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:
2784
Service:
DTV
Call Sign:
KVTJ-DT
Channel:
18 (UHF)
File Number:
0000028490
FRN:
0001554666
Date Submitted:
10/30/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

VICTORY TELEVISION NETWORK, INC.

Jim Grant

P.O. BOX 26207

LITTLE ROCK, AR 72221

United States

+1 (501) 223-2525 jim.grant@vtntv.com Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

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 Please see attached Transition Plan Narrative.

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 CST II
Year 1997
Type Inductive Output Tube
IOT Power Type Two
Power Capacity 60 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model THU9-48Evo
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 37 kW
Justification for New Transmitter Existing transmitter manufacturer, ABS, is no longer in business.

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) No
Power N/A
Rigid Conduit and Wiring Yes
Size 4 inches
Length 300.0 feet
Other Electrical Service Yes
Description Electrical installation for transmitter and other items related to overall KVTJ-DT electrical project.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size 20 tons
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 816.0 square feet
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Transport Stream Processing and Evaluation

KVTJ-DT has always required a transport stream multiplexer & encoder located at the transmit site. We will need another multiplexer & associated equipment to transition between transmitters.

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? 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 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: 780.0 kW
Manufacturer
Model TFU-31JTH-R 04
Year 1998

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? No
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 420.0 kW
Manufacturer
Model TFU-22JTH-R-O4
Year 2018
Justification for New Antenna Antenna is slotted coaxial and cut to a single channel. As such, it is not retunable.

Primary Antenna

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Other Antenna Costs

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

Primary Antenna

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Other Antenna Cost Not Listed

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 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: 780.0 kW
Manufacturer
Model TFU-24WB-1-R S230
Year 2018
Justification for New Antenna Interim antenna to operate lower on the tower for the pre-auction channel to avoid prolonged off-period during the transition in order to meet the construction deadline.

Interim Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Broadband or Single Channel? N/A
Feed Line Size N/A
Side Mount Brackets Do you require the separate purchase of side mount brackets for an antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? 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

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 1
Length 1090 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

Interim Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Flexible Air
Diameter 5 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 950 feet per run
Justification for New Transmission Line Interim transmission line to operate lower on the tower for the pre-auction channel to avoid prolonged off-period during the transition in order to meet the construction deadline.

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 Modify Existing
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? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1048797
Coordinates (NAD83) Latitude (NAD83) 35° 36' 16.0" N-
Longitude (NAD83) 090° 31' 18.0" W-
Overall Structure Height 999.99 feet
Support Structure Height 999.99 feet
Ground Elevation Above Mean Sea Level (AMSL) 215.88 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Victory Television Network, Inc.
Date Constructed 04/20/1998


Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Serious Reinforcements needed

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Interim Installation

Install interim antenna and transmission line.

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 350
Explanation Please see the attached Transition Plan Narrative.
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 Yes
FAA Consultation (including preparation of FAA Form 7460) Yes
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 No
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

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Other Professional Services Expenses Not Listed

Name Description

Outside Engineering Consultant

KVTJ-DT's transition complexity requires a local, outside engineer with subject-matter experience for occasional consulting.

Other Expenses

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

Name Description

Arkansas Use Tax

We must pay Arkansas use tax on taxable purchases. Our out-of-state vendors are not required to collect or remit the taxes on our behalf. We must calculate and pay use tax ourselves. We have estimated our tax obligation based on our repack budget.

Security Cameras

A set of security cameras in lieu of on-site security, paid personnel to oversee the tower crew, and/or additional storage costs.

Project-related Insurance

Insurance costs directly related to the KVTJ-DT repack project.

