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:
6568
Service:
DTV
Call Sign:
WBGU-TV
Channel:
22 (UHF)
File Number:
0000027984
FRN:
0002914638
Date Submitted:
10/18/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

BOWLING GREEN STATE UNIVERSITY

Anthony Short, General Manager

245 TROUP STREET

BOWLING GREEN, OH 43402

United States

+1 (419) 372-2700 ashort@bgsu.edu Government Entity

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

The Preparer is same as the reimbursement contact.

 

 

 

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 Purchase/install an aux antenna, a new transmitter (current one cannot be re-used) and we will use a spare transmission line to test our new channel (22) during the phase one testing period. Upon cutover we'll transition the above to permanent antenna.

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 Ultimate
Year 2003
Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power Capacity 10 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 UXLTE-20
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 7.5 kW
Justification for New Transmitter Our old Comark transmitter could not be retuned for the new channel (22).

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) Yes
Power 300 kVA
Rigid Conduit and Wiring Yes
Size 2 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

Information not provided.

Antennas

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

Primary Antenna

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Add Antenna Information

Section Question Response
Existing Antenna Description Type of change Retune Existing
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this antenna currently shared with any other stations? No
Is this antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 56
Design power capacity in use 40.0 %
Lower Limit 470.00 MHz
Upper Limit 728.00 MHz
Other Antenna Type N/A
ERP: 153.0 kW
Manufacturer Dielectric
Model TUF-04-14/56 H-I-T-R
Year 2003

Primary Antenna

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Adjustment to Existing Antenna

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

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

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

retune elbox complex

retuning elbox complex for new channel

Auxiliary Antenna

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Add Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Auxiliary (Backup)
Description of Use Backup antenna
Ownership Owned
Owner N/A
Site N/A
Is this antenna currently shared with any other stations? No
Is this antenna directional? No
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 Class A
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: 61.0 kW
Manufacturer
Model AL8PLUS
Year 2002

Auxiliary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Auxiliary (Backup)
Description of Use Aux/backup antenna to replace existing. Will be used for testing new channel prior to cutover
Change Type Purchase New
Is this a request for upgraded equipment? No
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? No
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
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: 137.0 kW
Manufacturer
Model ATC-BCH216M-22
Year 2018
Justification for New Antenna Current auxiliary antenna is not capable of new channel. Will install new auxiliary antenna for testing in phase 1 while not interrupting current channel/service

Auxiliary 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? 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? Yes

Auxiliary 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 Utilize Existing
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Dielectric
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 2
Length 1000 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Primary Line sweep and tuning bullets

Current transmission line is compatible with new channel, just needs swept and tuned

Auxiliary Transmission Line

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Add Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Utilize Existing
Use Auxiliary (Backup)
Description of Use Backup transmission line to side mount antenna
Ownership Owned
Owner N/A
Site N/A
Is this transmission currently shared with any other stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Andrew
Type Flexible Air
Diameter 1 5/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 1
Length 560 feet per run

Auxiliary 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 Move Equipment
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? Yes
ASR Number 1016071
Coordinates (NAD83) Latitude (NAD83) 41° 08' 12.0" N-
Longitude (NAD83) 083° 54' 24.0" W-
Overall Structure Height 1089.55 feet
Support Structure Height 1030.83 feet
Ground Elevation Above Mean Sea Level (AMSL) 727.03 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner BOWLING GREEN STATE UNIVERSITY
Date Constructed 08/13/2004


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? No
Number of Hours N/A
Explanation N/A
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 No
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 No
Number of Days N/A
Justification N/A

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 No
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
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? No
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 $441,886.44 $435,105.05 N/A $435,105.05 N/A
Total for all systems $1,247,618.52 $985,308.46 N/A $861,788.79 N/A
Primary Transmitter UXLTE-20 $441,886.44 $435,105.05 $435,105.05
Transformer 3 phase/480v - 300 KVA $36,800.00 $30,319.13 N/A $30,319.13 N/A
2" Rigid Conduit and Wiring (Cost per foot) $2,600.00 $2,299.48 N/A $2,299.48 N/A
UHF - Liquid Cooled Solid State Transmitter 7.5 kW $402,486.44 $402,486.44 N/A $402,486.44 N/A

Components

Actual Information Description File Name
Transformer 3 phase/480v - 300 KVA

Component Description:
Electricians (Terry, Kerry) 81 hours @ $85.00 per hour
Amount:
$6,885.00

