TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
INDIANAPOLIS COMMUNITY TELEVISION, INC. Doing Business As: INDIANAPOLIS COMMUNITY TELEVISION, INC.	Arnold Torres 3901 HIGHWAY 121 SOUTH BEDFORD, TX 76021 United States	+1 (817) 571-1229	ARNOLD.TORRES@DAYSTAR.COM	Not-for-Profit

Applicant

Address

Phone

Applicant Type

INDIANAPOLIS COMMUNITY TELEVISION, INC.

Doing Business As: INDIANAPOLIS COMMUNITY TELEVISION, INC.

Arnold Torres

3901 HIGHWAY 121 SOUTH

BEDFORD, TX 76021

United States

+1 (817) 571-1229

ARNOLD.TORRES@DAYSTAR.COM

Not-for-Profit

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
Henry Turner Engineer INDIANAPOLIS COMMUNITY TELEVISION, INC.	Henry Turner 3901 HIGHWAY 121 SOUTH Bedford, TX 76021 United States	+1 (817) 571-1229	HENRY.TURNER@DAYSTAR.COM

Applicant

Address

Phone

Henry Turner

Engineer

INDIANAPOLIS COMMUNITY TELEVISION, INC.

Henry Turner

3901 HIGHWAY 121 SOUTH

Bedford, TX 76021

United States

+1 (817) 571-1229

HENRY.TURNER@DAYSTAR.COM

Broadcaster Information and Transition Plan

Question	Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information.	No
Briefly describe transition plan	Coordinate with tower owner and other Broadcasters; transition during assigned phase. WDTI will transition by changing its antenna and transmitter, remaining at the same transmitter site.

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	PA10KVA
	Year	2008
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power Capacity	3.5 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	ELETXUD3600AC
	Transmitter Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	3.6 kW
	Justification for New Transmitter	Current transmitter cannot be retuned to new antenna at allotted power level. Banding issues and unavailability of parts are the determining factors.

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	Yes
	Description	Minimal electric services will be needed to implement new facility.
HVAC Service	Does the replacement transmitter require HVAC Service?	No
	Type	N/A
	Size	N/A
	Other Size	N/A
Transmitter Building Addition/Modification or Leasehold Improvement	Does the Transmitter Building require an addition, modification, other leashold improvement?	No
	Size	N/A
Channel 14 Costs	Is an RF Consulting Engineer needed?	N/A
	Is a channel 14 Mask Filer needed?	N/A
	Is additional field engineering time needed?	N/A
	Number of Days	N/A

Primary Transmitter

Other Transmitter Cost Not Listed

Name	Description
Mask Filter	Mask Filter

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?	Yes
Existing 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	N/A
	Design power capacity in use	N/A
	Lower Limit	N/A
	Upper Limit	N/A
	Other Antenna Type	N/A
	ERP:	28.0 kW
	Manufacturer
	Model	SWCD16OMF/44-DT
	Year	2008

Primary Antenna

New Antenna Costs

Section	Question	Response
New Antenna Description	Use	Primary (Main)
	Description of Use	N/A
	Change Type	Purchase New
	Is this a request for upgraded equipment?	Yes
	Ownership	Owned
	Owner	N/A
	Is antenna shared?	No
	Is antenna directional?	No
	Will antenna be located on or in close proximity to an antenna farm?	Yes
New Antenna Manufacturer and Types	Class	Full Power
	Mounting	Side 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:	18.2 kW
	Manufacturer
	Model	SWCDS8OI/23-EP
	Year	2017
	Justification for New Antenna	Existing antenna is non-tunable to new channel.

Primary Antenna

Other Antenna Costs

Section	Question	Response
Combiner for Shared Antenna	Do you need a Combiner for a Shared Antenna?	No
	Type
	Number of channels supported	N/A
	Frequencies of channels supported	N/A
	Frequency	N/A
	Do you need a combiner output splitter/switcher for dual feed lines?	N/A
Elbow Complex	Do you require the separate purchase of the Elbow Complex?	No
	Broadband or Single Channel?	N/A
	Feed Line Size	N/A
Side Mount Brackets	Do you require the separate purchase of side mount brackets for a high power antenna?	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

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	Leased
	Is this tower consider Complex?	Candelabra
	Is this tower currently shared with any other stations?	Yes
	One or more FM, AM or TV radio broadcaster(s)	Yes
	Others Types of Users	Yes
	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?	Yes
Existing Tower Structure Registration	ASR Number	1253064
Coordinates (NAD83)	Latitude (NAD83)	39° 53' 39.2" N-
	Longitude (NAD83)	086° 12' 20.5" W-
	Overall Structure Height	1009.83 feet
	Support Structure Height	849.73 feet
	Ground Elevation Above Mean Sea Level (AMSL)	829.06 feet
	Structure Type	GTOWER - Guyed Structure Used for Communication Purposes
	Tower Owner	American Tower, LLC
	Date Constructed	07/24/2006

