TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
HME Equity Fund II, LLC Doing Business As: HME Equity Fund II, LLC	Seth Ellis 121 S. Orange Avenue Suite 1500 Orlando, FL 32801 United States	+1 (407) 377-6851	sellis@assurancemezz.com	Limited Liability Company

Applicant

Address

Phone

Applicant Type

HME Equity Fund II, LLC

Doing Business As: HME Equity Fund II, LLC

Seth Ellis

121 S. Orange Avenue

Suite 1500

Orlando, FL 32801

United States

+1 (407) 377-6851

sellis@assurancemezz.com

Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant	Address	Phone	Email
[Confidential]

Preparer Contact Information

Preparer Contact Name and Information

Applicant	Address	Phone	Email
Davina Sashkin Counsel Fletcher, Heald & Hildreth, PLC	Davina Sashkin Fletcher, Heald & Hildreth, PLC 1300 N. 17th Street, Suite 1100 Arlington, VA 22209 United States	+1 (703) 812-0400	sashkin@fhhlaw.com

Applicant

Address

Phone

Davina Sashkin

Counsel

Fletcher, Heald & Hildreth, PLC

Davina Sashkin

Fletcher, Heald & Hildreth, PLC

1300 N. 17th Street, Suite 1100

Arlington, VA 22209

United States

+1 (703) 812-0400

sashkin@fhhlaw.com

Broadcaster Information and Transition Plan

Question	Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information.	No
Briefly describe transition plan	Revised plan includes proposed move to new tower location upon discovery of concerns with current tower site, antenna and transmitter. See attached Memo dated Jan. 18, 2018 for details.

Transmitters

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

Primary Transmitter

Existing Transmitter Information

Section	Question	Response
Existing Transmitter Description	Type of change	Purchase New
	Use	Primary (Main)
	Description of Use	N/A
	Ownership	Owned
	Owner	N/A
	Site	N/A
	Is this transmitter currently shared with another station?	No
	Is this transmitter currently in operating condition?	Yes
Existing Transmitter Manufacturer and Type	Manufacturer
	Model	UAX500AT
	Year	2015
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power Capacity	0.5 kW

Primary Transmitter

New Transmitter Costs

Section	Question	Response
New Transmitter	Use	Primary (Main)
	Change Type	Purchase New
	Is this a request for upgraded equipment?	Yes
	Manufacturer
	Model	UNKNOWN
	Transmitter Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	4 kW
	Justification for New Transmitter	Manufacturer warranty has been voided on current transmitter and it is therefore not retunable. A new transmitter is required. See attached Jan. 18, 2018 Memo for explanation.

Primary Transmitter

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

Primary Transmitter

Other Transmitter Cost Not Listed

Information not provided.

Antennas

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

Primary Antenna

Add 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 this antenna currently shared with any other stations?	No
	Is this 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	Class A
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Elliptical
	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:	4.0 kW
	Manufacturer
	Model	ATC-BPH8C2
	Year	2015

Primary Antenna

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	Class A
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Other
	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	Class A Single Station Antenna - Basic
	ERP:	15.0 kW
	Manufacturer
	Model	ALP8L7-HSW-15
	Year	2019
	Justification for New Antenna	Manufacturer warranty has been voided on current antenna and it is therefore not retunable. A new antenna is required. See attached Jan. 18, 2018 Memo for explanation.

Primary Antenna

Other Antenna Costs

Section	Question	Response
Combiner for Shared Antenna	Do you need a Combiner for a Shared Antenna?
	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?	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

Primary Antenna

Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Primary Transmission Line

Existing Transmission Line

Section	Question	Response
Existing Transmission Line Description	Type of change	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	Flexible Foam
	Diameter	7/8 inches
	Other Diameter	N/A
	Segment Length	N/A
	Other Segment Length	N/A
	Number of parallel runs	3
	Length	250 feet per run

Primary Transmission Line

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	Flexible Foam
	Diameter	7/8 inches
	Other Diameter	N/A
	Segment Length	N/A
	Other Segment Length	N/A
	Number of parallel runs	1
	Length	250 feet per run
	Justification for New Transmission Line	issues with current transmitter and antenna, as documented in attached Jan. 18, 2018 Memo, support conclusion that current transmission line may not be re-used for new facilities.

Primary Transmission Line

Other Transmission Line Expenses Not Listed

Information not provided.

Primary Transmission Line

Add 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 this transmission currently shared with any other stations?	No
	Is Transmission Line in operating condition?	Yes
Existing Transmission Line Manufacturer and Type	Manufacturer
	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	650 feet per run

Primary Transmission Line

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	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	650 feet per run
	Justification for New Transmission Line	The new tower is taller and the line has to be able to be sturdier as it has to bend. The vertical feet is 400 ft and the horizontal is 250 ft and it is one run. It is a total of 650 ft. Invoice and quote have been submitted with the detailed info.