Component Description:
Various electrical supplies for transformer phase
Amount:
$451.42

Component Description:
Various electrical supplies for the transformer phase
Amount:
$2,032.51

Component Description:
Electricians (Terry, Kerry, Wayne) 67 hours @ $85.00 per hour
Amount:
$5,695.00

Component Description:
Electricians (Terry, Kerry, Wayne) 30.50 hours @ $85.00 per hour
Amount:
$2,592.50

Component Description:
Electrical supplies for transformer phase
Amount:
$3,149.68

Component Description:
Various electrical parts for transformer phase
Amount:
$7,046.19

Component Description:
Electrician 4 hours @ $85.00 per hour. Low ambient control
Amount:
$554.33

Component Description:
Electricians (Terry, Kerry, Wayne) 22.50 hours @ $85.00 per hour
Amount:
$1,912.50
2" Rigid Conduit and Wiring (Cost per foot)

Component Description:
Wiring and supplies
Amount:
$291.04

Component Description:
Conduit, wiring and supplies
Amount:
$1,277.40

Component Description:
Wiring and supplies
Amount:
$731.04
UHF - Liquid Cooled Solid State Transmitter 7.5 kW

Component Description:
Change order - probe kit
Amount:
$216.45

Component Description:
Change order - 90 degree elbow, adapter and transmission line
Amount:
$2,855.11

Component Description:
Change order - insulated pipe clamp and piping clamps
Amount:
$64.62

Component Description:
Change order - 1 inch piping clamp
Amount:
$58.40

Component Description:
Change order - cable tray wire
Amount:
$351.52

Component Description:
Change order - Charge kit for liquid cooled transmitters
Amount:
$245.61

Component Description:
Streamscope ATSC1.0 Analyzer
Amount:
$29,900.00

Component Description:
Heat exchanger
Amount:
$4,417.40

Component Description:
Stabiline Automatic Voltage regulator
Amount:
$22,561.28

Component Description:
Transmitter RF plumbing
Amount:
$20,773.63

Component Description:
Blackmagic Desing Smartview
Amount:
$1,256.30

Component Description:
Additional charge for freight
Amount:
$132.00

Component Description:
RF load
Amount:
$13,785.91

Component Description:
Change order - Travel day charge
Amount:
$3,364.00

Component Description:
Cmask 20kw UHF ATSC tuned
Amount:
$16,065.00

Component Description:
Frieght - original estimate was $3,100.00
Amount:
$10,216.21

Component Description:
Hose install - installation and proof services - line 25 of quote
Amount:
$29,952.00

Component Description:
Boom Forklift to get transmitter off truck
Amount:
$1,022.07

Component Description:
ULXTE-20 High Efficiency Transmitter
Amount:
$243,217.33

Component Description:
Sencore receiver
Amount:
$2,031.60

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 $92,452.00 $91,792.00 N/A $68,642.00 N/A
Total for all systems $1,247,618.52 $985,308.46 N/A $861,788.79 N/A
Primary Antenna TUF-04-14/56 H-I-T-R $17,080.00 $16,750.00 $0.00
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $0.00 N/A
retune elbox complex $10,350.00 $10,350.00 estimated cost of elbow complex retuning $0.00 N/A
Auxiliary Antenna ATC-BCH216M-22 $75,372.00 $75,042.00 $68,642.00
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $0.00 N/A
UHF - Lower Power, Side Mount, Class A, basic slot antenna, 137 kW input, horizontally polarized $23,846.00 $23,846.00 Auxilliary antenna from Alive Telecom, plus freight charges - 2nd payment. First payment was approved under wrong item $23,846.00 N/A
UHF - Lower Power, Side Mount, Class A, basic slot antenna, 60 - 65 kW input, horizontally polarized $44,796.00 $44,796.00 ***System Notice: Estimate adjusted and locked because line has been superseded.***Cost of new aux antenna as current aux antenna isn't compatible with new channel 6-6-18 - added $500 to the $45,000 to cover extra shipping charges - see attached Alive Telecom quote $44,796.00 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
Sweep testing of existing top mounted wideband antenna
Amount:
$6,400.00
retune elbox complex

Component Description:
Mobilization of crew and labor to adjust antenna/elbow tuners
Amount:
$10,350.00
Sweep test of existing antenna

Component Description:
Sweep testing and tuning of new CH22 auxiliary antenna
Amount:
$6,400.00
UHF - Lower Power, Side Mount, Class A, basic slot antenna, 137 kW input, horizontally polarized

