Go to the Federal Communications Commission homepage at www.fcc.gov

FCC Form 399: Reimbursement Request

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

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

Facility ID:
31590
Service:
DTV
Call Sign:
WCTV
Channel:
20 (UHF)
File Number:
0000028726
FRN:
0018223693
Date Submitted:
04/20/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GRAY TELEVISION LICENSEE, LLC

Doing Business As: WCTV-TV

WCTV

4370 Peachtree Road, NE

Atlanta, GA 30319

United States

+1 (404) 504-9828 allfcclms@gray.tv Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Samuel Hariton

Widelity

Samuel Hariton

4031 University Dr

Suite 100

Fairfax, VA 22030

United States

+1 (339) 222-8107 sam.hariton@widelity.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. No
Briefly describe transition plan WCTV will be changing the antenna, line and transmitter on the main broadcast site. WCTV will utilize the existing auxiliary site on a different tower as an interim site.

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model CDUK3100UPG3
Year 2005
Type Inductive Output Tube
IOT Power Type Three
Power Capacity 90.0 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model ULXTE-72
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 47.2 kW
Justification for New Transmitter This is an old Harris IOT Transmitter that will not be able to be retuned. See GatesAir memo 1/1/2017.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service Yes
Description The new main transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors.
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

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Other Transmitter Cost Not Listed

Name Description

Primary Transmitter - Installation

Primary Transmitter - Installation

Building Renovations

Interior renovations required for installation of new transmitter.

Concrete Pads

Concrete pads required for new heat exchangers for the new transmitter.

HVAC

Undetermined tonnage and duct work required for plumbing new transmitter installation.

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use N/A
Change Type Purchase
Manufacturer
Model UAXTE 12R44
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 7.2 kW
Justification for New Transmitter Necessary to power interim facility while new main antenna is installed.

Interim Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
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 The new main transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors.
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
Inside RF System Is an additional interior RF system required to support this interim transmitter? Yes

Interim Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Antennas

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

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting 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: 1000.0 kW
Manufacturer
Model TFU-30DSC-RO4
Year 2005

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? No
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 750.0 kW
Manufacturer
Model TFU-30GTH/VP-R04
Year 2019
Justification for New Antenna The old antenna is an Side Mount and cannot be retuned and used a s a top mount

Primary Antenna

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Other Antenna Costs

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

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Top Plate Adapter

Adapter for the top of the tower

Interim Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Interim
Description of Use N/A
Change Type Purchase New
Ownership Owned
Owner N/A
Is antenna shared? Yes
Is antenna directional? No
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization 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: 100.0 kW
Manufacturer
Model TLP24B CH20
Year 2017
Justification for New Antenna Needed so that WCTV can continue to operate while the new main antenna, line and transmitter are installed.

Interim Antenna

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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 4
Frequencies of channels supported RF channel
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? No
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? B
Feed Line Size 3 1/8 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for an antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Enter a list of RF channel numbers.

RF Channel Number
17
20
30
33

Interim Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? Yes

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1970 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 78 feet per run
Justification for New Transmission Line Moving from a side mount to a top mount antenna, using the existing transmission line and buying 78 additional feet of it.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Primary Transmission Line - Nitrogen for Primary Transmission Line

Primary Transmission Line - Nitrogen for Primary Transmission Line

Primary Transmission Line-Ice Bridge

Primary Transmission Line-Ice Bridge

Interim Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Flexible Air
Diameter 3 inches
Segment Length N/A
Other Segment Length
Number of parallel runs 1
Length 870 feet per run
Justification for New Transmission Line Installing interim antenna

Interim Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Nitrogen for Interim Transmission Line

Nitrogen for Interim Transmission Line

Tower Equipment And Rigging Costs

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

Auxiliary Tower

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Add Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Auxiliary (Backup)
Description of Use Backup Tower
Ownership Owned
Is this tower consider Complex? No
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 No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1031203
Coordinates (NAD83) Latitude (NAD83) 30° 34' 28.0" N-
Longitude (NAD83) 084° 12' 09.0" W-
Overall Structure Height 898.94 feet
Support Structure Height 833.32 feet
Ground Elevation Above Mean Sea Level (AMSL) 144.36 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner Gray Television Group, Inc.
Date Constructed 01/01/1973

