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:
74007
Service:
DTV
Call Sign:
WSJV
Channel:
30 (UHF)
File Number:
0000027492
FRN:
0018223693
Date Submitted:
03/17/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WSJV License, LLC

Brady Dreasler

P.O. BOX 909

QUINCY, IL 62306

United States

+1 (217) 223-5100 bdreasler@quincymedia.com Limited Liability Company

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

Tony zumMallen

QCommunications, LLC

Tony zumMallen

705B SE Melody LN #314

Lees Summit, MO 64063

United States

+1 (816) 729-1177 tony@qcom1.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan The station will transition from ch28 to ch30 and will require a new transmitter and antenna along with an interim system to allow continuous operations during the transition

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 Diamond
Year 2001
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 14.0 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 ULXTE-24
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 16.1 kW
Justification for New Transmitter Transmitter manufacturer says existing transmitter is not tunable. One power-level step increase is requested. Due to current demonstrated headroom.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) Yes
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring Yes
Size 2 inches
Length 700.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 25 tons
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Transmitter - Training

Transmitter training - offsite - 1 week in duration at mfg site.

Disconnect existing Transmitter

Disconnect transmitter and components from existing configuration and move within building to make way for new facilities.

SALES TAX

SALES TAX

Site Survey - TX

Site survey and report are required to be performed before the new transmitter and components installation plan can be finalized.

Security - Site

This site requires security once the new transmission line and equipment arrive on site to be installed. Estimated length of 4-6 weeks.

FREIGHT

FREIGHT FROM THE MFG TO STAGING AREA PER Q-75224

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 ULXTE-24
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 16.1 kW
Justification for New Transmitter Required to maintain station broadcast operations during the channel reassignment project. Amended to adjust Interim system to more closely fit the main existing contour per Lohnes engineering.

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) Yes
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring Yes
Size 2 inches
Length 400.0 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
Inside RF System Is an additional interior RF system required to support this interim transmitter? Yes

Interim Transmitter

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Other Transmitter Cost Not Listed

Name Description

FREIGHT

FREIGHT FROM MFG TO STAGING AREA PER Q-75223

Sales Tax

Sales Tax for equipment and services

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Top 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: 311.0 kW
Manufacturer
Model TWS-30T
Year 2001

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Broadband Slot
Number of Stations Supported 1
Number of Panels/Bays 9
Lower Limit 470.00 MHz
Upper Limit 698.00 MHz
Design power capacity in use 50.0 %
Other Antenna Type N/A
ERP: 324.0 kW
Manufacturer
Model TFU-27ETT/VP-R 3T170
Year 2017
Justification for New Antenna Required to facilitate the new channel change. Added VP used horizontal cost as EST.

Primary Antenna

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Other Antenna Costs

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

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

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 Not in Stack
Polarization Horizontal
Type Broadband Slot
Number of Stations Supported 1
Number of Panels/Bays 16
Lower Limit 470.00 MHz
Upper Limit 698.00 MHz
Design power capacity in use 50.0 %
Other Antenna Type N/A
ERP: 160.0 kW
Manufacturer
Model TFU-16WB-R-RC160
Year 2016
Justification for New Antenna Required to maintain stations broadcast operations during the channel relocation project.

Interim Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? B
Feed Line Size 6 1/8 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for an antenna? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? Yes
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Interim Antenna

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Other Antenna Cost Not Listed

Name Description

FRIEGHT

FREIGHT FROM MFG TO STAGING AREA

Transmission Line

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

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 19 3/4 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1073 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1073 feet per run
Justification for New Transmission Line Required to operate on the new channel assignment frequencies. Corrected the existing TX Dia to 19 3/4 for CH 28. 19 3/4 will not work on new CH30. 3-8-19 updated new TX line to 19 1/2

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Disconnect existing Interior RF components

Disconnect interior RF transmission line and filters from existing configuration and move within the building to make way for new facilities.