Primary Transmission Line

Other Transmission Line Expenses Not Listed

Name	Description
Insulators for Transmission Line	Insulated hanger for 1-5/8 inch Heliax, single piece. Adapters for attaching hangers to tower

Tower Equipment And Rigging Costs

Section	Question	Response
Tower Equipment or Rigging Costs Changes	Do you have tower equipment or rigging costs changes?	Yes

Primary Tower

Existing Tower

Section	Question	Response
Existing Tower Description	Type of change	Move Equipment
	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?	Yes
	Is tower compliant with Rev G?	Yes
Existing Tower Structure Registration	Do you have a tower registration number?	No
Existing Tower Structure Registration	ASR Number
Coordinates (NAD83)	Latitude (NAD83)	42° 24' 29.0" N-
	Longitude (NAD83)	083° 05' 30.0" W-
	Overall Structure Height	199.80 feet
	Support Structure Height	199.80 feet
	Ground Elevation Above Mean Sea Level (AMSL)	831.00 feet
	Structure Type	MTOWER - Monopole
	Tower Owner	Woodward Broadcasting LLC
	Date Constructed	01/15/2015

Primary Tower

Tower Rigging Costs

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

Primary Tower

Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	Yes
	Number of Hours	600
	Explanation	Applicant has no internal resources capable of overseeing, identifying, purchasing, installing and commissioning this repack project. It will rely solely on outside services to manage all work required.
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	No
	Quantity	N/A
	Do you have Distributed Transmission System engineering services?	N/A
	Critical Facility	N/A
	Terrain-Shielded Facility	N/A
Attorney and Other Outside Consulting Services	Prepare and file Form FCC Construction Permit Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare and file Form FCC License to Cover Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare request for Special Temporary Authority	No
	Quantity	N/A
	NEPA Section 106 environmental review	No
	Environmental Assessment	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	No
	Number of Days	N/A
	Justification	N/A

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Name	Description
Other Transition- Related Professional Service Costs	Prepare and/or review reimbursement form
Quarterly Transition Reports	Quarterly Transition Reports

Other Expenses

Section	Question	Response
AM Pattern Disturbance	Is an Impact Study needed?	No
AM Pattern Disturbance	Is Remediation needed?	No
Facility Expenses	Name	N/A
	Other Distributed Transmission System Expenses Not listed	N/A
	Name	N/A
	Is Notification of a Medical Facility required as a result of DTV broadcasting?	Yes
Permit and Filing Costs	Local Zoning	Yes
	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	No
Other Miscellaneous Expenses	Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)?	Yes
	Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs?	Yes
	Does this relocation require Equipment Storage?	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

Other Expenses Not Listed

Name	Description
Other Miscellaneous Expenses	Other Miscellaneous Expenses.

Cost Information

Transmitters

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$236,500.00	$225,000.00	N/A	$0.00	N/A
Total for all systems	$555,440.00	$517,450.00	N/A	$101,668.08	N/A
Primary Transmitter UNKNOWN	$236,500.00	$225,000.00		$0.00
UHF - Air Cooled Solid State Transmitter 4 - 6 kW	$236,500.00	$225,000.00	N/A	$0.00	N/A

Components

Actual Information Description	File Name
UHF - Air Cooled Solid State Transmitter 4 - 6 kW	Component Description: Invoice is for new transmitter for Detroit. Requesting invoice amount less shipping - will request that under shipping section. Amount: $35,659.00

Cost Information

Antennas

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$26,300.00	$25,000.00	N/A	$18,930.64	N/A
Total for all systems	$555,440.00	$517,450.00	N/A	$101,668.08	N/A
Primary Antenna ALP8L7-HSW-15	$26,300.00	$25,000.00		$18,930.64
UHF - Lower Power Side Mount, Class A One Station antenna -- basic	$26,300.00	$25,000.00	N/A	$18,930.64	N/A

Components

Actual Information Description	File Name
UHF - Lower Power Side Mount, Class A One Station antenna -- basic	Component Description: Updated - After the invoice you will see an breakout/allocation of the Antenna and Transmission line costs with the shipping and the tax (7.25%) for each. I have attached the proposal that that is the detail of Antenna and Transmission line. Amount: $18,930.64