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
3032 WVUP-CD DTV

Auxiliary Tower

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Tower Modification Costs

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

Auxiliary Tower

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Tower Rigging Costs

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

Auxiliary Tower

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Other Tower Expenses Not Listed

Name Description

Structural Load Study

Structural engineering tower load study for poorly documented tower

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Owned
Is this tower consider Complex? No
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1019981
Coordinates (NAD83) Latitude (NAD83) 30° 40' 14.0" N-
Longitude (NAD83) 083° 56' 26.0" W-
Overall Structure Height 1999.98 feet
Support Structure Height 1925.83 feet
Ground Elevation Above Mean Sea Level (AMSL) 221.78 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Gray Television Group, Inc.
Date Constructed 01/01/1987

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
93356 WKVH FM
21801 WFSU-TV DTV

Primary Tower

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Tower Modification Costs

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

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Structural Load Study

Structural engineering tower load study for poorly documented tower

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 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 Yes
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
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 Yes
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility Yes
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
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

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Other Professional Services Expenses Not Listed

Name Description

Attorney Fees - Other Matters

Legal Services

Attorney fees 2100 license to cover - Auxiliary

Attorney fees 2100 license to cover (aux)

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change 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)? 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

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Other Expenses Not Listed

Name Description

Equipment Rental

Equipment Rental

FCC Filing Fees - Auxiliary Antenna License to Cover Filing Fees

Auxiliary Antenna License to Cover Filing Fees

FCC Filing Fees- Auxiliary Antenna Construction Permit

Auxiliary Antenna Construction Permit FCC Filing Fees

Site Security

Security for site while equipment is being stored for sites.

Tree Removal

Removing trees for tag line for tower work

Use Tax

Use Tax

Cost Information

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Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $3,636,028.16 $3,395,271.81 N/A $1,686,956.80 N/A
Total for all systems $5,838,991.27 $5,967,729.64 N/A $3,091,146.87 N/A
Interim Transmitter UAXTE 12R44 $450,580.04 $476,145.84 $290,148.22
UHF inside RF system including switching $147,500.00 $150,500.00 State and local taxes $0.00 N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $36,965.80 per ASCO SPD Quote and Weston Trawick Quote $1,468.21 N/A
Other Electrical Service: The new main transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors. $32,092.00 $32,092.00 see Estimated Cost Justification WCTV-180-Electrical Service New Interim Transmitter v0 $32,092.00 N/A
UHF - Air Cooled Solid State Transmitter 7.2 kW $256,588.04 $256,588.04 see Estimated Cost Justification WCTV-180-New Interim Transmitter v0 $256,588.01 N/A
Primary Transmitter ULXTE-72 $3,185,448.12 $2,919,125.97 $1,396,808.58
Concrete Pads $2,150.00 $2,150.00 N/A N/A N/A
Building Renovations $44,866.38 $44,866.38 Please see Estimated Cost Justification WCTV-110-Building renovations New 1st Primary Transmitter v1 $44,866.38 N/A
HVAC $76,502.60 $76,502.60 Please see WCTV - Primary Transmitter HVAC - Verified Budget Increase Justification v0 $54,632.60 N/A
Primary Transmitter - Installation $1,367.66 $1,367.66 see Estimated Cost Justification WCTV-110-New 1st Primary Transmitter Installation v1 $1,132.25 N/A
Other Electrical Service: The new main transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors. $53,261.50 $53,261.50 see Estimated Cost Justification WCTV-110-Electrical Service New 1st Primary Transmitter V3 $52,699.50 N/A
Transformer 3 phase/480v - 300 KVA $36,800.00 $9,163.00 GatesAir Quote Q-81345 $0.00 N/A
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,473,000.00 $1,234,314.85 Per GatesAir Quote Q-81345 ($254,022.13) N/A
UHF - Liquid Cooled Solid State Transmitter 76 kW $1,497,499.98 $1,497,499.98 ***System Notice: Estimate adjusted and locked because line has been superseded.*** $1,497,499.98 N/A

Components

Actual Information Description File Name
UHF inside RF system including switching Information not provided.
Service entrance 3 phase/800 amp/208 volt

Component Description:
installed new 3" EMT with junctions tor generator hook up and (1) dedicated 20 AMP quad recp for fans and equipment
Amount:
$1,468.21
Other Electrical Service: The new main transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors.