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 Rigid
Diameter 6 1/8 inches
Segment Length 19 ¾ '
Other Segment Length
Number of parallel runs 1
Length 1075 feet per run
Justification for New Transmission Line Required to have continuous operations during the channel reassignment project.

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 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? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1011421
Coordinates (NAD83) Latitude (NAD83) 41° 36' 58.0" N-
Longitude (NAD83) 086° 11' 38.0" W-
Overall Structure Height 1047.89 feet
Support Structure Height 986.21 feet
Ground Elevation Above Mean Sea Level (AMSL) 870.07 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner WSJV Television, Inc.
Date Constructed 10/01/1988


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

Name Description

Tower Structural Study

Broadcast Tower Structural Analysis

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 934
Explanation Required to assist in the turnkey management of the channel relocation project in order that the existing internal personal can maintain and operate the stations daily operational requirements and plans.
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 2
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 2
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 No
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

Name Description

General Repack Legal Services

See attached memo-QMI Repack Invoice Memo for Shared Legal Expenses (Matter 10441100054) for Form 399-

Quarterly reporting

Preparation and submittal of the FCC required quarterly report 387 by PM and attorney.

Vendor Travel Expenses

Reimbursable Vendor Travel expenses for working in the field on behalf of the station for the Repack project - see quote for estimated expenses.

Shared Antenna Study

Evaluation of potential for WSJV to share antenna

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? Yes
Is Remediation needed? Yes
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 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

Additional Insurance

Additional insurance to cover equipment while in storage

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 $2,406,944.26 $1,711,638.00 N/A $10,995.00 N/A
Total for all systems $4,195,211.98 $3,255,815.21 N/A $128,623.84 N/A
Interim Transmitter ULXTE-24 $924,322.13 $745,576.59 ($199,608.01)
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW $684,000.00 $515,054.46 WSJV- Gates Q-75223 - Lines A+B+E ($225,972.97) N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A $3,331.66 N/A
2" Rigid Conduit and Wiring (Cost per foot) $10,400.00 $10,000.00 N/A N/A N/A
UHF inside RF system including switching $147,500.00 $140,000.00 N/A $23,033.30 N/A
FREIGHT $5,400.00 $5,400.00 FRIEGHT FROM MFG TO STAGING AREA PER Q-75223 N/A N/A
Sales Tax $38,822.13 $38,822.13 estimated sales tax for new transmitter and services. Final total will be included in quote. EST PER Q-75223 N/A N/A
Primary Transmitter ULXTE-24 $1,482,622.13 $966,061.41 $210,603.01
SALES TAX $38,822.13 $38,822.13 SALES TAX PER GATES Q-75224 $12,940.71 N/A
FREIGHT $5,400.00 $5,400.00 FREIGHT FROM MFG TO STAGING AREA PER Q-75224 $1,800.00 N/A
Site Survey - TX $20,000.00 $20,000.00 Site survey and report are required to be performed before the new transmitter and components installation plan can be finalized. $10,500.00 N/A
Disconnect existing Transmitter $20,000.00 $20,000.00 Disconnect transmitter and components from existing configuration and move within building to make way for new facilities. $495.00 N/A
Transmitter - Training $3,300.00 $3,300.00 Transmitter training - offsite - 1 week in duration at mfg site. N/A N/A
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW $684,000.00 $515,054.46 Q-75224- ,LINES A+B+E = TRANSMITTER PRICING PER COST OF CATALOG $15,200.00 N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $13,700.00 N/A N/A N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A $11,516.65 N/A
Transformer 3 phase/480v - 300 KVA $36,800.00 $35,000.00 N/A $1,665.83 N/A
25 Ton system $91,500.00 $87,000.00 N/A N/A N/A
2" Rigid Conduit and Wiring (Cost per foot) $18,200.00 $17,500.00 N/A N/A N/A
Security - Site $17,500.00 $17,500.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW $494,500.00 $156,484.82 ***System Notice: Estimate adjusted and locked because line has been superseded.*** $156,484.82 N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW