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID	Call Sign	Service
37102	WHMB-TV	DTV
69115	WICR	FM

Other Types of Users

Users
WUDZ-LD
WUDP-LD
WUDM-LD
WSDI-LD
WQDE-LD
WIPX-LD
WECY-LD
W236CR
W248AW

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:	Minor Reinforcements needed

Primary Tower

Tower Rigging Costs

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

Primary Tower

Other Tower Expenses Not Listed

Name	Description
Tower Permit Drawing Package	Generation of construction drawings.
Ground and Building A and E Permit Drawing Package	Ground and Building A and E Permit Drawing Package.
Construction Project Management, tower modifications.	Tower modification supervision.

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	Yes
	Number of Hours	95
	Explanation	Project management, per tower owner. Scheduling and management of timelines and schedules.
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	Yes
	Environmental Assessment	Yes
	ASR Modification	Yes
	FAA Consultation (including preparation of FAA Form 7460)	Yes
	Negotiation of Lease and other Matter for Shared Locations	Yes
	Prepare or Review FCC Form 399 for Reimbursement	Yes
	Address transition timing and coordination issues w/ other stations and wireless providers	Yes
RF Field Engineering Services	Comprehensive coverage verification via field study	No
	RF exposure measurements	Yes
	Additional Field Engineering Service	Yes
	Number of Days	7
	Justification	Installation of transmitter and supervision of antenna installation.

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Name	Description
Site Coordination Meeting	Site coordination meeting with broadcasters, contractors and vendors involved with site deliveries and construction.

Other Expenses

Section	Question	Response
AM Pattern Disturbance	Is an Impact Study needed?	No
AM Pattern Disturbance	Is Remediation needed?	No
Facility Expenses	Name	N/A
	Other Distributed Transmission System Expenses Not listed	N/A
	Name	N/A
	Is Notification of a Medical Facility required as a result of DTV broadcasting?	Yes
Permit and Filing Costs	Local Zoning	Yes
	Non-zoning permits	Yes
	BLM or NFS Coordination	No
	FCC Construction Permit Minor Change	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?	Yes
	Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change?	Yes
	Does this relocation require MVPD Notification of a Channel Change?	Yes

Other Expenses

Other Expenses Not Listed

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	$169,011.50	$140,946.50	N/A	$0.00	N/A
Total for all systems	$985,301.50	$609,305.50	N/A	$18,654.10	N/A
Primary Transmitter ELETXUD3600AC	$169,011.50	$140,946.50		$0.00
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW	$155,600.00	$127,535.00	Per Elektronica estimate 5971 plus $10,000 (estimated tax and freight)	N/A	N/A
Mask Filter	$8,411.50	$8,411.50	N/A	N/A	N/A
Other Electrical Service: Minimal electric services will be needed to implement new facility.	$5,000.00	$5,000.00	N/A	$0.00	N/A

Components

Information not provided.

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	$54,630.00	$54,300.00	N/A	$0.00	N/A
Total for all systems	$985,301.50	$609,305.50	N/A	$18,654.10	N/A
Primary Antenna SWCDS8OI/23-EP	$54,630.00	$54,300.00		$0.00
Sweep test of existing antenna	$6,730.00	$6,400.00	N/A	N/A	N/A
UHF - High Power, Side Mount, basic slot antenna, 18 kW input, elliptically or circularly polarized	$47,900.00	$47,900.00	N/A	N/A	N/A

Components

Information not provided.

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	$624,200.00	$222,167.00	N/A	$0.00	N/A
Total for all systems	$985,301.50	$609,305.50	N/A	$18,654.10	N/A
Primary Tower GTOWER	$624,200.00	$222,167.00		$0.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study	$26,300.00	$8,267.00	N/A	N/A	N/A
Ground and Building A and E Permit Drawing Package	$4,700.00	$4,700.00	N/A	N/A	N/A
Minor tower reinforcement/modifications	$158,000.00	$45,000.00	N/A	N/A	N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas)	$421,000.00	$150,000.00	N/A	N/A	N/A
Construction Project Management, tower modifications.	$9,500.00	$9,500.00	N/A	N/A	N/A
Tower Permit Drawing Package	$4,700.00	$4,700.00	N/A	N/A	N/A