Cost Information

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Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $1,812,679.00 $1,714,913.00 N/A $1,212,867.07 N/A
Total for all systems $4,333,913.18 $4,139,447.38 N/A $3,162,739.58 N/A
Primary Transmitter THU9-48Evo $1,812,679.00 $1,714,913.00 $1,212,867.07
Transport Stream Processing and Evaluation $48,299.00 $48,299.00 KVTJ-DT has always required a transport stream multiplexer & encoder located at the transmit site. We will need a new multiplexer & associated equipment to transition between transmitters (see attached narrative.) $48,299.00 N/A
Other -- Building Addition Size: 816.0 $67,980.00 $67,980.00 Addition of the new HVAC on west side of the KVTJ-DT building requires an extension of the building's ice shield and fence line to account for this new equipment. A 1,000 ft tower produces large ice spears that would destroy the HVAC units. See narrative. $67,980.00 N/A
20 Ton system $115,500.00 $102,440.00 Original HVAC system estimate has been revised lower based on the vendor quote received. Cost remains below Widelity Catalog cost range, June 2018 revision. Added a supplemental ducting invoice. $102,440.00 N/A
Switchgear - industrial 800 amp $38,200.00 $28,846.00 Switchgear for KVTJ-DT electrical capacity expansion project. see narrative. $28,846.00 N/A
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,473,000.00 $1,400,000.00 N/A $921,624.07 N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $13,468.00 Service entrance disconnect upgrade and related labor necessary to integrate KVTJ-DT's service entrance equipment to support the increased electrical capacity needed to complete the repack transition. see narrative. $13,468.00 N/A
4" Rigid Conduit and Wiring (Cost per foot) $30,300.00 $28,880.00 4" rigid conduit and wiring to support the increase in electrical capacity required to complete the transmitter transition. 300ft needed. see narrative. $28,800.00 N/A
Other Electrical Service: Electrical installation for transmitter and other items related to overall KVTJ-DT electrical project. $25,000.00 $25,000.00 hourly labor costs associated with all aspect of KVTJ-DT transmitter electrical installation including capacity expansion project. $1,410.00 N/A

Components

Actual Information Description File Name
Transport Stream Processing and Evaluation

Component Description:
KVTJ-DT Triveni Digital Invoice, Quote, and narrative for transport stream related equipment.
Amount:
$28,300.00

Component Description:
Harmonic Multiplexer for KVTJ-DT for transitioning between existing and new transmitters (see attached narrative.)
Amount:
$19,999.00
Other -- Building Addition Size: 816.0

Component Description:
KVTJ-DT Transmitter building expansion of ice shield and fence line to accommodate repack required HVAC system.
Amount:
$67,980.00
20 Ton system

Component Description:
Ground and site preparation costs related to installation of the 20-ton HVAC system. Gravel and dirt fill was needed to be placed in the area of the HVAC build out to receive deliveries and perform work with heavy machinery.
Amount:
$3,800.00

Component Description:
20 Ton HVAC System (Heating & Cooling) cost component inclusive of all electrical, ducting, masonry materials, and labor.
Amount:
$96,240.00

Component Description:
Ducting work necessary following KVTJ's transition from our pre-repack transmitter to our post-repack transmitter. Adheres to a time and material billing standard.
Amount:
$2,400.00
Switchgear - industrial 800 amp

Component Description:
KVTJ-DT switchgear and installation.
Amount:
$28,846.00
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW

Component Description:
Initial payment for primary transmitter & related equipment. The two shipping line items on this invoice are not included in this total. This invoice represents a 30% down payment necessary to start work on this component.
Amount:
$276,487.23

Component Description:
Final payment for KVTJ-DT main transmitter. $92162.40 amount is invoice total minus shipping and tax which are placed on separate cost components within the 399.
Amount:
$92,162.40

Component Description:
2nd payment for primary transmitter & related equipment. The two shipping line items on this invoice are not included in this total. This invoice represents a 60% down payment necessary to start work on this component.
Amount:
$552,974.44
Service entrance 3 phase/800 amp/208 volt

Component Description:
KVTJ-DT service entrance 3 phase equipment and installation.
Amount:
$13,468.00
4" Rigid Conduit and Wiring (Cost per foot)

Component Description:
KVTJ-DT 4" rigid conduit and wiring (cost represented in feet on invoice)
Amount:
$28,800.00
Other Electrical Service: Electrical installation for transmitter and other items related to overall KVTJ-DT electrical project.