Component Description:
Electrical Engineering Services
Amount:
$5,125.00

Component Description:
Work Performed
Amount:
$26,967.00
UHF - Air Cooled Solid State Transmitter 7.2 kW

Component Description:
Transmitter
Amount:
$21,773.45

Component Description:
Transmitter, Mask Filter System. Rf Accessories, Installation and Proof
Amount:
$166,015.29

Component Description:
A. Transmitter
Amount:
$68,799.27
Concrete Pads Information not provided.
Building Renovations

Component Description:
2'X4' #2310 Radar
Amount:
$297.13

Component Description:
Original Contract
Amount:
$6,920.12

Component Description:
398095 WCTV Metcalf Transmitter
Amount:
$12,716.25

Component Description:
Radar SO Edge
Amount:
$396.63

Component Description:
2x4 120V LED Troffer w/ Prismatic LE
Amount:
$295.02

Component Description:
Ceiling Tiles for Transmitter Building
Amount:
$122.07

Component Description:
Main Beam
Amount:
$35.11

Component Description:
No longer seeking reimbursement // 2'x4' #2310 Radar Sq Edge Ceiling 64SF
Amount:
N/A

Component Description:
No longer seeking reimbursement // 9/16 x3-1/4 PFJ WM713 Base
Amount:
N/A

Component Description:
RADAR S0 EDGE CELING
Amount:
$686.99

Component Description:
Removing reimbursement request // Radar SO Edge
Amount:
N/A

Component Description:
Contract Billing
Amount:
$23,313.13

Component Description:
9/16 X3-1/4 PFJ
Amount:
$83.93
HVAC

Component Description:
Electrical
Amount:
$16,977.00

Component Description:
Install 2 Hail Coil guards on 2 split systems.
Amount:
$2,660.00

Component Description:
Mercalf Buildings HVAC Install
Amount:
$22,900.00

Component Description:
WCTV Metcalf
Amount:
$5,270.00

Component Description:
Contract Billing
Amount:
$16,977.00

Component Description:
Materials, Crew Hours Labor
Amount:
$6,825.60
Primary Transmitter - Installation

Component Description:
GREAT STUFF 16 oz. Pestblock Insulating Foam
Amount:
$258.05

Component Description:
Nuts, bolts and coolant for the transmitter.
Amount:
$639.82

Component Description:
Service Fee
Amount:
$86.69

Component Description:
Service Fee
Amount:
$147.69
Other Electrical Service: The new main transmitter will require reconfiguration of the electrical service on site. The electrical work cost has been estimated based on verbal guidance from local electrical contractors.

Component Description:
WCTV-110-Electrical Service New 1st Primary Transmitter
Amount:
$10,345.13

Component Description:
WCTV-110-Electrical Service New 1st Primary Transmitter
Amount:
$12,716.25

Component Description:
Electrical Engineer
Amount:
$6,325.00

Component Description:
WCTV-110-Electrical Service New 1st Primary Transmitter
Amount:
$23,313.12
Transformer 3 phase/480v - 300 KVA Information not provided.
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW

Component Description:
Credit Memo
Amount:
($254,022.13)
UHF - Liquid Cooled Solid State Transmitter 76 kW

Component Description:
Transmitter, Mask Filter System, RF Accessories, Install & Proof
Amount:
$1,497,499.98