Components

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	$106,520.00	$167,425.00	N/A	$18,654.10	N/A
Total for all systems	$985,301.50	$609,305.50	N/A	$18,654.10	N/A
Outside Professional Services	$106,520.00	$167,425.00		$18,654.10
Site Coordination Meeting	$2,500.00	$2,500.00	N/A	N/A	N/A
Additional Field Engineering Service, 7 Days	$12,000.00	$12,000.00	N/A	N/A	N/A
RF Exposure Measurements	$21,050.00	$10,000.00	N/A	N/A	N/A
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase	$2,105.00	$500.00	N/A	N/A	N/A
ASR modification (prepare FCC Form 854)	$2,105.00	$200.00	N/A	N/A	N/A
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet	$10,520.00	$10,000.00	N/A	N/A	N/A
NEPA Section 106 environmental review, if needed	$6,310.00	$1,800.00	N/A	N/A	N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization	$3,680.00	$3,500.00	N/A	N/A	N/A
Attorney Fees - Negotiation of lease and other matters for shared locations	$4,210.00	$4,000.00	N/A	$637.50	N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$2,365.00	$2,250.00	N/A	N/A	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$5,260.00	$5,000.00	N/A	N/A	N/A
Prepare request for Special Temporary Authorization	$2,050.00	$1,500.00	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	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$3,155.00	$3,000.00	N/A	N/A	N/A
Perform engineering study for new channel assignment and antenna development	$7,360.00	$7,000.00	N/A	N/A	N/A
Address transition timing and coordination issues w/ other stations and wireless	$2,630.00	$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	$15,010.00	$99,675.00	see Estimated Cost Justification WDTI-510-Project Management v0	$18,016.60	N/A

Components

Actual Information Description	File Name
Site Coordination Meeting	Information not provided.
Additional Field Engineering Service, 7 Days	Information not provided.
RF Exposure Measurements	Information not provided.
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.
Environmental Assessment, if triggered by NEPA Section 106 review or for certain structures over 450 feet	Information not provided.
NEPA Section 106 environmental review, if needed	Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization	Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations	Component Description: Total Professional Services Amount: $131.00 Component Description: Total Professional Services Amount: $223.50 Component Description: Total Professional Services Amount: $69.50 Component Description: Total Professional Services Amount: $69.50 Component Description: Total Professional Services Amount: $69.50 Component Description: Total Professional Services Amount: $74.50
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	Information not provided.
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	Information not provided.
Perform engineering study for new channel assignment and antenna development	Information not provided.
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: Project Management Amount: $1,528.75 Component Description: Project Management Amount: $26.40 Component Description: Project Management Amount: $1,710.15 Component Description: Project Management Amount: $2,433.10 Component Description: Project Management Amount: $1,563.20 Component Description: Project Management Amount: $2,558.70 Component Description: Project Management Amount: $1,627.10 Component Description: Project Management Amount: $1,962.25 Component Description: Project Management Amount: $1,803.40 Component Description: Project Management Amount: $1,288.65 Component Description: Project Management Amount: $1,514.90

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	$30,940.00	$24,467.00	N/A	$0.00	N/A
Total for all systems	$985,301.50	$609,305.50	N/A	$18,654.10	N/A
Other Expenses	$30,940.00	$24,467.00		$0.00
Disposal Costs (for equipment and other waste, net of any salvage value)	$5,000.00	$5,000.00	N/A	N/A	N/A
Non-zoning permits	$750.00	$750.00	N/A	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
FCC Filing Fees - Form 2100 minor change CP application	$1,110.00	$1,070.00	N/A	N/A	N/A
DTV Medical Facility Notification	$11,550.00	$5,132.00	N/A	N/A	N/A
MVPD Notification of Channel Change	$500.00	$500.00	N/A	N/A	N/A
Develop and air announcement of upcoming channel change	$500.00	$500.00	N/A	N/A	N/A
Equipment Storage	$3,500.00	$3,500.00	N/A	N/A	N/A
Equipment Delivery and Handling Charges	$5,000.00	$5,000.00	N/A	N/A	N/A
Local Zoning	$2,500.00	$2,500.00	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	$985,301.50	$609,305.50	$18,654.10

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.	Yes
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.	Arnold Torres Business Administrator 05/06/2020

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.

Arnold Torres

Business Administrator

05/06/2020

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.	Arnold Torres Business Administrator 05/06/2020

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.

Arnold Torres

Business Administrator

05/06/2020

Certification

Section	Question	Response
Submission of Final Allocation or Accounting Information 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 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 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 all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates. 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 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.	Arnold Torres Business Administrator 05/06/2020

Section

Question

Response

Submission of Final Allocation or Accounting Information Statements

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 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 all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates.
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 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.

Arnold Torres

Business Administrator

05/06/2020

(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

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Other Types of Users

Primary Tower

Tower Modification 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

Certification

Attachments