Component Description:
WSJV-GATES-INT TX-INV-TE10004486-1A - TX PAYMENT 1ST.
Amount:
$171,684.82

Component Description:
Credit memo to return funds to FCC via wire transfer.
Amount:
($569,342.61)

Component Description:
WSJV GATES INT INV TE10004486-2 2ND THIRD FOR LINES A B AND E
Amount:
$171,684.82
Switchgear - industrial 800 amp

Component Description:
WSJV GATES INT INV TE10004486-2 LINE D
Amount:
$1,665.83

Component Description:
WSJV GATES INT INV TE10004486-1A LINE D
Amount:
$1,665.83
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
UHF inside RF system including switching

Component Description:
WSJV-GATES INT INV TE10004486-1A 1ST THIRD LINE C
Amount:
$11,516.65

Component Description:
WSJV-GATES INT INV TE10004486-2 2ND THIRD LINE C
Amount:
$11,516.65
FREIGHT Information not provided.
Sales Tax Information not provided.
SALES TAX

Component Description:
WSJV-MAIN-TX-SALES-TAX- DIF TE10004485-1A AND -1
Amount:
$1,050.09

Component Description:
WSJV-GATES-INV TE10004485-1-SALES TAX
Amount:
$11,890.62

Component Description:
WSJV- GATES-MAIN- 2ND INV TE10004485-2 -TAX
Amount:
$12,940.71
FREIGHT

Component Description:
WSJV-MAIN-INV-TE10004485-1A- FREIGHT
Amount:
$1,800.00

Component Description:
WSJV-GATES-MAIN- INV TE10004485-2-FREIGHT
Amount:
$1,800.00
Site Survey - TX

Component Description:
WSJV-SITE SURVEY-INV-QC18-030
Amount:
$10,500.00
Disconnect existing Transmitter

Component Description:
WSJV - Transmitter room prep- fro Decomm and install- INV-2501- PO19975
Amount:
$495.00
Transmitter - Training Information not provided.
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW

Component Description:
WSJV GATES MAIN INV TE10004485-2 - LINES A B AND E
Amount:
$171,684.82

Component Description:
WSJV-MAIN-TX-INV-TE10004485-1A- LINE A,B, E - DIF FROM -1 INV.
Amount:
$15,200.00
Service entrance 3 phase/800 amp/208 volt Information not provided.
Switchgear - industrial 800 amp

Component Description:
WSJV-GATES MAIN INV TE10004485-2 LINE C
Amount:
$11,516.65

Component Description:
WSJV-Gates-INT INV TE10004485-1A LINE C RF Comp - Switchgear -Credit from TE10004485-1 - PER RFAS 6-25-18
Amount:
($198.65)

Component Description:
WSJV-GATES- MAIN-INV TE10004485-1 ITEM C RF
Amount:
$11,715.30

Component Description:
WSJV-MAIN TX - RETURN OF DIFFERENCE FROM TE10004485-1 AND TE10004485-1A FOR LINE C
Amount:
($198.65)
Transformer 3 phase/480v - 300 KVA

Component Description:
WSJV-GATES-INV TE10004485-1-ELEC ITEM D
Amount:
$1,665.83

Component Description:
WSJV-GATES-MAIN INV TE10004485-2 - LINE D
Amount:
$1,665.83
25 Ton system Information not provided.
2" Rigid Conduit and Wiring (Cost per foot) Information not provided.
Security - Site Information not provided.
UHF - Liquid Cooled Solid State Transmitter 8.2 - 13 kW

Component Description:
WSJV-GATES-MAIN-INV TE10004485-1- ITEMS A,B,AND E
Amount:
$156,484.82