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $531,452.00 $456,984.06 N/A $213,631.86 N/A
Total for all systems $5,838,991.27 $5,967,729.64 N/A $3,091,146.87 N/A
Interim Antenna TLP24B CH20 $203,370.00 $185,476.80 $22,117.60
New combiner, cost per channel (without antenna) $84,200.00 $132,617.80 Please see attached WCTV Combiner - DTVPros Quote JEHQ1704 and Gray PO 1944 which includes taxes and freight. $0.00 N/A
Elbow complex, broadband, at antenna input, per 3 1/8. feedline (if needed) $9,340.00 $8,624.00 Quote JEHQ1317 N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $3,200.00 N/A
UHF - Lower Power Side Mount, One Station antenna . medium power (50-200 kW), elliptically or circularly polarized $103,100.00 $37,835.00 per DTVPros quote JEHQ1672 $18,917.60 N/A
Primary Antenna TFU-30GTH/VP-R04 $328,082.00 $271,507.26 $191,514.26
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,300.00 $14,944.00 JEHQ1267-04 $10,214.40 N/A
Sweep test of existing antenna $6,730.00 $9,868.26 see Estimated Cost Justification WCTV-210-Sweep test New Primary Antenna v0 $8,538.26 N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $289,500.00 $227,143.00 JEHQ1267-04 $157,120.00 N/A
Top Plate Adapter $19,552.00 $19,552.00 JEHQ1267-04 $15,641.60 N/A

Components

Actual Information Description File Name
New combiner, cost per channel (without antenna)

Component Description:
RF System 4 Channel
Amount:
$94,227.20
Elbow complex, broadband, at antenna input, per 3 1/8. feedline (if needed) Information not provided.
Sweep test of existing antenna

Component Description:
WCTV-280-Sweep test New Interim Antenna
Amount:
$3,200.00
UHF - Lower Power Side Mount, One Station antenna . medium power (50-200 kW), elliptically or circularly polarized

Component Description:
UHF - LOW POWER SIDE MOUNT
Amount:
$18,917.60
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
WCTV-210-Elbow complex New Primary Antenna
Amount:
$3,830.40

Component Description:
WCTV-210-Elbow complex New Primary Antenna
Amount:
$3,192.00

Component Description:
WCTV-210-Elbow complex New Primary Antenna
Amount:
$3,192.00
Sweep test of existing antenna

Component Description:
WCTV-210-Sweep test New Primary Antenna
Amount:
$1,600.00

Component Description:
WCTV-210-Sweep test New Primary Antenna
Amount:
$1,920.00

Component Description:
Engineering field services to assess transmitter
Amount:
$3,418.26

Component Description:
WCTV-210-Sweep test New Primary Antenna
Amount:
$1,600.00
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized

Component Description:
UHF- HIGH POWER TOP MOUNT
Amount:
$49,100.00

Component Description:
UHF- HIGH POWER TOP MOUNT
Amount:
$49,100.00

Component Description:
UHF-High Power Top Mount (200-1000KW)
Amount:
$58,920.00
Top Plate Adapter

Component Description:
WCTV-210-Top plate adapter New Primary Antenna
Amount:
$4,888.00

Component Description:
WCTV-210-Top plate adapter New Primary Antenna
Amount:
$5,865.60

Component Description:
WCTV-210-Top plate adapter New Primary Antenna
Amount:
$4,888.00

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $84,520.53 $85,957.59 N/A $53,575.88 N/A
Total for all systems $5,838,991.27 $5,967,729.64 N/A $3,091,146.87 N/A
Interim Transmission Line $51,571.76 $38,076.96 $36,383.11
Nitrogen for Interim Transmission Line $241.76 $241.76 Please see Estimated Cost Justification WCTV-380-New Interim Transmission Line- Nitrogen V0 $241.76 N/A
Flexible Air Transmission Line - dielectric, 3" $51,330.00 $37,835.20 per DTVPros quote JEHQ1672 $36,141.35 N/A
Primary Transmission Line $32,948.77 $47,880.63 $17,192.77
Rigid Transmission Line - copper, 6 1/8" $15,756.00 $30,687.86 Please see Estimated Cost Justification WCTV-310-New Primary Transmission Line v0 ($0.00) N/A
Primary Transmission Line-Ice Bridge $17,033.00 $17,033.00 Please see John D Jones AC proposal 40177 $17,033.00 N/A
Primary Transmission Line - Nitrogen for Primary Transmission Line $159.77 $159.77 Please see Estimated Cost Justification WCTV-310-New Primary Transmission Line - Nitrogen v0 $159.77 N/A

