TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
CITIZENS T.V., INC. Applicant Doing Business As: CITIZENS T.V., INC.	P.O. BOX 2 MILTON-FREEWATER, OR 97862 United States	+1 (541) 938-5183	mgreer@bmi.net	Other

Applicant

Address

Phone

Applicant Type

CITIZENS T.V., INC.

Applicant

Doing Business As: CITIZENS T.V., INC.

P.O. BOX 2

MILTON-FREEWATER, OR 97862

United States

+1 (541) 938-5183

mgreer@bmi.net

Other

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	Applicant had three out of core stations and one in-core station displaced by a full service. Due to loss of input channels, a microwave link was built. It was a cooperative agreement with Oregon Pubic Broadcasting, who bore most of the expense.

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	Retune Existing
	Use	Primary (Main)
	Ownership	Owned
	Is this transmitter currently shared with another station?	No
	Is this transmitter currently in operating condition?	Yes
Existing Transmitter Manufacturer and Type	Manufacturer	Larcan
	Model	MXi101U
	Year	2012
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	.05 kW

Primary Transmitter

Retuning Transmitter Costs

Section	Question	Response
New Mask Filter	Does the transmitter require a new mask filter?	Yes
	Mask Filter Type	Stringent
	Power	100-200W
New Exciter	Is a new exciter needed?	No

Primary Transmitter

Other Transmitter Costs

Section	Question	Response
Other Transmitter Costs
Other Transmitter Costs	Does the transmitter installation require a Transmitter Building Site Survey/Installation?	No
Electrical Service	Service Entrance (3 phases 800A 208V)	No
	Switchgear (industrial 800 amp)	No
	Transformer (480V)	No
	Rigid Conduit and Wiring	No
	Other Electrical Service	No
HVAC Service	Does the replacement transmitter require HVAC Service?	No
Transmitter Building Addition/Modification or Leasehold Improvement	Does the Transmitter Building require an addition, modification, other leashold improvement?	No

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	Retune Existing
	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	Other
	Other Antenna Type	UHF Panel
	ERP:	1.0 kW
	Manufacturer	SCA
	Model	Panel Array
	Year	2012

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

Facility ID	Call Sign
11496	K28FT-D
11360	K24ME-D
11497	K34NS-D
21569	K19KU-D

Primary Antenna

Adjustment to Existing Antenna

Section	Question	Response
Sweep Test of Existing Antenna	Do you need a sweep test of existing antenna?

Primary Antenna

Other Antenna Costs

Section	Question	Response
Combiner for Shared Antenna	Do you need a Combiner for a Shared Antenna?	Yes
	Type	New
	Number of channels supported	5
	Frequencies of channels supported	RF channel
	Frequency	N/A

Enter a list of RF channel numbers.

RF Channel Number
28
19
20
24
34

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?	Yes
	Number of Hours	80
	Explanation	Project Management of displaced channels, coordinate engineering studies, application filings, equipment replacement, tower construction, and equipment installation.
Outside RF consulting Engineering Services	Perform engineering study for displacement application	Yes
	Prepare engineering section of Form FCC Construction Permit Application	No
	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	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)?	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
tower for Microwave	See Microwave Twr Statement_02.pdf and Recap Expenses.pdf

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	$12,762.50	$1,470.00	N/A	$900.00	N/A
Total for all systems	$56,256.74	$12,141.74	N/A	$10,531.74	N/A
Primary Transmitter MXi101U	$12,762.50	$1,470.00		$900.00
100-200W w mask filter Stringent	$1,762.50	$900.00	N/A	$900.00	N/A
Retune - UHF and VHF - minor re-channel issues	$11,000.00	$570.00	See Gapinski Quote	N/A	N/A

Components

Actual Information Description	File Name
100-200W w mask filter Stringent	Component Description: new mask filter Amount: $900.00
Retune - UHF and VHF - minor re-channel issues	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	$23,500.00	$925.00	N/A	$925.00	N/A
Total for all systems	$56,256.74	$12,141.74	N/A	$10,531.74	N/A
Primary Antenna Panel Array	$23,500.00	$925.00		$925.00
1 kW UHF Combiner (per channel)	$23,500.00	$925.00	N/A	$925.00	N/A

Components

Actual Information Description	File Name
1 kW UHF Combiner (per channel)	Component Description: combiner cost divided by 4 stations Amount: $925.00

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	$14,002.50	$4,035.00	N/A	$2,995.00	N/A
Total for all systems	$56,256.74	$12,141.74	N/A	$10,531.74	N/A
Outside Professional Services	$14,002.50	$4,035.00		$2,995.00
Perform engineering study for displacement application	$1,800.00	$275.00	N/A	$235.00	N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,052.50	$50.00	N/A	$50.00	N/A
Form 399 assistance or other Program Management costs	$1,000.00	$1,000.00	BWS Project Management of Eligibility filing and 1876 preparation and submission See BWS Citizens Estimate.pdf	$1,000.00	N/A
Prepare/ Review 399 reimbursement form	$1,710.00	$1,710.00	N/A	$1,710.00	N/A
Project management of the transition	$8,440.00	$1,000.00	Project Management see: CTV K20MJ-D Projectv2.pdf	N/A	N/A

Components

Actual Information Description	File Name
Perform engineering study for displacement application	Component Description: Prepare displacement & STA Amount: $235.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	Component Description: fee for filing Amount: $50.00
Form 399 assistance or other Program Management costs	Component Description: 399 Reimbursement Eligility Fee Amount: $1,000.00
Prepare/ Review 399 reimbursement form	Component Description: 399 Form filing Fee Amount: $1,710.00
Project management of the transition	Information not provided.

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	$5,991.74	$5,711.74	N/A	$5,711.74	N/A
Total for all systems	$56,256.74	$12,141.74	N/A	$10,531.74	N/A
Other Expenses	$5,991.74	$5,711.74		$5,711.74
FCC Filing Fees - Form 2100 license to cover application	$335.00	$170.00	N/A	$170.00	N/A
tower for Microwave	$5,351.74	$5,351.74	loss of off air input required cooperative agreement with OPB to get microwave reception at site.	$5,351.74	N/A
FCC Filing Fees - Special Temporary Authorization request	$305.00	$190.00	N/A	$190.00	N/A

Components

Actual Information Description	File Name
FCC Filing Fees - Form 2100 license to cover application	Component Description: FCC filing fee Amount: $170.00
tower for Microwave	Component Description: invoice divided by four stations Amount: $251.55 Component Description: invoice divided by four stations Amount: $315.95 Component Description: invoice divided by four stations Amount: $863.22 Component Description: invoice divided by four stations crane service Amount: $335.00 Component Description: invoice divided by four stations Amount: $3,298.00 Component Description: invoice divided by four stations Amount: $214.25 Component Description: N/A Amount: N/A Component Description: invoice divided by four stations Amount: $53.08 Component Description: invoice divided by four stations Amount: $20.69
FCC Filing Fees - Special Temporary Authorization request	Component Description: STA Fee Amount: $190.00

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$56,256.74	$12,141.74	$10,531.74

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 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.	Susan Hansen Consultant 07/17/2020

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.

Susan Hansen

Consultant

07/17/2020

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.	David Houchin President 07/17/2020

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.

David Houchin

President

07/17/2020

(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

Retuning Transmitter Costs

Primary Transmitter

Other Transmitter Costs

Primary Transmitter

Other Transmitter Cost Not Listed

Antennas

Primary Antenna

Existing Antenna Information

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

Primary Antenna

Adjustment to Existing Antenna

Primary Antenna

Other Antenna Costs

Enter a list of RF channel numbers.

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

Components

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