Component Description:
Electrical work related to removing the CH48 transmitter and completing the repack project.
Amount:
$960.00

Component Description:
Electrical work related to removing the CH48 transmitter and completing the repack project.
Amount:
$450.00

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 $500,520.00 $485,675.20 N/A $376,286.70 N/A
Total for all systems $4,333,913.18 $4,139,447.38 N/A $3,162,739.58 N/A
Interim Antenna TFU-24WB-1-R S230 $191,990.00 $186,400.00 $177,923.52
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,260.00 $0.00 The interim scatter study cost will now be bundled into the interim antenna cost component. N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $6,400.00 N/A
UHF - High Power, Side Mount, basic slot antenna, 780 kW input, directional,, horizontally polarized $180,000.00 $180,000.00 Catalog estimated cost for UHF-Lower Power Side Mount: One station - 200-500kW, horizontally polarized $171,523.52 N/A
Primary Antenna TFU-22JTH-R-O4 $308,530.00 $299,275.20 $198,363.18
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $6,400.00 N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $289,500.00 $275,000.00 N/A $174,087.98 N/A
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,300.00 $17,875.20 Elbow complex required to be integrated at KVTJ-DT was more expensive than the FCC cost estimates contemplated. $17,875.20 N/A

Components

Actual Information Description File Name
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

Component Description:
Initial payment for field engineer interim line/antenna sweep study with report. This invoice represents a 45% down payment necessary to start work on this component.
Amount:
$2,880.00

Component Description:
Final payment for field engineer interim line/antenna sweep study with report. This invoice represents the final payment on this component.
Amount:
$640.00

Component Description:
Initial payment for field engineer interim line/antenna sweep study with report. This invoice represents a 45% down payment necessary to start work on this component.
Amount:
$2,880.00
UHF - High Power, Side Mount, basic slot antenna, 780 kW input, directional,, horizontally polarized

Component Description:
Final payment for KVTJ-DT interim antenna. This is the sum of items costing $15,727.04 and $1,425.32 on invoice # 6946.
Amount:
$17,152.36

Component Description:
Initial payment for interim antenna/mount, & the interim scatter study. Scatter study is bundled into cost of interim antenna hardware. This invoice represents a 45% down payment necessary to start work on this component.
Amount:
$77,185.58

Component Description:
2nd payment for interim antenna/mount, & the interim scatter study. Scatter study is bundled into cost of interim antenna hardware. This invoice represents a 45% down payment necessary to start work on this component.
Amount:
$77,185.58
Sweep test of existing antenna

Component Description:
Initial payment for field engineer primary line/antenna sweep study with report. This invoice represents a 45% down payment necessary to start work on this component.
Amount:
$2,880.00

Component Description:
Final payment for sweep testing of the primary KVTJ-DT antenna and line.
Amount:
$640.00

Component Description:
2nd payment for field engineer primary line/antenna sweep study with report. This invoice represents a 45% down payment necessary to start work on this component.
Amount:
$2,880.00
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized

Component Description:
Final Payment for KVTJ-DT primary antenna. This is the sum of items costing $15,182.62, $1,912.96, $237.16, & $76.04.
Amount:
$17,408.78

Component Description:
2nd payment for primary antenna/mount. This is an elliptical antenna, but we are not requesting reimbursement ($30912) for the optional aspect. See attached letter. Invoice represents a 45% down payment necessary to start work on this component.
Amount:
$78,339.60

Component Description:
Initial payment for primary antenna/mount. This is an elliptical antenna, but we are not requesting reimbursement ($30912) for the optional aspect. See attached letter. Invoice represents a 45% down payment necessary to start work on this component.
Amount:
$78,339.60
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
First and only payment for KVTJ-DT Elbow Complex.
Amount:
$17,875.20