Cost Information

Transmission Line

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$35,400.00	$47,200.00	N/A	$17,931.17	N/A
Total for all systems	$555,440.00	$517,450.00	N/A	$101,668.08	N/A
Primary Transmission Line	$2,750.00	$18,000.00		$17,931.17
Flexible Foam Transmission Line - dielectric, 7/8"	$2,750.00	$18,000.00	WHPS was moved to a taller tower and therefore there were more turns the transmission line had to go thru. So a more sturdier line had to be purchased and more line had to be purchased as it was a taller tower. We had to purchase 1 5/8" line.	$17,931.17	N/A
Primary Transmission Line	$32,650.00	$29,200.00		$0.00
Insulators for Transmission Line	$11,200.00	$11,200.00	Insulator hangers needed for transmission line.	N/A	N/A
Flexible Air Transmission Line - dielectric, 1 5/8"	$21,450.00	$18,000.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Flexible Foam Transmission Line - dielectric, 7/8"	Component Description: After the invoice you will see an breakout/allocation of the Antenna and Transmission line costs with the shipping and the tax (7.25%) for each. I have attached the proposal that that is the detail of Antenna and Transmission line. Amount: $17,931.17
Insulators for Transmission Line	Information not provided.
Flexible Air Transmission Line - dielectric, 1 5/8"	Information not provided.

Cost Information

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	$84,200.00	$60,000.00	N/A	$0.00	N/A
Total for all systems	$555,440.00	$517,450.00	N/A	$101,668.08	N/A
Primary Tower MTOWER	$84,200.00	$60,000.00		$0.00
Short Tower (less than 500')	$84,200.00	$60,000.00	N/A	$0.00	N/A

Components

Actual Information Description	File Name
Short Tower (less than 500')	Component Description: Electrical work for power for station on the tower. Along with the invoice is the 2 quotes which detail the work that was done. Amount: $15,010.93 Component Description: This is for an isolation inductor system that has to be installed on the tower in order to work on the tower for safety since it is an AM tower and has higher voltage. Will request shipping amount under the shipping section. Amount: $13,300.00

Actual Information Description

File Name

Short Tower (less than 500')

Component Description:: Electrical work for power for station on the tower. Along with the invoice is the 2 quotes which detail the work that was done.
Amount:: $15,010.93

Component Description:: This is for an isolation inductor system that has to be installed on the tower in order to work on the tower for safety since it is an AM tower and has higher voltage. Will request shipping amount under the shipping section.
Amount:: $13,300.00

Cost Information

Outside Professional Services

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$132,490.00	$126,250.00	N/A	$60,744.27	N/A
Total for all systems	$555,440.00	$517,450.00	N/A	$101,668.08	N/A
Outside Professional Services	$132,490.00	$126,250.00		$60,744.27
Quarterly Transition Reports	$6,000.00	$6,000.00	N/A	$1,510.00	N/A
Other Transition- Related Professional Service Costs	$2,500.00	$2,500.00	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	$3,667.00	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	$1,803.75	N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,580.00	$1,500.00	N/A	$0.00	Cost of preparing the section was more than expected
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$3,155.00	$3,000.00	N/A	$2,000.00	N/A
Prepare and or review reimbursement form	$2,630.00	$2,500.00	N/A	$2,492.75	N/A
Project management of the transition	$94,800.00	$90,000.00	Project management expenses.	$42,520.77	N/A
Address transition timing and coordination issues w/ other stations and wireless	$2,630.00	$2,500.00	N/A	$1,500.00	N/A
Perform engineering study for new channel assignment and antenna development	$7,360.00	$7,000.00	N/A	$5,250.00	N/A

Components

Actual Information Description	File Name
Quarterly Transition Reports	Component Description: Initial first quarterly transition reports for W33BY-D the Detroit Station. The fees are all the ones denoted with the letter F next to them. Amount: $475.00 Component Description: Work on preparing quarterly transition reports. Amount: $1,035.00
Other Transition- Related Professional Service Costs	Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations	Component Description: Various attorney fees for repack items for W33BY-D for Detroit station. The fees are all the ones denoted with the letter A next to them. Amount: $3,667.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	Component Description: These are the attorney fees for the construction permit application on form 2100. The fees are all the ones denoted with the letter C next to them. Also some of the line items have CP as an abbreviation for Construction permit application. Amount: $1,803.75
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	Component Description: Preparation of engineering section of FCC form 2100 Amount: $2,000.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	Component Description: Work on Construction Permit Application for form 2100 Amount: $2,000.00
Prepare and or review reimbursement form	Component Description: These are the attorney fees for preparing and reviewing the reimbursement form 399. The fees are all the ones denoted with the letter D next to them. Amount: $2,492.75
Project management of the transition	Component Description: Project Management services for the Detroit stations WHPS Amount: $8,881.25 Component Description: Project Management services for the Detroit stations WHPS Amount: $5,643.75 Component Description: Project Management services for the Detroit stations WHPS Amount: $6,562.50 Component Description: Project management fees for Detroit. Amount: $7,253.27 Component Description: Project Management services for the Detroit stations WHPS Amount: $14,180.00 Component Description: Project management services. A narrative letter is attached explaining the breakout of the invoice. Expense receipts are attached to the invoice. Also this company does not use specific invoice numbers so I just did a description Amount: $8,503.27
Address transition timing and coordination issues w/ other stations and wireless	Component Description: Address issues, research and coordinate between parties. Amount: $1,500.00
Perform engineering study for new channel assignment and antenna development	Component Description: Perform and engineering structural analysis. PO request with detail and cancelled check attached. Invoice has been updated with Call Letters and W-9 is attached. Amount: $3,250.00 Component Description: Engineering study work for new channel assignment and antenna development Amount: $2,000.00 Component Description: Getting Clarification from vendor on invoice Amount: N/A Component Description: Getting Clarification from vendor on invoice Amount: N/A Component Description: Getting Clarification from vendor on invoice Amount: N/A Component Description: Engineering work for new channel assignment and antenna development Amount: $2,000.00