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 $591,525.00 $456,867.24 N/A ($221,437.77) N/A
Total for all systems $4,195,211.98 $3,255,815.21 N/A $128,623.84 N/A
Interim Antenna TFU-16WB-R-RC160 $330,835.00 $197,467.24 ($326,767.59)
UHF - Lower Power Side Mount, One station antenna - medium power (50-200 kW), horizontally polarized $89,400.00 $85,000.00 N/A ($383,406.84) N/A
Elbow complex, broadband, at antenna input, per 3 1/8. feedline (if needed) $9,340.00 $6,583.50 ***System Notice: Estimate adjusted and locked because line has been superseded.***WSJV REQUIRES 6-75 DIGIT ELBOW PER DIELETRIC $5,386.50 N/A
UHF - Lower Power Side Mount, One station antenna - medium power (50-200 kW), horizontally polarized $89,400.00 $10,192.49 ***System Notice: Estimate adjusted and locked because line has been superseded.***ANT IS ENTERED TWICE THE SYSTEM LEFT TO SAYING THE OLD ENTRY HAD BEEN SUPERSEDED. THIS WAS OPEN SO I ENTERED THE BALANCE FOR THE REQUIRED INTERIM ANT PER INV 93045 $0.00 N/A
FRIEGHT $4,455.00 $4,455.00 FREIGHT FROM MFG TO STAGING AREA. $0.00 N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,260.00 $5,000.00 N/A N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $0.00 N/A
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed) $13,700.00 $11,970.00 Elbow price per DIE OC 417001 uploaded with INV 93045,MAN00098 and MAN00116 $5,386.50 N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $22,000.00 N/A N/A N/A
UHF - Lower Power Side Mount, One station antenna - medium power (50-200 kW), horizontally polarized $89,400.00 $45,866.25 ***System Notice: Estimate adjusted and locked because line has been superseded.***WSJV REQUIRES TFU-16WB C160 ANTENNA PER DIELETRIC. $45,866.25 N/A
Primary Antenna TFU-27ETT/VP-R 3T170 $260,690.00 $259,400.00 $105,329.82
UHF - High Power Top Mount One Station antenna elliptically or circularly polarized $235,000.00 $235,000.00 tool did not populate the predetermined est catalog price for an equivalent horizontally antenna. $97,063.32 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $2,880.00 N/A
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed) $13,700.00 $13,000.00 N/A $5,386.50 N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,260.00 $5,000.00 N/A N/A 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:
Credit memo to return funds to FCC via wire transfer.
Amount:
($429,273.09)

Component Description:
WSKV- DIE- INT ANT - LINE 1 INV MAN00098 - 10-18-18 -
Amount:
$45,866.25
Elbow complex, broadband, at antenna input, per 3 1/8. feedline (if needed)

Component Description:
INTERIM ELBOW WSJV -INV MAN00116-LINE 19 -6-4-NO CHANGE
Amount:
$5,386.50

Component Description:
WSJV-DIE-INTERIM- INV 93045 LINE 18 BALANCE
Amount:
$1,197.00

Component Description:
ELBOW-WSJV-INV MAN00098 ADDED QUOTE 10-4-018 LINE 19
Amount:
$5,386.50
UHF - Lower Power Side Mount, One station antenna - medium power (50-200 kW), horizontally polarized

Component Description:
WSJV-DIELETRIC-INTERIM ANT-INV 93045 - BALANCE LINE 1
Amount:
$10,192.49
FRIEGHT

Component Description:
WSJV-DIELECTRIC- INV 93045 - LINE 19 FREIGHT-2/3 payment
Amount:
$2,935.38
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) Information not provided.
Sweep test of existing antenna Information not provided.
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
WSJV- DIE INT ELBOW - INV MAN00098 LINE 19
Amount:
$5,386.50
Side mount brackets for high power antennas (if not included in antenna base cost) Information not provided.
UHF - Lower Power Side Mount, One station antenna - medium power (50-200 kW), horizontally polarized

Component Description:
INTERIM ANT WSJV - INV-MAN00116 LINE 1 6-4 - DIELECTRIC REVISED INV LINE 1 TO MATCH TOTAL DUE.
Amount:
$45,866.25