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 $99,750.00 $95,000.00 N/A $71,613.67 N/A
Total for all systems $4,333,913.18 $4,139,447.38 N/A $3,162,739.58 N/A
Interim Transmission Line $99,750.00 $95,000.00 $71,613.67
Flexible Air Transmission Line - dielectric, 5" $99,750.00 $95,000.00 N/A $71,613.67 N/A
Primary Transmission Line $0.00 $0.00 $0.00

Components

Actual Information Description File Name
Flexible Air Transmission Line - dielectric, 5"

Component Description:
Equipment and small parts related to flushing the transmission line and then integrating it into our existing pressurization system. The main dehydration pump was included with the line but not all the necessary pieces to fully integrate it were included.
Amount:
$3,283.60

Component Description:
Final payment for interim line and parts. This is the sum of items costing $5,046.40, $178.10, $4.19, $178.10, $19.60, $121.95, $127.56, $133.18, $6.12, $0.87, $19.16, $16.59, $1.54, $492.51, $15.76, and $412.78.
Amount:
$6,774.41

Component Description:
Initial payment for interim line & related line equipment. This invoice represents a 45% down payment necessary to start work on this component.
Amount:
$30,484.83

Component Description:
Pressurization manifold that was necessary to interconnect all the feedline hoses to share the dehydrator and integrate the interim transmission line.
Amount:
$586.00

Component Description:
2nd payment for interim line & related line equipment. This invoice represents a 45% down payment necessary to start work on this component.
Amount:
$30,484.83

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 $1,488,800.00 $1,425,000.00 N/A $1,168,239.01 N/A
Total for all systems $4,333,913.18 $4,139,447.38 N/A $3,162,739.58 N/A
Primary Tower TOWER $1,488,800.00 $1,425,000.00 $1,168,239.01
Interim Installation $200,000.00 $200,000.00 N/A $98,723.00 N/A
Serious tower reinforcement/modifications $1,052,000.00 $1,000,000.00 Please see the attached Transition Plan Narrative and Structural Analysis. $907,352.01 N/A
Tall Tower (greater than 500') $210,500.00 $200,000.00 Main antenna installation. $154,364.00 N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $25,000.00 N/A $7,800.00 N/A

Components

Actual Information Description File Name
Interim Installation

Component Description:
2nd payment for tower equipment & rigging of side-mounted interim antenna and interim transmission line. This invoice represents a 40% downpayment necessary to start work on this component.
Amount:
$38,539.20

Component Description:
Attachment of our interim antenna into our coaxial switch.
Amount:
$2,375.00

Component Description:
Final payment for tower equipment & rigging of side-mounted interim antenna and interim transmission line.
Amount:
$9,634.80

Component Description:
Initial payment for tower equipment & rigging of side-mounted interim antenna and interim transmission line. This invoice represents a 50% downpayment necessary to start work on this component.
Amount:
$48,174.00
Serious tower reinforcement/modifications

Component Description:
Tower modification required by tower crew to safely operate on the KVTJ-DT tower to perform the necessary reinforcements.
Amount:
$7,056.25

Component Description:
Final payment for for serious tower modifications necessary to accommodate the increased tower load resulting from new primary antenna & new interim antenna/line.
Amount:
$88,715.20

Component Description:
Final tower work to repair a tower issue found following the major tower work. Our engineering consultants advised that we could not change channels without fixing this issue. Proposal (page 2) is the quote. Corrected to add KVTJ-DT Call Sign.
Amount:
$6,643.76

Component Description:
Initial payment for serious tower modifications necessary to accommodate the increased tower load resulting from new primary antenna & new interim antenna/line. This invoice represents a 50% downpayment necessary to start work on this component.
Amount:
$443,576.00

Component Description:
The major tower work has left the landscape around the tower site significantly damaged. We lease the land and must do remediation for the damage that was caused by the large trucks that came onto the unpaved, pastureland transmitter site.
Amount:
$5,200.00

Component Description:
2nd payment for serious tower modifications necessary to accommodate the increased tower load resulting from new primary antenna & new interim antenna/line. This invoice represents a 40% downpayment necessary to start work on this component.
Amount:
$354,860.80