Components

Actual Information Description File Name
Nitrogen for Interim Transmission Line

Component Description:
RRCXLILG-NI - Rent Cyl Ind Large Nitrogen
Amount:
$51.85

Component Description:
Nitrogen Industrial 300
Amount:
$160.35

Component Description:
RRCYLILG-NI - Rent Cyl Ind Large Nitrogen
Amount:
$29.56
Flexible Air Transmission Line - dielectric, 3"

Component Description:
R16142 ELBOW 6-50 5.5 X 5.5 CU
Amount:
$17,622.18

Component Description:
WCTV-380-New Interim Transmission Line
Amount:
$18,519.17
Rigid Transmission Line - copper, 6 1/8"

Component Description:
Credit Memo - Moving side mount to top mount is an upgrade related to the purchase of a new TX Line.
Amount:
($10,103.91)

Component Description:
WCTV-310-New Primary Transmission Line
Amount:
$3,157.47

Component Description:
WCTV-310-New Primary Transmission Line
Amount:
$3,788.97

Component Description:
WCTV-310-New Primary Transmission Line
Amount:
$3,157.47

Component Description:
Invoice moved to correct budget category
Amount:
N/A
Primary Transmission Line-Ice Bridge

Component Description:
WCTV Tower Ice Rack
Amount:
$17,033.00
Primary Transmission Line - Nitrogen for Primary Transmission Line

Component Description:
Rent Cyl Ind Large Nitrogen
Amount:
$64.99

Component Description:
Nitrogen
Amount:
$94.78

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $1,360,800.00 $1,695,129.00 N/A $889,340.00 N/A
Total for all systems $5,838,991.27 $5,967,729.64 N/A $3,091,146.87 N/A
Primary Tower TOWER $684,000.00 $1,023,729.00 $775,440.00
Structural Load Study $26,200.00 $26,200.00 Estimated Cost Justification WCTV-410-Structural Analysis Existing Primary Tower V0 $26,200.00 N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $10,500.00 Hodge Invoice 19G000400.1 $10,500.00 N/A
Major tower reinforcement/modifications $421,000.00 $621,729.00 see Estimated Cost Justification WCTV-410-Reinforcements Existing Primary Tower V1 $373,440.00 N/A
Tall Tower (greater than 500') $210,500.00 $365,300.00 see Justifying Quote WCTV GTI America Q19-06-008 and 19-66-036 $365,300.00 N/A
Auxiliary Tower GTOWER $676,800.00 $671,400.00 $113,900.00
Major tower reinforcement/modifications $421,000.00 $430,000.00 State and local taxes $0.00 N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $7,400.00 Hodge Invoice 19G000300.1 $7,400.00 N/A
Tall Tower (greater than 500') $210,500.00 $215,000.00 Please see Q19-06-037-3 WCTV WVUP Tallahassee combined antenna install $87,500.00 N/A
Structural Load Study $19,000.00 $19,000.00 see Estimated Cost Justification WCTV-450-Structural Analysis Existing Auxiliary Tower v1 $19,000.00 N/A

Components

Actual Information Description File Name
Structural Load Study

Component Description:
Engineer Evaluation
Amount:
$7,875.00

Component Description:
Engineering Evaluation, Appurtence Mapping, Corrosion Risk Analysis
Amount:
$5,225.00

Component Description:
Engineering Evaluation
Amount:
$5,225.00

Component Description:
Engineering Evaluation
Amount:
$7,875.00

Component Description:
Please deny this invoice
Amount:
N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study