Component Description:
REENTER INTERIM ANT -LINE1 -WSJV DIELECTRIC - ADDED QUOTE 10-4-18 - 10-18-18 - superseded see new line item
Amount:
N/A
UHF - High Power Top Mount One Station antenna elliptically or circularly polarized

Component Description:
MAIN ANTENNA-WSJV-10% DEP INV. LINES 1 AND 3
Amount:
$21,569.63

Component Description:
MAIN ANTENNA-WSJV-35% DEP INV - LINES 1 AND 3
Amount:
$75,493.69
Sweep test of existing antenna

Component Description:
SWEPP- MAIN ANTENNA WSJV- DEP35% INV LINE 24
Amount:
$2,240.00

Component Description:
SWEEP MAIN ANTENNA WSJV- 10% DEP INV LINE 24
Amount:
$640.00
Elbow complex, broadband, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
ELBOW-MAIN ANTENNA 10% DEP WSJV-LINE 4
Amount:
$1,197.00

Component Description:
ELBOW-MAIN ANTENNA- WSJV-35% DEP INV. LINE 4
Amount:
$4,189.50
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) Information not provided.

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $558,196.00 $472,610.25 N/A $221,437.77 N/A
Total for all systems $4,195,211.98 $3,255,815.21 N/A $128,623.84 N/A
Interim Transmission Line $328,950.00 $254,094.25 $149,534.29
Rigid Transmission Line - copper, 6 1/8" $217,150.00 $166,149.20 Interim system required 61/8" line. We tried to engineer down the size. Supporting final engineering requirements for interim attached. $74,767.14 N/A
Rigid Transmission Line - copper, 3 1/8" $111,800.00 $87,945.05 ***System Notice: Estimate adjusted and locked because line has been superseded.***WSJV- REQUIRES 6-75 DIA LINE FOR INTERIM. $74,767.15 N/A
Primary Transmission Line $229,246.00 $218,516.00 $71,903.48
Rigid Transmission Line - copper, 6 1/8" $216,746.00 $206,016.00 N/A $71,903.48 N/A
Disconnect existing Interior RF components $12,500.00 $12,500.00 Disconnect interior RF transmission line and filters from existing configuration and move within the building to make way for new facilities. N/A N/A

Components

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

Component Description:
WSJV-DIE-INTERIM LINE INV MAN00098 ADDED QUOTE- LINES 2 AND 18 10-4-18
Amount:
$74,767.14
Rigid Transmission Line - copper, 3 1/8"

Component Description:
WSJV-INV MAN00116 -INTERIM ANT- LINES 2, 18, 21. 6-4-NO CHANGE
Amount:
$74,767.15

Component Description:
INTERIM LINE WSJV- LINES 2 AND18
Amount:
$74,767.15

Component Description:
WSJV DIE- INTERIM - INV 93045 LINES 2 AND 17 BALANCE
Amount:
$13,177.90
Rigid Transmission Line - copper, 6 1/8"

Component Description:
LINE-MAIN ANTENNA-WSJV-10% DEP INV. LINE 5
Amount:
$15,978.55

Component Description:
LINE-MAIN ANTENNA WSJV-DPE INV 35% LINE 5
Amount:
$55,924.93
Disconnect existing Interior RF components 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 $214,400.00 $203,900.00 N/A $3,900.00 N/A
Total for all systems $4,195,211.98 $3,255,815.21 N/A $128,623.84 N/A
Primary Tower GTOWER $214,400.00 $203,900.00 $3,900.00
Tower Structural Study $3,900.00 $3,900.00 Per Paul J. Ford Invoice # 200834 $3,900.00 N/A
Tall Tower (greater than 500') $210,500.00 $200,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Tower Structural Study

