidentals - GSA, RentalCar
Amount:
$9,075.00

Component Description:
Project Manage FCC Repacking - local coordination, RF Tx and current and new site coordination and legal coordination
Amount:
$10,612.50

Component Description:
Repacking Monthly hours for soliciting, reviewing and consolidating
Amount:
$7,312.50

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Project manage. Oversight, Quality control
Amount:
$2,700.00

Component Description:
Project Management
Amount:
$5,795.30

Component Description:
Project Management
Amount:
$3,830.70

Component Description:
Prepare Tx site Rack Elevations, update BOM, dataflow dwg
Amount:
$26,062.50

Component Description:
Please deny this invoice
Amount:
N/A

Component Description:
KALO-510-Outside Project Management of the Transition - includes Widelity and OPM
Amount:
$750.00

Component Description:
Please deny this invoice.
Amount:
N/A

Component Description:
Working with KKAI on tower purchase and install planning
Amount:
$6,150.00

Component Description:
Prepare Tx revised site Rack Elevations, update BOM, dataflow dwg
Amount:
$25,162.50

Component Description:
"Review, planning, updates, strategy for repacking move of 38, install of 18 and total State coverage via cable/RF"
Amount:
$8,250.00

Component Description:
Review, discussion research move to Racine PJ, Tom, Gary, Anne, Gary, Kevin
Amount:
$6,600.00

Component Description:
Project Management
Amount:
$3,696.80

Component Description:
Created KALO preliminary project budget spreadsheet, researched antenna systems from MCI, conducted transmission site research using online FCC data.
Amount:
$16,360.00

Component Description:
Project Manage FCC Repacking - local coordination, RF Tx and current and new site coordination and legal coordination
Amount:
$8,550.00

Component Description:
Project Manage FCC Repacking - local coordination, RF Tx and microwave frequencies (STL/TSL) current and new site coordination and legal coordination
Amount:
$11,587.50

Component Description:
RentalCar
Amount:
$23,400.00

Component Description:
Project Management
Amount:
$3,717.90

Component Description:
Project Management
Amount:
$18,027.90
PJ Video Engineering Consulting

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consultation for the spectrum repack of KALO-TV in Hawaii
Amount:
$2,500.00

Component Description:
Consultation for the upgrade and spectrum repack of KALO
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consultation for the spectrum repack of KALO-TV in Hawaii
Amount:
$1,250.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consultation for the spectrum repack of KALO-TV in Hawaii
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consultation for the spectrum repack of KALO-TV in Hawaii
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00

Component Description:
Consulting
Amount:
$2,500.00
File for STL PCN and STL FCC License

Component Description:
Legal Services
Amount:
$10,518.84

Component Description:
Legal services
Amount:
$732.46
Additional Field Engineering Service, 36 Days

Component Description:
KALO-530-RF - Additional Engineering Days
Amount:
$9,675.00

Component Description:
KALO-530-RF - Additional Engineering Days
Amount:
$17,475.00
RF Exposure Measurements Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
KALO-550-Attorney Fees STA
Amount:
$315.00

Component Description:
KALO-550-Attorney Fees STA
Amount:
$990.00
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:
KALO-530-RF Eng new channel study
Amount:
$6,525.00

Component Description:
KALO-530-RF Eng new channel study
Amount:
$1,875.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
KALO-550-Attorney fees 2100 CP application
Amount:
$450.00

Component Description:
KALO-550-Attorney fees 2100 CP application
Amount:
$1,530.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Prepare and or review reimbursement form

Component Description:
KALO-550-Reimbursement form
Amount:
$135.00

Component Description:
KALO-550-Reimbursement form
Amount:
$1,125.00

Component Description:
KALO-550-Reimbursement form
Amount:
$450.00

Component Description:
KALO-550-Reimbursement form
Amount:
$450.00

Component Description:
KALO-550-Reimbursement form
Amount:
$135.00

Component Description:
KALO-550-Reimbursement form
Amount:
$1,755.00
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
Legal services
Amount:
$1,125.00

Component Description:
Legal services
Amount:
$585.00

Component Description:
Legal services
Amount:
$1,080.00

Component Description:
Legal services
Amount:
$720.00

Component Description:
Legal services
Amount:
$2,655.00

Component Description:
Professional Services Rendered Re: KALO TV
Amount:
$585.00