Component Description:
WCTV-410-Tower Mapping
Amount:
$5,250.00

Component Description:
Please deny this invoice
Amount:
N/A

Component Description:
WCTV-410-Tower Mapping-
Amount:
$5,250.00
Major tower reinforcement/modifications

Component Description:
Reinforcing Materials, Freight, Installation, Rigging Plan Review
Amount:
$248,289.00

Component Description:
POLE SOCKET / Guide Flange WCTV - ADDED PER CHANGE ORDER
Amount:
$125,151.00
Tall Tower (greater than 500')

Component Description:
Tower rigging services
Amount:
$243,975.00

Component Description:
Weather days
Amount:
$40,000.00

Component Description:
25% Tower Equipment and Rigging
Amount:
$81,325.00

Component Description:
N/A
Amount:
N/A
Major tower reinforcement/modifications Information not provided.
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study

Component Description:
WCTV-450-Tower Mapping
Amount:
$3,700.00

Component Description:
Engineering Evaluation
Amount:
$3,700.00
Tall Tower (greater than 500')

Component Description:
Tower Rigging Services
Amount:
$65,625.00

Component Description:
Tower rigging services
Amount:
$21,875.00
Structural Load Study

Component Description:
WCTV-450-Structural Analysis Existing Auxiliary Tower
Amount:
$4,250.00

Component Description:
Engineering Evaluation
Amount:
$10,500.00

Component Description:
50% deposit - Engineering Evaluation, Appurtenance Mapping & Corrosion Risk Analysis
Amount:
$4,250.00

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $127,170.10 $243,361.70 N/A $226,565.10 N/A
Total for all systems $5,838,991.27 $5,967,729.64 N/A $3,091,146.87 N/A
Outside Professional Services $127,170.10 $243,361.70 $226,565.10
Attorney fees 2100 license to cover - Auxiliary $124.50 $124.50 Please see WCTV Attorney and Filing Fees Categories Revision Justification Cover Letter $124.50 N/A
Attorney Fees - Other Matters $1,740.60 $1,740.60 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time $1,489.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $370.00 Please see WCTV Attorney and Filing Fees Categories Revision Justification Cover Letter $370.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $900.00 N/A
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, Construction Permit Application $2,105.00 $2,000.00 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 $1,525.00 N/A
Project management of the transition $94,010.00 $214,876.60 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $214,876.60 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $5,675.00 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A $83.00 N/A
Attorney Fees - Aux Antenna, prepare and File Form 2100 Construction Permit or License Application $4,210.00 $4,000.00 N/A $747.00 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
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, License to Cover Application $1,580.00 $1,500.00 N/A $775.00 N/A

Components

Actual Information Description File Name
Attorney fees 2100 license to cover - Auxiliary

Component Description:
WCTV-550-Attorney Fees 2100 License To Cover (Aux)
Amount:
$124.50
Attorney Fees - Other Matters

Component Description:
Total Professional Services
Amount:
$370.00

Component Description:
For Professional Services Rendered
Amount:
$740.00

Component Description:
Legal Services
Amount:
$379.00

Component Description:
Professional Services
Amount:
$251.60
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
Prepare and file CP Extension request.
Amount:
$370.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Regarding repack Ch-20 top-mount main antenna facility
Amount:
$250.00

Component Description:
Develop final configuration for main antenna
Amount:
$650.00
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, Construction Permit Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
CP Application
Amount:
$1,525.00
Project management of the transition