Component Description:
Fencing repairs necessitated by the recently completed tower work to reinforce it and install new antennas for repack at KVTJ-DT.
Amount:
$1,300.00
Tall Tower (greater than 500')

Component Description:
2nd payment for tower equipment & rigging of new top-mounted primary antenna & removal of existing top-mounted primary antenna. This invoice represents a 40% downpayment necessary to start work on this component.
Amount:
$61,745.60

Component Description:
Final payment for tower equipment & rigging of new top-mounted primary antenna & removal of existing top-mounted primary antenna.
Amount:
$15,436.40

Component Description:
Initial payment for tower equipment & rigging of new top-mounted primary antenna & removal of existing top-mounted primary antenna. This invoice represents a 50% downpayment necessary to start work on this component.
Amount:
$77,182.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study

Component Description:
Mapping studies necessary to prepare the KVTJ-DT tower to support loading required to complete the repack. Tower was analyzed with proposed loads and then a recommendation was made for changes to support that load.
Amount:
$6,400.00

Component Description:
KVTJ-DT tower survey requested by Paul J Ford structural analysis firm & Marsand Inc consulting engineers. FAA required 1A survey was needed before the required structural analysis of the existing KVTJ-DT tower could be completed.
Amount:
$1,400.00

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 $100,083.53 $95,243.53 N/A $27,442.08 N/A
Total for all systems $4,333,913.18 $4,139,447.38 N/A $3,162,739.58 N/A
Outside Professional Services $100,083.53 $95,243.53 $27,442.08
Outside Engineering Consultant $12,493.53 $12,493.53 A long-time former employee and current contract engineer for KVTJ-DT we have utilized to aide our repack efforts. Specifically, he has advised and assisted with RF, HVAC, and electrical issues directly related to KVTJ's repack needs. $12,493.53 test
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase $2,105.00 $2,000.00 N/A N/A N/A
ASR modification (prepare FCC Form 854) $2,105.00 $2,000.00 N/A N/A N/A
Project management of the transition $55,300.00 $52,500.00 N/A $3,000.00 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $1,250.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $2,250.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $1,125.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A $600.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $4,988.00 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A $1,343.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 N/A $392.55 N/A

Components

Actual Information Description File Name
Outside Engineering Consultant

Component Description:
Consulting and engineering work related to HVAC and electrical work & materials necessary to complete the repack.
Amount:
$711.00

Component Description:
Consulting and engineering work related to HVAC and electrical work necessary to complete the repack.
Amount:
$2,025.00

Component Description:
Labor costs related to integrating the new KVTJ electrical system required by the repack into the preexisting grounding system.
Amount:
$500.00

Component Description:
Labor costs to install the new equipment rack required to remove the old transmitter.
Amount:
$3,875.00

Component Description:
Electrical materials related to the labor contained on invoice #202597. This was to install the new equipment rack required to remove the old CH48 transmitter.
Amount:
$382.53

Component Description:
Invoice and quote for consulting labor performed. Invoiced according to "time & materials" method. Updated and REVISED to comply with reimbursement guidelines.
Amount:
$4,800.00

Component Description:
Repack related inspection and planning work related to HVAC, CH48 transmitter removal, and grounding.
Amount:
$200.00
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase Information not provided.
ASR modification (prepare FCC Form 854) Information not provided.
Project management of the transition

Component Description:
Invoice for project management of the transition. Our CEs visited the KVTJ-DT site to assess it. Pay terms are 50% upfront & 50% final. This is the invoice for the final 50%. REVISED
Amount:
$3,000.00

Component Description:
REVISED Invoice for project management of the transition. Our CEs visited the KVTJ-DT site to assess it. Pay terms are 50% upfront & 50% final. Another request will be submitted for the final 50%. This invoice contains costs related to other components
Amount:
$3,000.00
Prepare and or review reimbursement form

Component Description:
REVISED Invoice to prepare & review schedule 399 reimbursement form for KVTJ-DT. Pay terms are 50% upfront & 50% final. Another request will be submitted for the final 50%. This invoice contains costs related to other components
Amount:
$1,250.00