Component Description:
Structural analysis - Paul J. Ford - INV 200834
Amount:
$3,900.00
Tall Tower (greater than 500') 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 $324,708.06 $313,366.06 N/A $88,510.18 N/A
Total for all systems $4,195,211.98 $3,255,815.21 N/A $128,623.84 N/A
Outside Professional Services $324,708.06 $313,366.06 $88,510.18
Shared Antenna Study $480.00 $480.00 Per Carl T Jones Consulting Engineers INV 858-00-0043 WSJV $480.00 N/A
Vendor Travel Expenses $21,965.00 $21,965.00 Reimbursable Vendor Travel expenses for working in the field on behalf of the station for the Repack project - see quote for estimated expenses. QC17007 $2,096.62 N/A
Quarterly reporting $7,000.00 $7,000.00 Preparation and submittal of the FCC required quarterly report 387 by PM and attorney. N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $7,360.00 $7,000.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $4,100.00 $3,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $840.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $6,230.00 Per actual costs $6,230.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $5,000.00 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A N/A N/A
Project management of the transition $147,572.00 $140,100.00 N/A $47,362.50 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $3,660.00 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 - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 N/A N/A N/A
General Repack Legal Services $22,841.06 $22,841.06 See attached memo-QMI Repack Invoice Memo for Shared Legal Expenses (Matter 10441100054) for Form 399- $22,841.06 N/A

Components

Actual Information Description File Name
Shared Antenna Study

Component Description:
shared antenna study - Carl T Jones - INV 858-00-0043 WSJV
Amount:
$480.00
Vendor Travel Expenses

Component Description:
WSJV-QCOMM-TRAVEL INV QC17-147 ITEMS 1010-1015
Amount:
$2,096.62
Quarterly reporting Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Eng Services - Lohnes - INV 202010-0275-06
Amount:
$840.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
CP AND ENGR SUPPORT - WSJV - INV
Amount:
$2,270.00

Component Description:
Eng portion of Form 2100 - Lohnes - INV 201910-0275-06
Amount:
$3,960.00
Perform engineering study for new channel assignment and antenna development

Component Description:
WSJV - LOHNES - MAP CONTOUR - INV 201803-74007
Amount:
$1,000.00

Component Description:
WSJV - Antenna Development study - Lohnes - INV 201910-0275-06
Amount:
$1,300.00

Component Description:
NEW CH ENGR-WSJV - INV
Amount:
$2,700.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Prepare and or review reimbursement form Information not provided.
Project management of the transition

Component Description:
WSJV - PM 8THRU12 - INV QC18-022
Amount:
$11,002.50

Component Description:
WSJV-QCOMM-PM-QC17-147 ITEM 4004-MAR-AUG17
Amount:
$16,950.00

Component Description:
WSJV- PM 1THRU3-18 INV QC18-050
Amount:
$6,412.50

Component Description:
WSJV - PM AUG THRU OCT 18 - IV QC18-083
Amount:
$3,600.00

Component Description:
PM - WSJV - DEP 50PERCENT INV
Amount:
$70,007.50

Component Description:
WSJV-PM 4THRU7-18 INV QC18-066
Amount:
$9,397.50
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
LEGAL WSJV- CP APRIL17
Amount:
$470.00

Component Description:
LEGAL WSJV - CP AUG17
Amount:
$517.00

Component Description:
LEGAL WSJV CP - JULY 17
Amount:
$1,579.00

Component Description:
LEGAL WSJV CP MAY17
Amount:
$453.00

Component Description:
LEGAL WSJV - CP - JUNE17
Amount:
$500.00

Component Description:
LEGAL WSJV CP SEPT17
Amount:
$141.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
General Repack Legal Services

Component Description:
WSJV - BROOKS GEN INV 3952584 10-30
Amount:
$28.29

Component Description:
WSJV - BROOKS GEN INV FEB 18 INV 3950148 10-30
Amount:
$28.28

Component Description:
WSJV - GNERAL LEGAL JUNE 17 INV 3941325 - 10-30
Amount:
$266.44

Component Description:
WSJV-BROOKS-MAY18 INV 3953759
Amount:
$49.50

Component Description:
WSJV BROOKS GEN MAR 18 INV 3951201 10-30
Amount:
$28.28

Component Description:
Legal March 2019 - Brooks - 3965352
Amount:
$364.00

Component Description:
Legal November 2017 - Brooks - INV 3946860
Amount:
$188.00