Cost Information

Other Expenses

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$40,550.00	$34,000.00	N/A	$4,062.00	N/A
Total for all systems	$555,440.00	$517,450.00	N/A	$101,668.08	N/A
Other Expenses	$40,550.00	$34,000.00		$4,062.00
DTV Medical Facility Notification	$11,550.00	$5,000.00	N/A	N/A	N/A
Other Miscellaneous Expenses	$5,000.00	$5,000.00	N/A	N/A	N/A
MVPD Notification of Channel Change	$5,000.00	$5,000.00	N/A	$4,062.00	N/A
Develop and air announcement of upcoming channel change	$2,500.00	$2,500.00	N/A	N/A	N/A
Equipment Storage	$2,500.00	$2,500.00	N/A	N/A	N/A
Equipment Delivery and Handling Charges	$5,000.00	$5,000.00	N/A	$0.00	N/A
Disposal Costs (for equipment and other waste, net of any salvage value)	$5,000.00	$5,000.00	N/A	N/A	N/A
Non-zoning permits	$2,000.00	$2,000.00	N/A	N/A	N/A
Local Zoning	$2,000.00	$2,000.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
DTV Medical Facility Notification	Information not provided.
Other Miscellaneous Expenses	Information not provided.
MVPD Notification of Channel Change	Component Description: Notification of Cable and Satellite MVPD Providers of new RF Channel Amount: $4,062.00
Develop and air announcement of upcoming channel change	Information not provided.
Equipment Storage	Information not provided.
Equipment Delivery and Handling Charges	Component Description: Shipping cost for isolation inductor equipment. Amount: $900.00 Component Description: Shipping cost for Transmitter. Amount: $900.00
Disposal Costs (for equipment and other waste, net of any salvage value)	Information not provided.
Non-zoning permits	Information not provided.
Local Zoning	Information not provided.

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$555,440.00	$517,450.00	$101,668.08

Reimbursement Status

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

Certification

Section	Question	Response
Submission of 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.
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. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD). The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a 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.	Ann Olsen Consultant 10/28/2019

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.

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.
The above-named entity acknowledges that all certifications and attached documentation are considered material representations.
The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.
The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).
The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.
The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.
The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.
The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a 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.

Ann Olsen

Consultant

10/28/2019

Certification

Section	Question	Response
Submission of Actual Cost Documentation Statements	WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).
The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) . The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Ann Olsen Consultant 10/28/2019

Section

Question

Response

Submission of Actual Cost Documentation Statements

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

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

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

Ann Olsen

Consultant

10/28/2019

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

Applicant Information

Applicant Name, Type, and Contact Information

Reimbursement Contact Information

Reimbursement Contact Name and Information

Preparer Contact Information

Preparer Contact Name and Information

Broadcaster Information and Transition Plan

Transmitters

Primary Transmitter

Existing Transmitter Information

Primary Transmitter

New Transmitter Costs

Primary Transmitter

Other Transmitter Costs

Primary Transmitter

Other Transmitter Cost Not Listed

Antennas

Primary Antenna

Add Antenna Information

Primary Antenna

New Antenna Costs

Primary Antenna

Other Antenna Costs

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Primary Transmission Line

Existing Transmission Line

Primary Transmission Line

New Transmission Line

Primary Transmission Line

Other Transmission Line Expenses Not Listed

Primary Transmission Line

Add Transmission Line

Primary Transmission Line

New Transmission Line

Primary Transmission Line

Other Transmission Line Expenses Not Listed

Tower Equipment And Rigging Costs

Primary Tower

Existing Tower

Primary Tower

Tower Rigging Costs

Primary Tower

Other Tower Expenses Not Listed

Outside Professional Services Costs

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Other Expenses

Other Expenses

Other Expenses Not Listed

Cost Information

Transmitters

Components

Cost Information

Antennas

Components

Cost Information

Transmission Line

Components

Cost Information

Tower Equipment and Rigging Costs

Components

Cost Information

Outside Professional Services

Components

Cost Information

Other Expenses

Components

Cost Information

Grand Total

Reimbursement Status

Certification

Certification

Attachments