Component Description:
Legal services
Amount:
$1,530.00

Component Description:
Legal services
Amount:
$495.00

Component Description:
Legal services
Amount:
$270.00

Component Description:
Legal services
Amount:
$45.00

Component Description:
Legal services
Amount:
$1,215.00

Component Description:
Legal services
Amount:
$5,265.00

Component Description:
Legal Services
Amount:
$270.00
RF Upgrade Engineering and FCC Filing 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 $151,501.00 $143,777.60 N/A $53,481.60 N/A
Total for all systems $1,819,543.94 $1,987,049.11 N/A $956,482.29 N/A
Other Expenses $151,501.00 $143,777.60 $53,481.60
Accounting $6,706.00 $6,706.00 Please see attached justification document for accounting category N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $200.00 FCC filing fee effective September 2018 N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $5,500.00 $5,500.00 Hauling and disposal of used antennas and feedline. $375.00 N/A
STL transmitter and receiver, SAF or equiv. 7 GHz $35,000.00 $35,000.00 May be Required for interim transmission site. Please see attached OPM Services LLC Quote rev 3 and cover letter for KALO interim site N/A N/A
MVPD Notification of Channel Change $300.00 $300.00 2 hours labor. N/A N/A
Develop and air announcement of upcoming channel change $6,000.00 $6,000.00 Please see attached quote # 1030 from PJ Video - Independent producer to be used for the announcements. $540.00 N/A
Equipment Delivery and Handling Charges $4,800.00 $4,800.00 Delivery to storage and to very remote Hawaiian location. N/A N/A
ASI-to-IP converter, Dektec DTE-3120 $2,500.00 $2,500.00 Please see attached OPM Services LLC Quote rev 3 and cover letter for KALO interim site N/A N/A
TRAVEL - GSA - Per Person Per Trip $48,705.00 $48,705.00 Required in order to accommodate staff and personnel for proper installation of interim transmission site. Please see attached OPM Services LLC Quote rev 3 and cover letter for KALO interim site; Justifying Invoice - KALO OPM 399-#18-April Travel $48,705.00 N/A
Legal Work $27,000.00 $27,000.00 Generation of Shared Use Agreement, lease documents, review of revised Form 399. N/A N/A
DTV Medical Facility Notification $11,550.00 $3,861.60 Per Justifying Quote OPM Services 399-DTV Notification $3,861.60 N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 FCC Filing Fee as of September 2018 N/A N/A
Equipment Storage $1,800.00 $1,800.00 N/A N/A N/A

Components

Actual Information Description File Name
Accounting

Component Description:
August monthly accounting
Amount:
$775.00

Component Description:
January monthly accounting; answer emails
Amount:
$545.00

Component Description:
Paying Repack bills
Amount:
$135.50

Component Description:
Paying bills in the month of May
Amount:
$438.50

Component Description:
December monthly accounting
Amount:
$139.00

Component Description:
Services provided in June - paying bills
Amount:
$429.50

Component Description:
November monthly accounting
Amount:
$499.00

Component Description:
Services performed in February; Paying Repack vendor bills
Amount:
$1,439.00

Component Description:
September monthly accounting
Amount:
$1,257.50

Component Description:
Services performed in March: Paying monthly bills
Amount:
$1,048.00
FCC Filing Fees - Special Temporary Authorization request Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
KALO-610-Disposal Costs
Amount:
$375.00
STL transmitter and receiver, SAF or equiv. 7 GHz Information not provided.
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change

Component Description:
KALO-610-Channel Change Announcements
Amount:
$540.00
Equipment Delivery and Handling Charges Information not provided.
ASI-to-IP converter, Dektec DTE-3120 Information not provided.
TRAVEL - GSA - Per Person Per Trip

Component Description:
Roundtrip travel San Diego to Hawaii and back
Amount:
$3,345.00

Component Description:
Gary labor travel to Hawaii
Amount:
$10,395.00

Component Description:
Gary labor travel to Hawaii
Amount:
$10,395.00

Component Description:
Travel Day- Gary Stigal Round Trip
Amount:
$13,230.00

Component Description:
Paul labor travel to Roundtrip Hawaii- San Diego
Amount:
$11,340.00
Legal Work Information not provided.
DTV Medical Facility Notification

Component Description:
DTV Notification Service
Amount:
$3,861.60
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
Equipment Storage Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,819,543.94 $1,987,049.11 $956,482.29

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.

Tom Jordan

Secretary/Treasurer/Chief Financial Officer


09/06/2019

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.

Tom Jordan

Secretary/Treasurer/Chief Financial Officer


09/06/2019

Attachments

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