Component Description:
2nd payment for antenna - the first payment was approved under the wrong item
Amount:
$23,046.00

Component Description:
Crane work to unload antenna from semi truck
Amount:
$800.00
UHF - Lower Power, Side Mount, Class A, basic slot antenna, 60 - 65 kW input, horizontally polarized

Component Description:
This is for the 50% down payment for the new auxiliary antenna
Amount:
$21,750.00

Component Description:
Balance due for antenna
Amount:
$23,046.00

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 $4,343.89 $4,343.89 N/A $4,343.89 N/A
Total for all systems $1,247,618.52 $985,308.46 N/A $861,788.79 N/A
Primary Transmission Line $4,343.89 $4,343.89 $4,343.89
Primary Line sweep and tuning bullets $4,343.89 $4,343.89 N/A $4,343.89 N/A
Auxiliary Transmission Line $0.00 $0.00 $0.00

Components

Actual Information Description File Name
Primary Line sweep and tuning bullets

Component Description:
Additional pieces to connect transmission line to antenna - shipping charges not included in quote
Amount:
$3,393.89

Component Description:
Primary line sweep test
Amount:
$950.00

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 $210,500.00 $78,247.70 N/A $14,075.00 N/A
Total for all systems $1,247,618.52 $985,308.46 N/A $861,788.79 N/A
Primary Tower TOWER $210,500.00 $78,247.70 $14,075.00
Tall Tower (greater than 500') $210,500.00 $78,247.70 N/A $14,075.00 N/A

Components

Actual Information Description File Name
Tall Tower (greater than 500')

Component Description:
Perform tower structural analysis to test for loading conditions and de-rated ice conditions
Amount:
$8,500.00

Component Description:
Mobilization of crew to install new auxiliary ch 22 antenna
Amount:
$64,172.70

Component Description:
Tower services - climb, measure and detail tower. Prepare necessary drawings
Amount:
$5,575.00

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 $135,960.00 $55,000.00 N/A $19,228.03 N/A
Total for all systems $1,247,618.52 $985,308.46 N/A $861,788.79 N/A
Outside Professional Services $135,960.00 $55,000.00 $19,228.03
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $1,486.28 N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $0.00 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 -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 $1,000.00 N/A $1,000.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,991.75 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $13,750.00 Underestimated cost of engineering study $13,750.00 The initial estimate for the engineering evaluation was way under estimated. At the time of the completion of the form, we just ball parked this figure.
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A $0.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
RF Exposure Measurements $21,050.00 $20,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
This is internal engineering costs for preparation of the Form 2100 application
Amount:
$411.28

Component Description:
Preparation of license application and construction permit
Amount:
$1,075.00

Component Description:
Prepare engineering portion of FCC Form 2100
Amount:
$1,075.00
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Attorney Fees -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

Component Description:
Prepare engineering report for special temporary authorization
Amount:
$1,000.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Preparation of engineering portion of construction permit
Amount:
$2,125.00

Component Description:
Internal engineering costs to prepare engineering section of Form 2100 construction permit
Amount:
$866.75
Perform engineering study for new channel assignment and antenna development

Component Description:
xxxx
Amount:
$12,850.00

Component Description:
Perform engineering evaluation for new Channel 22
Amount:
$900.00

Component Description:
Perform tower reinforcing study and report for development of new antenna
Amount:
$12,850.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Prepare and or review reimbursement form 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 $12,750.00 $3,650.00 N/A $3,225.00 N/A
Total for all systems $1,247,618.52 $985,308.46 N/A $861,788.79 N/A
Other Expenses $12,750.00 $3,650.00 $3,225.00
MVPD Notification of Channel Change $200.00 $200.00 N/A $775.00 The amount estimated is much higher than what our attorney charged us for this service.
Develop and air announcement of upcoming channel change $500.00 $500.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $500.00 $500.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $2,450.00 N/A $2,450.00 N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change

Component Description:
Attorney services for notifying MPVD 's about channel change
Amount:
$775.00

Component Description:
Attorney fees for MVPD notice
Amount:
$775.00
Develop and air announcement of upcoming channel change Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
DTV Medical Facility Notification

Component Description:
Medical Notification mailing
Amount:
$2,450.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,247,618.52 $985,308.46 $861,788.79

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.

Tina Simon

General Manager


10/18/2019

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.

Tina Simon

General Manager


10/18/2019

Attachments

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