Component Description:
REVISED Invoice to prepare & review schedule 399 reimbursement form for KVTJ-DT. Pay terms are 50% upfront & 50% final. $1250 represents the final payment. This invoice contains costs related to other components.
Amount:
$1,250.00
Perform engineering study for new channel assignment and antenna development

Component Description:
REVISED Invoice to perform eng study-new channel assignment & antenna development. Pay terms are 50% upfront & 50% final. $2250 represents the final payment. Inv contains costs related to other components.
Amount:
$2,250.00

Component Description:
REVISED inv. to perform eng study-new channel assignment & antenna development. Pay terms are 50% upfront & 50% final. $2250 represents initial payment. Another request will be submitted for the final 50%. Inv contains costs related to other components
Amount:
$2,250.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
REVISED Invoice to prepare the engineering section of FCC Form 2100 & the CP application for KVTJ-DT. Pay terms are 50% upfront & 50% final. $1125.00 represents the initial payment. This invoice contains costs related to other components.
Amount:
$1,125.00

Component Description:
REVISED Invoice to prepare the engineering section of FCC Form 2100 & the CP application for KVTJ-DT. Pay terms are 50% upfront & 50% final. $1125.00 represents the final payment. This invoice contains costs related to other components.
Amount:
$1,125.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare request for Special Temporary Authorization

Component Description:
Final payment related to filing STAs for KVTJ-DT. REVISED
Amount:
$600.00

Component Description:
REVISED Invoice to prepare STA interim facility request for KVTJ-DT. Pay terms are 50% upfront & 50% final. Another request will be submitted for the final 50%. This invoice contains costs related to other components
Amount:
$600.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
KVTJ-DT Wiley Rein LLP - Outside Professional Services: Email consultation with attorneys to Prepare Form 2100 Construction Permit Application & general issues related to KVTJ-DT repack.
Amount:
$816.00

Component Description:
KVTJ-DT Wiley Rein LLP - Outside Professional Services: Consultation with attorneys to prepare Form 2100 Construction Permit Application and prepare/file minor modification application.
Amount:
$3,415.00

Component Description:
KVTJ-DT Wiley Rein LLP - Outside Professional Services: Attorney e-mail consultation with management prior to preparing Form 2100 Construction Permit Application.
Amount:
$68.00

Component Description:
KVTJ-DT Wiley Rein LLP - Outside Professional Services: Conference calls and e-mails with attorneys to discuss issues related to preparing Form 2100 Construction Permit Application.
Amount:
$689.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Conference call and research related to filing the KVTJ-DT license to cover application.
Amount:
$935.00

Component Description:
Attorney fees related to filing KVTJ-DT's license to cover application and consultation on matters related to completing the repack project.
Amount:
$408.00
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
Fees related to filing a repack related STA for KVTJ-DT. Net 30 terms as indicated on invoice means that the due date is 12/7/2018.
Amount:
$266.00

Component Description:
Legal fees related to STA filing for KVTJ-DT repack. NET30 terms means the due date is 12/7/2018.
Amount:
$126.55

