TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
KITTITAS COUNTY TV IMPROVEMENT DISTRICT # 1 Doing Business As: KITTITAS COUNTY TV IMPROVEMENT DISTRICT # 1	205 West 5th Ave., Suite 105 ELLENSBURG, WA 98926 United States	+1 (509) 899-3982	kctvdistrict@hotmail.com	Government Entity

Applicant

Address

Phone

Applicant Type

KITTITAS COUNTY TV IMPROVEMENT DISTRICT # 1

Doing Business As: KITTITAS COUNTY TV IMPROVEMENT DISTRICT # 1

205 West 5th Ave., Suite 105

ELLENSBURG, WA 98926

United States

+1 (509) 899-3982

kctvdistrict@hotmail.com

Government Entity

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.	Yes
Briefly describe transition plan	K38KL was displaced to Channel 26 - K26NF

Transmitters

Section	Question	Response
Transmitter Related Expenses	Do you have transmitter related expenses?	No

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)
	Ownership	Owned
	Is the existing antenna shared with another station or stations?	Yes
	Is the existing antenna directional?	Yes
	Is antenna in operating condition?	Yes
	Is antenna located on or in close proximity to an antenna farm?	No
Existing Antenna Manufacturer and Type
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Broadband Panel
	Number of Stations Supported	2
	Number of Panels	2
	Design power capacity in use	100.0 %
	Lower Limit	470.00 MHz
	Upper Limit	800.00 MHz
	ERP:	0.045 kW
	Manufacturer
	Model	K72314
	Year	2009

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID	Call Sign
168149	K23NE-D

Primary Antenna

New Antenna Costs

Section	Question	Response
New Antenna Description	Use	Primary (Main)
	Change Type	Purchase New
	Ownership	Owned
	Is antenna shared?	No
	Is antenna directional?	Yes
	Will antenna be located on or in close proximity to an antenna farm?	No
New Antenna Manufacturer and Types
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Other
	Other Antenna Type	TUA-C2
	ERP:	1.53 kW
	Manufacturer
	Model	TUA-C2
	Year	2017
	Justification for New Antenna	New Channel has a different pattern

Primary Antenna

Other Antenna Costs

Section	Question	Response
Elbow Complex	Do you require the separate purchase of the Elbow Complex?	No
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?	No

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	No
Outside RF consulting Engineering Services	Perform engineering study for displacement application	No
	Prepare engineering section of Form FCC Construction Permit Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare engineering section of Form FCC License to Cover Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare request for Special Temporary Authority	No
	Prepare Form 601	No
Attorney and Other Outside Consulting Services	Prepare and file Form FCC Construction Permit Application	No
	Prepare and file Form FCC License to Cover Application	No
	Prepare request for Special Temporary Authority	No
	Negotiation of Lease and other Matter for Shared Locations	No
	Prepare or Review FCC Form 399 for Reimbursement	Yes
	Form 399 assistance or other program management costs	Yes
RF Field Engineering Services	Comprehensive coverage verification via field study	No
	RF exposure measurements	No
	Additional Field Engineering Service	No

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

Section	Question	Response
AM Pattern Disturbance	Is an Impact Study needed?	No
AM Pattern Disturbance	Is Remediation needed?	No
Permit and Filing Costs	FCC Construction Permit Major Change	No
	FCC Construction Permit Minor Change	No
	FCC License to Cover Application	No
	FCC Special Temporary Authority Application	No
Other Miscellaneous Expenses	Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)?	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
Point to Point Microwave (STL/ICR)	Frequency Coordination for Unidirection System	No
	Frequency Coordination for Bi-Direction System	No
	New Point to Point Microwave System	No

Other Expenses

Other Expenses Not Listed

Name	Description
Equipment Survey	Travel to site, determine equipment required
Receive antenna	Off air input changed channel from 41 to 29 - replace stinger for RX antenna
Retune remove install antenna retune xmtr	Remove / install antennas, retune K38KL to Ch 26 minor parts