Component Description:
Project Management
Amount:
$1,831.65

Component Description:
Project Management
Amount:
$2,641.95

Component Description:
Project Management
Amount:
$4,254.50

Component Description:
Project Management
Amount:
$3,953.15

Component Description:
Project Management
Amount:
$7,653.90

Component Description:
Project Management
Amount:
$11,188.05

Component Description:
Project Management
Amount:
$17,332.25

Component Description:
Project Management
Amount:
$5,473.15

Component Description:
Project Management
Amount:
$1,921.85

Component Description:
Project Management
Amount:
$11,728.65

Component Description:
Project Management
Amount:
$2,348.65

Component Description:
Project Management
Amount:
$5,814.65

Component Description:
Project management
Amount:
$11,077.60

Component Description:
Project Management
Amount:
$1,944.80

Component Description:
Project Management
Amount:
$3,190.95

Component Description:
Project Management
Amount:
$2,922.55

Component Description:
Project Management
Amount:
$2,671.95

Component Description:
Project Management,
Amount:
$6,520.90

Component Description:
Project Management
Amount:
$2,890.75

Component Description:
Project management
Amount:
$2,435.15

Component Description:
Project Management
Amount:
$1,941.95

Component Description:
Project Management
Amount:
$2,573.35

Component Description:
Project Management
Amount:
$802.25

Component Description:
Project Management
Amount:
$9,091.60

Component Description:
Project Management
Amount:
$2,551.30

Component Description:
Project Management
Amount:
$2,964.40

Component Description:
Project Management
Amount:
$2,772.95

Component Description:
Project Management
Amount:
$2,460.90

Component Description:
Project Management
Amount:
$5,323.75

Component Description:
Project Management
Amount:
$2,078.85

Component Description:
Project Management
Amount:
$6,781.20

Component Description:
Project Management
Amount:
$801.45

Component Description:
Project Management
Amount:
$1,328.55

Component Description:
Project Management
Amount:
$10,671.70

Component Description:
Transition Related Project Management Costs
Amount:
$1,950.00

Component Description:
Project Management
Amount:
$6,609.55

Component Description:
Project Management
Amount:
$2,500.60

Component Description:
Project Management
Amount:
$5,160.05

Component Description:
Project management
Amount:
$2,516.90

Component Description:
Project Management
Amount:
$28.20

Component Description:
Project Management
Amount:
$3,418.55

Component Description:
Project Management
Amount:
$1,706.25

Component Description:
Project Management
Amount:
$1,773.60

Component Description:
Project Management
Amount:
$3,834.80

Component Description:
Project Management
Amount:
$1,541.50

Component Description:
Project Management
Amount:
$733.30

Component Description:
Project Management
Amount:
$4,124.40

Component Description:
Project Management
Amount:
$1,690.60

Component Description:
Project Management
Amount:
$15,347.05
Perform engineering study for new channel assignment and antenna development

Component Description:
Review of interim on repack Ch-20 with side-mount antenna and as-built transmitter
Amount:
$525.00

Component Description:
Review system gain-loss and corresponding TPO required for repack Ch-20 main antenna, various discussions.
Amount:
$650.00

Component Description:
Develop technical parameters for planned auxiliary antenna
Amount:
$900.00

Component Description:
Conduct channel study
Amount:
$187.50

Component Description:
Perform engineering study for new channel assignment
Amount:
$1,300.00

Component Description:
Consulting Engineer Regarding repack CH-20 main antenna/line configuration
Amount:
$575.00

Component Description:
WCTV-530-RF Eng Channel Study
Amount:
$1,200.00

Component Description:
Consulting Engineer
Amount:
$525.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
WCTV-550-Attorney fees 2100 license to cover (main)
Amount:
$83.00
Attorney Fees - Aux Antenna, prepare and File Form 2100 Construction Permit or License Application

Component Description:
For Professional Services Rendered
Amount:
$747.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
RF Consulting Engineer Fees- Aux Antenna: Prepare engineering section of FCC Form 2100, License to Cover Application

Component Description:
WCTV-530-RF Eng 2100 license to cover (aux)
Amount:
$775.00