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 $332,080.65 $323,615.65 N/A $306,291.05 N/A
Total for all systems $4,333,913.18 $4,139,447.38 N/A $3,162,739.58 N/A
Other Expenses $332,080.65 $323,615.65 $306,291.05
Project-related Insurance $900.00 $900.00 The KVTJ-DT repack project occasionally has costs related to insurance such as transit insurance for large items (antennas, transmitters) and site-based insurance costs related to the ongoing construction project. $900.00 N/A
Security Cameras $5,599.90 $5,599.90 In lieu of requesting reimbursement for additional security, in-house labor to supervise a tower crew for 2+ months, and/or storage costs; we are requesting four security cameras that we can use to monitor the site in real-time. $5,599.90 N/A
Arkansas Use Tax $235,887.75 $235,887.75 We must pay Arkansas use tax on taxable purchases. Our out-of-state vendors are not required to collect or remit the taxes on our behalf. We must calculate and pay use tax ourselves. We have projected our tax obligation based on our repack budget. $222,497.30 N/A
DTV Medical Facility Notification $11,550.00 $3,140.00 Actual cost for this service has come in significantly under our original estimate and we are revising this estimate downward. $3,140.00 N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $34,805.00 $34,805.00 Disposal of antenna, transmitter, RF system $34,805.00 N/A
Equipment Delivery and Handling Charges $40,000.00 $40,000.00 Shipping for main and interim antennas and interim transmission line. We now know that actual costs for delivery will be higher than originally estimated. $38,850.85 N/A
Develop and air announcement of upcoming channel change $498.00 $498.00 N/A $498.00 We ultimately needed to mail more letters than we originally estimated.
MVPD Notification of Channel Change $1,200.00 $1,200.00 N/A N/A N/A

Components

Actual Information Description File Name
Project-related Insurance

Component Description:
Transit insurance for interim and primary antennas and line to cover the shipment in transit from Maine to Arkansas. KVTJ-DT ONLY.
Amount:
$400.00

Component Description:
A one-time short term increase in the KVTJ-DT "floater" insurance coverage to account for the site becoming as a "construction site" due to the significant amount of repack-related work happening at the site.
Amount:
$500.00
Security Cameras

Component Description:
Front security light to illuminate this part of the building which was not covered by the other lights.
Amount:
$500.00

Component Description:
Security cameras in lieu of other reimbursable costs (storage, outside security staff, or personnel oversight costs) related to the repack.
Amount:
$3,599.90

Component Description:
LED Security Lights attached to the KVTJ building to illuminate the construction area where equipment and materials were left. Complimentary to the approved security cameras. Inclusive of the electrical work necessary to install.
Amount:
$1,500.00
Arkansas Use Tax

Component Description:
Sales tax for the tower safety modification of the KVTJ-DT tower.
Amount:
$546.86

Component Description:
Sales tax on the pressurization parts and equipment invoice.
Amount:
$264.98

Component Description:
Sales and use tax on the security light.
Amount:
$38.75

Component Description:
Arkansas sales tax for invoice 6934 related to tower work and modification at KVTJ-DT.
Amount:
$9,102.91

Component Description:
sales and use tax for the interim antenna flex line installation.
Amount:
$184.06

Component Description:
Sales tax for air pressure manifold invoice
Amount:
$49.06

Component Description:
Arkansas sales tax on the KVTJ LED security lights
Amount:
$116.25

Component Description:
Sales tax on the KVTJ-DT disposal and network cable plant relocation invoice.
Amount:
$906.75

Component Description:
Sales tax for |1| 20 Ton HVAC System (heating & cooling), |2| delivery & handling, |3| disposal components.
Amount:
$7,618.64

Component Description:
Sales tax on KVTJ-DT ducting time and materials invoice.
Amount:
$186.00

Component Description:
Total Arkansas sales tax payment for invoice #6946 covering taxes owed on multiple cost components.
Amount:
$3,568.44

Component Description:
Arkansas sales tax on invoice 6948 covering multiple cost components related to KVTJ-DT main transmitter.
Amount:
$7,488.94

Component Description:
Arkansas sales tax for all components of KVTJ-DT electrical capacity upgrade listed on invoice #51474.
Amount:
$5,719.42

Component Description:
Arkansas sales tax on the KVTJ-DT transmitter disposal invoice.
Amount:
$1,305.88

Component Description:
Sales and use tax on the KVTJ-DT landscape repair.
Amount:
$403.00

Component Description:
Arkansas sales and use tax for gravel and site preparations at KVTJ-DT
Amount:
$604.50

Component Description:
Sales and use tax true-up for previously approved and reimbursed invoices from MARSAND Inc. Please see attached narrative for more information.
Amount:
$177,083.13

Component Description:
Sales tax for KVTJ-DT viewer rescan notice mailers.
Amount:
$44.82

