TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
Jason V Boyer	Jason Boyer 1 SOUTH MAIN SYLACAUGA, AL 35150 United States	+1 (256) 454-0457	jasonboyer20@aol.com	Individual

Applicant

Address

Phone

Applicant Type

Jason V Boyer

Jason Boyer

1 SOUTH MAIN

SYLACAUGA, AL 35150

United States

+1 (256) 454-0457

jasonboyer20@aol.com

Individual

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant	Address	Phone	Email
[Confidential]

Preparer Contact Information

Preparer Contact Name and Information

Applicant	Address	Phone	Email
The Preparer is same as the reimbursement contact.

Broadcaster Information and Transition Plan

Question	Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information.	No
Briefly describe transition plan	Modification of license facility move from current channel 47 to our post assignment channel 23. Having to purchase new transmitter, antenna, tower, misc.

Transmitters

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

Primary Transmitter

Existing Transmitter Information

Section	Question	Response
Existing Transmitter Description	Type of change	Purchase New
	Use	Primary (Main)
	Description of Use	N/A
	Ownership	Owned
	Owner	N/A
	Site	N/A
	Is this transmitter currently shared with another station?	No
	Is this transmitter currently in operating condition?	Yes
Existing Transmitter Manufacturer and Type	Manufacturer
	Model	UTX1k
	Year	2005
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power Capacity	.5 kW

Primary Transmitter

New Transmitter Costs

Section	Question	Response
New Transmitter	Use	Primary (Main)
	Change Type	Purchase New
	Is this a request for upgraded equipment?	Yes
	Manufacturer
	Model	UAXTE-2R37
	Transmitter Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	1.2 kW
	Justification for New Transmitter	Existing transmitter manufacturer is out of business and the transmitter is no longer supported

Primary Transmitter

Other Transmitter Costs

Section	Question	Response
Electrical Service	Service Entrance (3 phases 800A 208V)	No
	Switchgear (industrial 800 amp)	No
	Transformer (480V)	No
	Power	N/A
	Rigid Conduit and Wiring	No
	Size	N/A
	Length	N/A
	Other Electrical Service	No
	Description	N/A
HVAC Service	Does the replacement transmitter require HVAC Service?	Yes
	Type	Cooling Only
	Size	5 tons
	Other Size	N/A
Transmitter Building Addition/Modification or Leasehold Improvement	Does the Transmitter Building require an addition, modification, other leashold improvement?	No
	Size	N/A
Channel 14 Costs	Is an RF Consulting Engineer needed?	N/A
	Is a channel 14 Mask Filer needed?	N/A
	Is additional field engineering time needed?	N/A
	Number of Days	N/A

Primary Transmitter

Other Transmitter Cost Not Listed

Information not provided.

Antennas

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

Primary Antenna

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	Class A
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Slotted Coaxial
	Number of Stations Supported	N/A
	Number of Panels	N/A
	Design power capacity in use	N/A
	Lower Limit	N/A
	Upper Limit	N/A
	Other Antenna Type	N/A
	ERP:	3.0 kW
	Manufacturer
	Model	ALP8LI-HSOC-25
	Year	2005

Primary Antenna

New Antenna Costs

Section	Question	Response
New Antenna Description	Use	Primary (Main)
	Description of Use	N/A
	Change Type	Purchase New
	Is this a request for upgraded equipment?	No
	Ownership	Owned
	Owner	N/A
	Is antenna shared?	No
	Is antenna directional?	No
	Will antenna be located on or in close proximity to an antenna farm?	No
New Antenna Manufacturer and Types	Class	Class A
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Slotted Coaxial
	Number of Stations Supported	N/A
	Number of Panels/Bays	N/A
	Lower Limit	N/A
	Upper Limit	N/A
	Design power capacity in use	N/A
	Other Antenna Type	N/A
	ERP:	8.0 kW
	Manufacturer
	Model	ATC-BCH48M-23
	Year	2017
	Justification for New Antenna	Existing antenna cannot be modified for use on the new channel

Primary Antenna

Other Antenna Costs

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

Primary Antenna

Other Antenna Cost Not Listed

Information not provided.

Transmission Line

Section	Question	Response
Transmission Line Related Expenses	Do you have transmission line related expenses?	No

Tower Equipment And Rigging Costs

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

Primary Tower

Existing Tower

Section	Question	Response
Existing Tower Description	Type of change	Modify Existing
	Tower Use	Primary (Main)
	Description of Use	N/A
	Ownership	Owned
	Is this tower consider Complex?	Terrain Constrained
	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?	Unknown
	Is tower compliant with Rev G?	Unknown
Existing Tower Structure Registration	Do you have a tower registration number?	No
Existing Tower Structure Registration	ASR Number
Coordinates (NAD83)	Latitude (NAD83)	33° 24' 41.6" N-
	Longitude (NAD83)	086° 12' 27.0" W-
	Overall Structure Height	150.00 feet
	Support Structure Height	150.00 feet
	Ground Elevation Above Mean Sea Level (AMSL)	1683.00 feet
	Structure Type	TOWER - Free Standing or Guyed Structure
	Tower Owner	Joseph V. Early
	Date Constructed	07/11/1996

Primary Tower

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:	Major Reinforcements needed

Primary Tower

Tower Rigging Costs

Section	Question	Response
Tower Rigging Costs	Complex Tower	Terrain constrained
Helicopter Services Required	Are helicopter services required?	No

Primary Tower

Other Tower Expenses Not Listed

Information not provided.