Cost Information

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Other Expenses

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $99,020.48 $91,025.48 N/A $21,077.23 N/A
Total for all systems $5,838,991.27 $5,967,729.64 N/A $3,091,146.87 N/A
Other Expenses $99,020.48 $91,025.48 $21,077.23
Use Tax $22,021.35 $22,021.35 Please see WCTV Use Tax Budget Revision Justification Letter N/A N/A
Equipment Rental $9,454.30 $9,454.30 Please see Estimated Cost Justification WCTV-610-Equipment Rental V0 $9,453.68 N/A
MVPD Notification of Channel Change $2,000.00 $2,000.00 Please see Estimated Cost Justification WCTV-610-MVPD Notifications v0 $2,000.00 N/A
Develop and air announcement of upcoming channel change $10,000.00 $10,000.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $1,019.83 $1,019.83 Please See Estimated Cost Justification WCTV-610-Disposal Costs v2 $1,019.83 N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $1,310.00 per Estimated Cost Justification WCTV-610-STA FCC Filing Fees v1 $1,310.00 N/A
Equipment Storage $12,000.00 $12,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $2,440.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 Estimated Cost Justification WCTV-610-License to Cover FCC Filing Fees v0 $335.00 N/A
Equipment Delivery and Handling Charges $14,000.00 $14,000.00 N/A $3,013.72 N/A
Tree Removal $3,000.00 $3,000.00 N/A $2,500.00 N/A
Site Security $12,000.00 $12,000.00 N/A N/A N/A
FCC Filing Fees- Auxiliary Antenna Construction Permit $1,110.00 $1,110.00 Please see WCTV Auxiliary Antenna Construction Permit FCC Filing Fees Budget Justification Letter $1,110.00 N/A
FCC Filing Fees - Auxiliary Antenna License to Cover Filing Fees $335.00 $335.00 Please see WCTV Attorney and Filing Fees Categories Revision Justification Cover Letter $335.00 N/A

Components

Actual Information Description File Name
Use Tax Information not provided.
Equipment Rental

Component Description:
Performed QUOTED REPAIR
Amount:
$963.00

Component Description:
RENTAL GENERATOR
Amount:
$7,527.68

Component Description:
Service fee
Amount:
$963.00
MVPD Notification of Channel Change

Component Description:
Total Professional Services
Amount:
$2,000.00
Develop and air announcement of upcoming channel change Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
Const. and Demolitio
Amount:
$210.22

Component Description:
setup fee - county
Amount:
$158.36

Component Description:
Const. and Demolitio
Amount:
$198.97

Component Description:
Rent - 0 Hauls
Amount:
$117.00

Component Description:
Const. and Demolitio
Amount:
$218.28

Component Description:
Rent - O Hauls
Amount:
$117.00
FCC Filing Fees - Special Temporary Authorization request

Component Description:
WCTV-610-STA FCC Filing Fees
Amount:
$200.00

Component Description:
WCTV-610-STA FCC Filing Fees-
Amount:
$1,110.00
Equipment Storage Information not provided.
DTV Medical Facility Notification Information not provided.
FCC Filing Fees - Form 2100 license to cover application

Component Description:
File WCTV license to cover.
Amount:
$335.00
Equipment Delivery and Handling Charges

Component Description:
Scissor Lift 19' Electric
Amount:
$646.10

Component Description:
Scissor Lift 19' Electric-Rental
Amount:
$1,006.75

Component Description:
Freight and driver
Amount:
$1,360.87
Tree Removal

Component Description:
Clearing right of way for the tower cable
Amount:
$2,500.00
Site Security Information not provided.
FCC Filing Fees- Auxiliary Antenna Construction Permit

Component Description:
WCTV-610- Aux Antenna Construction Permit FCC Filing Fees
Amount:
$1,110.00
FCC Filing Fees - Auxiliary Antenna License to Cover Filing Fees

Component Description:
WCTV-610-License to Cover FCC Filing Fees (Aux)
Amount:
$335.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $5,838,991.27 $5,967,729.64 $3,091,146.87

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
Construction of final facilities or all necessary modifications are complete. No
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator. No

Certification

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Section Question Response
Submission of Estimated Expenses Statements

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

  1. The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  3. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  4. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).

  5. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  6. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.

  7. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  8. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

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

Robert Folliard , III .

Assistant Secretary


04/20/2021

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

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

  1. The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

  3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  4. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  5. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .

  6. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  7. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

  8. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  9. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.

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

Robert Folliard , III .

Assistant Secretary


04/20/2021

Attachments

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