Cost Information

Transmitters

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	$9,381.15	$9,381.15	N/A	$9,381.15	N/A
Total for all systems	$19,084.35	$16,289.35	N/A	$16,289.35	N/A
Primary Antenna TUA-C2	$9,381.15	$9,381.15		$9,381.15
UHF-Low Power, Side Mount, Other, 1.53kW input, Horizontal	$9,381.15	$9,381.15	Dielectric antenna, multiple invoices RS Technology	$9,381.15	N/A

Components

Actual Information Description	File Name
UHF-Low Power, Side Mount, Other, 1.53kW input, Horizontal	Component Description: Sales Tax Amount: $452.48 Component Description: Dielectric antenna charge Amount: $4,482.00 Component Description: antenna tax Amount: $437.90 Component Description: K26NF antenna $1800 balance Amount: $1,800.00 Component Description: Cost to assemble antenna Amount: $255.00 Component Description: antenna freight Amount: $1,953.77

Cost Information

Transmission Line

Information not provided.

Cost Information

Tower Equipment and Rigging Costs

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	$5,865.00	$3,070.00	N/A	$3,070.00	N/A
Total for all systems	$19,084.35	$16,289.35	N/A	$16,289.35	N/A
Outside Professional Services	$5,865.00	$3,070.00		$3,070.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,052.50	$60.00	See BWS Invoice 6189	$60.00	N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$2,102.50	$300.00	N/A	$300.00	N/A
Form 399 assistance or other Program Management costs	$1,000.00	$1,000.00	Complete Turnkey Project Management 399 Eligibility and 1876 Filing.	$1,000.00	N/A
Prepare/ Review 399 reimbursement form	$1,710.00	$1,710.00	N/A	$1,710.00	N/A

Components

Actual Information Description	File Name
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	Component Description: Prepare License to Cover Construction K26NF-D Amount: $60.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	Component Description: Engineering Cost for Displacement Application K38KL FI 168148 Amount: $300.00
Form 399 assistance or other Program Management costs	Component Description: 399 Eligibility and 1876 Turnkey Project Management Amount: $1,000.00
Prepare/ Review 399 reimbursement form	Component Description: Complete Turnkey 399 Reimbursement Project Management Amount: $1,710.00

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	$3,838.20	$3,838.20	N/A	$3,838.20	N/A
Total for all systems	$19,084.35	$16,289.35	N/A	$16,289.35	N/A
Other Expenses	$3,838.20	$3,838.20		$3,838.20
Retune remove install antenna retune xmtr	$2,839.20	$2,839.20	Retune transmitter, remove and install antennas.	$2,839.20	N/A
Equipment Survey	$175.00	$175.00	1/2 Cost of trip cost to survey equipment needs RS Technology Invoice 3755	$175.00	N/A
Receive antenna	$824.00	$824.00	K38KL (26) used to receive Ch 41 as off air input, it was changed to Ch 29 so receive antenna needed some parts changed to accommodate Ch 29 as an input.	$824.00	N/A

Components

Actual Information Description	File Name
Retune remove install antenna retune xmtr	Component Description: sales tax Amount: $229.20 Component Description: Remove old antennas install new antenna Amount: $1,720.00 Component Description: rf adaptor Amount: $540.00 Component Description: Trip charge to retune transmitter, remove and install antennas. Amount: $350.00
Equipment Survey	Component Description: 1/2 trip charge to survey equipment Amount: $175.00
Receive antenna	Component Description: Receive input changed from 41 to 29 Filter $415 Amount: $415.00 Component Description: Receive input changed from 41 to 29 stinger $409 Amount: $409.00

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$19,084.35	$16,289.35	$16,289.35

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.	Susan Hansen Consultant 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.

Susan Hansen

Consultant

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.	Joel Underhill Acting Chairman 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.

Joel Underhill

Acting Chairman

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

Antennas

Primary Antenna

Existing Antenna Information

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Primary Antenna

New Antenna Costs

Primary Antenna

Other Antenna Costs

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Tower Equipment And Rigging Costs

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

Cost Information

Antennas

Components

Cost Information

Transmission Line

Cost Information

Tower Equipment and Rigging Costs

Cost Information

Outside Professional Services

Components

Cost Information

Other Expenses

Components

Cost Information

Grand Total

Reimbursement Status

Certification

Certification

Attachments