Primary Tower

Existing Tower

Section	Question	Response
Existing Tower Description	Type of change	Construct New
	Tower Use	Primary (Main)
	Description of Use	N/A
	Ownership	Owned
	Is this tower consider Complex?	Terrain Constrained
	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?	Unknown
	Is tower compliant with Rev G?	Unknown
Existing Tower Structure Registration	Do you have a tower registration number?	No
Existing Tower Structure Registration	ASR Number
Coordinates (NAD83)	Latitude (NAD83)	33° 24' 41.6" N-
	Longitude (NAD83)	086° 12' 27.0" W-
	Overall Structure Height	150.00 feet
	Support Structure Height	150.00 feet
	Ground Elevation Above Mean Sea Level (AMSL)	1683.00 feet
	Structure Type	TOWER - Free Standing or Guyed Structure
	Tower Owner	Joseph V. Early
	Date Constructed	07/11/1996

Primary Tower

Tower Construction Costs

Section	Question	Response
Construct New Tower	Use	Primary (Main)
	Description of Use	N/A
	Is this a request for upgraded equipment?	No
	Height	150.00 feet
	Justification for New Tower	Existing tower is undocumented, which prevents a tower study and modification

Primary Tower

Tower Rigging Costs

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

Primary Tower

Other Tower Expenses Not Listed

Name	Description
Tower Mapping for undocumented or poorly documented tower and tower load study	Tower Mapping and Load Study

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	Yes
	Number of Hours	595
	Explanation	Strategic Support
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	No
	Quantity	N/A
	NEPA Section 106 environmental review	No
	Environmental Assessment	No
	ASR Modification	No
	FAA Consultation (including preparation of FAA Form 7460)	No
	Negotiation of Lease and other Matter for Shared Locations	No
	Prepare or Review FCC Form 399 for Reimbursement	No
	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

Other Professional Services Expenses Not Listed

Name	Description
Preparation of engineering portion of form 399	Preparation of engineering portion of form 399

Other Expenses

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

Other Expenses

Other Expenses Not Listed

Information not provided.

Cost Information

Transmitters

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$146,250.00	$86,025.00	N/A	$34,784.43	N/A
Total for all systems	$497,980.00	$332,600.00	N/A	$106,126.93	N/A
Primary Transmitter UAXTE-2R37	$146,250.00	$86,025.00		$34,784.43
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW	$126,000.00	$79,050.00	WOIL GatesAir Quote Q-57692	$27,809.43	N/A
5 Ton system	$20,250.00	$6,975.00	Purchasing 3 Ton per Sleeping Giant Heating and Cooling Est #697 (5 Ton is min selection in LMS).	$6,975.00	N/A

Components

Actual Information Description	File Name
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW	Component Description: UAXTE-2R37 Transmitter, 70% payment of comparable equipment Amount: $27,809.43
5 Ton system	Component Description: Installation labor and materials Amount: $6,975.00

Cost Information

Antennas

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$26,300.00	$7,750.00	N/A	$0.00	N/A
Total for all systems	$497,980.00	$332,600.00	N/A	$106,126.93	N/A
Primary Antenna ATC-BCH48M-23	$26,300.00	$7,750.00		$0.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic	$26,300.00	$7,750.00	please see attached Alive Telecom Quote 041919	N/A	N/A

Components

Actual Information Description	File Name
UHF - Lower Power Side Mount, Class A One Station antenna -- basic	Component Description: ATC-BCH48M-23 Coaxial Slot Antenna, 4 Deg BT, 8-Bay, Omnioid Pattern, Slot Covers, 1-5/8 Input Amount: $2,875.00

Cost Information

Transmission Line

Information not provided.

Cost Information

Tower Equipment and Rigging Costs

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$206,955.00	$122,755.00	N/A	$62,377.50	N/A
Total for all systems	$497,980.00	$332,600.00	N/A	$106,126.93	N/A
Primary Tower TOWER	$0.00	$0.00		$0.00
Primary Tower TOWER	$0.00	$0.00		$0.00
Primary Tower	$206,955.00	$122,755.00		$62,377.50
New tower	$120,755.00	$120,755.00	Please see Estimated Cost Justification WOIL-410-New Primary Tower - Construct New v0	$60,377.50	N/A
Tower Mapping for undocumented or poorly documented tower and tower load study	$2,000.00	$2,000.00	Please see Rohn Invoice 69587	$2,000.00	N/A
Short Tower (less than 500')	$84,200.00	$0.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
New tower	Component Description: Intial Downpayment 50% Amount: $60,377.50
Tower Mapping for undocumented or poorly documented tower and tower load study	Component Description: Renfro MTN Site Visit Amount: $2,000.00
Short Tower (less than 500')	Information not provided.