Component Description:
Arkansas sales tax for the KVTJ-DT elbow complex. Invoice 6936.
Amount:
$1,550.02

Component Description:
Sales tax for KVTJ-DT transmitter building expansion.
Amount:
$5,390.90

Component Description:
Sales tax for the KVTJ camera invoice
Amount:
$323.99
DTV Medical Facility Notification

Component Description:
KVTJ-DT Medical Notification quote & invoice from DTV Notification.
Amount:
$3,140.00
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
Demolition and disposal costs related to removing existing equipment throughout the KVTJ-DT electrical capacity expansion project.
Amount:
$1,900.00

Component Description:
Disposal costs associated with the 20 ton HVAC (heating & cooling) component inclusive of hazardous material disposal.
Amount:
$940.00

Component Description:
Disposal costs related to the KVTJ-DT transmitter building expansion. We will need to haul away waste generated from the expansion project.
Amount:
$715.00

Component Description:
Disposal and Demolition of the full KVTJ-DT transmitter. It is a very large analog transmitter with outside heat exchangers and significant piping, RF, and electrical in the ceiling.
Amount:
$16,850.00

Component Description:
20ft on site dumpster service for KVTJ-DT for management of waste and trash generated throughout the repack project.
Amount:
$2,700.00

Component Description:
The KVTJ-DT networking plant is integrated into the old transmitter cabinets which must be disposed of. We cannot fully dispose of the final two cabinets without relocating and reterminating all this wiring to a new location next to the new transmitter.
Amount:
$11,700.00
Equipment Delivery and Handling Charges

Component Description:
2nd payment ($3825) for delivery/handling costs on the primary antenna. This invoice represents a 45% down payment necessary to start work on this component.
Amount:
$3,825.00

Component Description:
Initial payment for delivery/handling costs on interim antenna, primary antenna, & interim transmission line. The two line items are $3,825 & $5,130. This invoice represents a 45% down payment necessary to start work on this component.
Amount:
$8,955.00

Component Description:
Delivery and handling for KVTJ-DT electrical capacity upgrade
Amount:
$785.00

Component Description:
Shipping costs related to the KVTJ-DT transmitter on invoice # 6948. The sum of two line items $320.00 and $1129.33.
Amount:
$1,449.33

Component Description:
Delivery & handling costs for the 20-ton HVAC system (heating & cooling) component.
Amount:
$1,125.00

Component Description:
2nd payment ($5130) for delivery/handling costs on interim antenna & interim transmission line. This invoice represents a 45% down payment necessary to start work on this component.
Amount:
$5,130.00

Component Description:
Shipping costs related to invoice 6946 which are the antenna and line components. Sum of the $850 and $1140 lines within the invoice.
Amount:
$1,990.00

Component Description:
2nd payment for delivery/handling costs on the primary transmitter. The two line items are $1920 & $6776. This invoice represents a 60% down payment necessary to start work on this component.
Amount:
$8,696.00

Component Description:
Delivery and handling charges for construction materials related to the KVTJ-DT transmitter building expansion.
Amount:
$865.00

Component Description:
Shipping and handling for the KVTJ-DT pressurization parts.
Amount:
$135.52

Component Description:
Initial payment for delivery/handling costs on the primary transmitter. The two line items are $960 & $3388 . This invoice represents a 30% down payment necessary to start work on this component.
Amount:
$4,348.00

Component Description:
Shipping costs related to the KVTJ-DT elbow complex on invoice 6936.
Amount:
$1,500.00

Component Description:
delivery and handling for air pressure manifold.
Amount:
$47.00
Develop and air announcement of upcoming channel change

Component Description:
Cost to mail channel change rescan notices to our active viewer mailing list within the KVTJ-DT coverage area. NET30 terms means the due date is 12-30-18.
Amount:
$498.00
MVPD Notification of Channel Change Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $4,333,913.18 $4,139,447.38 $3,162,739.58

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. Yes
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.

Jim Grant

General Manager


10/30/2019

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.

Jim Grant

General Manager


10/30/2019

Attachments

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