Component Description:
Legal Nov 2020 - Brooks - INV 3990926
Amount:
$374.00

Component Description:
Legal May 2017 - INV 3940165
Amount:
$453.00

Component Description:
WSJV - Brooks - Gen Legal Aug 2019 - INV 3971021
Amount:
$780.00

Component Description:
Gen Legal Dec 2019 - Brooks - INV 3976820
Amount:
$884.00

Component Description:
General legal Jan 2020 - Brooks - INV 3977753
Amount:
$1,008.00

Component Description:
Legal - Period ending OCT 2019 - Brooks INV 3974480
Amount:
$3,447.50

Component Description:
General Legal Jan 2019 - Brooks - INV 3962866
Amount:
$3,120.00

Component Description:
Gen Legal April 2019 - Brooks - INV 3966161
Amount:
$156.00

Component Description:
Legal Dec 2017 - Brooks - INV 3947920
Amount:
$188.00

Component Description:
Legal June 2019 - Brooks - INV 3968512
Amount:
$156.00

Component Description:
Legal July 2020 - Brooks - INV 3985552
Amount:
$52.00

Component Description:
Legal April 2020 - Brooks - INV 3981495
Amount:
$2,040.00

Component Description:
Legal October 31, 2020 - Brooks - INV 3989470
Amount:
$1,720.00

Component Description:
Legal Sept 2020 - INV 3988343
Amount:
$312.00

Component Description:
Legal Sept 2019 - Brooks - INV 3972818
Amount:
$156.00

Component Description:
Legal - June 2020 - Brooks - INV 3984323
Amount:
$79.50

Component Description:
Legal Dec 2018 - Brooks - INV 3961873
Amount:
$49.50

Component Description:
Lega Feb 2020 - Brooks - INV 3978896
Amount:
$104.00

Component Description:
Legal Oct 2017 - Brooks - INV 3945573
Amount:
$141.00

Component Description:
Legal Oct 2018 - Brooks - Inv 3959629
Amount:
$148.50

Component Description:
Legal Nov 2018 - Brooks - INV 3960718
Amount:
$297.00

Component Description:
Legal July 2019 - Brooks - INV 3970199
Amount:
$312.00

Component Description:
General Legal - March 2020 - Brooks - INV 3980276
Amount:
$3,191.00

Component Description:
BROOKS-QMI GENERAL WSJV MAY17 INV
Amount:
$190.85

Component Description:
WSJV - GENERAL LEGAL DEC 17 INV 3947925 10-30
Amount:
$40.28

Component Description:
BROOKS-QMI GENERAL WSJV NOV17 INV
Amount:
$221.57

Component Description:
WSJV - BROOKS GEN INV 3949059 JAN 18 10-30
Amount:
$35.36

Component Description:
WSJV - BROOKS - APRIL18 - INV3952579
Amount:
$1,089.00

Component Description:
BROOKS-QMI GENERAL WSJV AUG17 INV
Amount:
$117.85

Component Description:
WSJV - GENERAL LEGAL MAY 17- INV 3940170 -10-30
Amount:
$190.86

Component Description:
WSJV - GENERAL LEGAL JULY 17 INV 3942230 10-30
Amount:
$275.00