Cost Information

Outside Professional Services

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$117,030.00	$114,675.00	N/A	$5,790.00	N/A
Total for all systems	$497,980.00	$332,600.00	N/A	$106,126.93	N/A
Outside Professional Services	$117,030.00	$114,675.00		$5,790.00
Preparation of engineering portion of form 399	$1,250.00	$1,250.00	Justification Letter for Southern Broadcast Solutions - Preparation of Engineering Portion of Form 399	$1,250.00	N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$2,365.00	$2,000.00	N/A	N/A	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$5,260.00	$4,500.00	N/A	N/A	N/A
Prepare request for Special Temporary Authorization	$2,050.00	$300.00	Please see WOIL Eng STA Budget Category Justification attachment	N/A	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 engineering section of FCC Form 2100 (main), Construction Permit Application	$3,155.00	$2,500.00	N/A	$1,200.00	N/A
Project management of the transition	$94,010.00	$99,675.00	See Widelity Strategic Quote	$390.00	N/A
Perform engineering study for new channel assignment and antenna development	$7,360.00	$2,950.00	see Estimated Cost Justification WOIL-530-RF Eng - New Channel Study v0	$2,950.00	N/A

Components

Actual Information Description	File Name
Preparation of engineering portion of form 399	Component Description: Preparation of engineering portion of form 399 Amount: $1,250.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	Information not provided.
Prepare request for Special Temporary Authorization	Component Description: Consulting Amount: $300.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	Component Description: WOIL-530-RF Eng - Construction Permit Application (Main) Amount: $400.00 Component Description: WOIL-530-RF Eng - Construction Permit Application (Main) Amount: $800.00
Project management of the transition	Component Description: Project Management Amount: $26.25 Component Description: Project Management Amount: $363.75
Perform engineering study for new channel assignment and antenna development	Component Description: Field Engineering WOIL guyed tower Amount: $850.00 Component Description: Consulting - Per Hour (Quantity) Amount: $900.00 Component Description: Consulting - Per Hour (Quantity) Amount: $1,200.00

Cost Information

Other Expenses

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$1,445.00	$1,395.00	N/A	$0.00	N/A
Total for all systems	$497,980.00	$332,600.00	N/A	$106,126.93	N/A
Other Expenses	$1,445.00	$1,395.00		$0.00
FCC Filing Fees - Form 2100 license to cover application	$335.00	$325.00	N/A	N/A	N/A
FCC Filing Fees - Form 2100 minor change CP application	$1,110.00	$1,070.00	N/A	N/A	N/A

Components

Information not provided.

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$497,980.00	$332,600.00	$106,126.93

Reimbursement Status

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

Section	Question	Response
Submission of Estimated Expenses Statements	WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.
The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD). The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Joseph Earley President 12/02/2019

Section

Question

Response

Submission of Estimated Expenses Statements

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

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

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

Joseph Earley

President

12/02/2019

Certification

Section	Question	Response
Submission of Actual Cost Documentation Statements	WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).
The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) . The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Joseph Earley President 12/02/2019

Section

Question

Response

Submission of Actual Cost Documentation Statements

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

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

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

Joseph Earley

President

12/02/2019

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

Applicant Information

Applicant Name, Type, and Contact Information

Reimbursement Contact Information

Reimbursement Contact Name and Information

Preparer Contact Information

Preparer Contact Name and Information

Broadcaster Information and Transition Plan

Transmitters

Primary Transmitter

Existing Transmitter Information

Primary Transmitter

New Transmitter Costs

Primary Transmitter

Other Transmitter Costs

Primary Transmitter

Other Transmitter Cost Not Listed

Antennas

Primary Antenna

Existing Antenna Information

Primary Antenna

New Antenna Costs

Primary Antenna

Other Antenna Costs

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Tower Equipment And Rigging Costs

Primary Tower

Existing Tower

Primary Tower

Tower Modification Costs

Primary Tower

Tower Rigging Costs

Primary Tower

Other Tower Expenses Not Listed

Primary Tower

Existing Tower

Primary Tower

Tower Construction Costs

Primary Tower

Tower Rigging Costs

Primary Tower

Other Tower Expenses Not Listed

Outside Professional Services Costs

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Other Expenses

Other Expenses

Other Expenses Not Listed

Cost Information

Transmitters

Components

Cost Information

Antennas

Components

Cost Information

Transmission Line

Cost Information

Tower Equipment and Rigging Costs

Components

Cost Information

Outside Professional Services

Components

Cost Information

Other Expenses

Components

Cost Information

Grand Total

Reimbursement Status

Certification

Certification

Attachments