Component Description:
BROOKS-QMI GENERAL WSJV JUNE17 INV
Amount:
$266.44

Component Description:
WSJY- BROOKS - LEGAL JAN 18 INV 3949054
Amount:
$49.50

Component Description:
BROOKS-QMI GENERAL WSJV JULY17 INV
Amount:
$275.00

Component Description:
BROOKS-QMI GENERAL WSJV OCT17 INV
Amount:
$322.28

Component Description:
WSJV- AUG18 - BROOKS INV 3957119
Amount:
$198.00

Component Description:
BROOKS-QMI GENERAL WSJV SEPT17 INV
Amount:
$80.57

Component Description:
WSJV-BROOKS JUL18 - INV 3955732
Amount:
$49.50

Component Description:
WSJV-BROOKS - MAR-18- INV 3951196
Amount:
$49.50

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 $99,438.66 $97,433.66 N/A $25,218.66 N/A
Total for all systems $4,195,211.98 $3,255,815.21 N/A $128,623.84 N/A
Other Expenses $99,438.66 $97,433.66 $25,218.66
Additional Insurance $118.66 $118.66 Per Winters Insurance invoice 99459 $118.66 N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 Required FCC notification. N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $2,950.00 N/A
AM Pattern Disturbance -- Remedy $21,050.00 $20,000.00 N/A N/A N/A
AM Pattern Disturbance -- Impact study $7,890.00 $7,500.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $15,000.00 $15,000.00 Required FCC announcements and good will public relations must we upheld. The production airing and disseminating of these announcements are fundamental to our operations. N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $10,000.00 $10,000.00 Rent 40 yard dumpster with multiple pickups. Estimated 6- months on site. Potential hazardous waste management issues. N/A N/A
Equipment Storage $20,300.00 $20,300.00 Expecting multiple staggered equipment deliveries from different vendors and need to store and stage new equipment prior to installation date. Anticipate from 6-24 months of storage time. $20,300.00 N/A
Equipment Delivery and Handling Charges $8,000.00 $8,000.00 Transport, forklift rental and handling fees from staging area to transmitter site. $1,850.00 N/A

Components

Actual Information Description File Name
Additional Insurance

Component Description:
Additional insurance to cover equipment in storage. Winters - INV 99459
Amount:
$118.66
MVPD Notification of Channel Change Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
DTV Medical Facility Notification

Component Description:
Medical Notifications - RF Notif - INV 1268
Amount:
$2,950.00
AM Pattern Disturbance -- Remedy Information not provided.
AM Pattern Disturbance -- Impact study Information not provided.
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.
Equipment Storage

Component Description:
WSJV - CASEY STORAGE 3RD QTR 18 - INV 1012-1 - 10-31
Amount:
$1,800.00

Component Description:
4th Qtr 2019 storage fees - Casey's - INV 1059
Amount:
$1,800.00

Component Description:
1st qtr 2020 storage - Casey's - INV 1043
Amount:
$1,800.00

Component Description:
3rd Qtr 2019 rent - Casey's - INV 1058
Amount:
$1,800.00

Component Description:
3rd qtr rent 2020 - Casey's INV 1062
Amount:
$1,800.00

Component Description:
storage 2nd qtr 2020 - Casey's - INV 1061
Amount:
$1,800.00

Component Description:
2nd Qtr 2019 rent - Casey's - INV 1057
Amount:
$1,800.00

Component Description:
4th Qtr 2018 storage - Casey's - INV 1023
Amount:
$1,800.00

Component Description:
WSJV- CASEYS STORAGE - 10/11-1-11-18
Amount:
$1,800.00

Component Description:
WSJV-CASEYS - STORAGE 4THRU7-1-18
Amount:
$1,800.00

Component Description:
WSJV-CASEYS - FORKLIFT OFFLOAD 1-12-18-INV 1004
Amount:
$500.00

Component Description:
WSJV -CASEYS- STORAGE 1-4-12-18 - INV 1003
Amount:
$1,800.00
Equipment Delivery and Handling Charges

Component Description:
Eq delivery & forklift - Casey's - INV 1063
Amount:
$750.00

Component Description:
Equipment handling (forklift rental) - Casey's - INV 1044
Amount:
$1,100.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $4,195,211.98 $3,255,815.21 $128,623.84

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.

BRADY DREASLER

CORPORATE DIRECTOR OF ENGINEERING


03/17/2021

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.

BRADY DREASLER

CORPORATE DIRECTOR OF ENGINEERING


03/17/2021

Attachments

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