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:
70428
Service:
DCA
Call Sign:
WBXC-CD
Channel:
18 (UHF)
File Number:
0000027571
FRN:
0018223693
Date Submitted:
06/10/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

L4 MEDIA GROUP, LLC

Doing Business As: L4 MEDIA GROUP, LLC

PO Box 60606

Suite 2450

Chicago, IL 60606

United States

+1 (312) 505-5931 ssaldana@sktytrading.com 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

Tim Wolak

Director

Banded IT Solutions

2425 Bentshire Dr

Jacksonville, FL 32246

United States

+1 (312) 231-7895 twolak@bandeditsolutions.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 Current transmission system consists of a single transmitter feeding a flexible transmission line which connects to an antenna on the tower. Work includes tower study/rehabilitation to support new antenna, mounting antenna and retuning transmitter.

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 Retune Existing
Use Primary (Main)
Ownership Owned
Owner 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 Elettronika
Model TXUD1000
Year 2015
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.0 kW

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed N/A
New Mask Filter
Power 1.5 kW
Other Power N/A
New Exciter Is a new exciter needed? No

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) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? 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

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? 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 Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 2.5 kW
Manufacturer
Model JA/LS-CF-16
Year 2011

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? No
Ownership Owned
Owner N/A
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 Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 0.042 kW
Manufacturer
Model TLP-16H (SP)
Year 2018
Justification for New Antenna Current antenna is for channel 46 and cannot be retuned to repack channel 18. Applicant is proposing to replace with similar pattern tuned to the repack channel.

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

Primary Antenna

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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? No

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

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 Leased
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) No
Others Types of Users Yes
Is tower documented for structural analysis? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1032919
Coordinates (NAD83) Latitude (NAD83) 40° 06' 40.0" N-
Longitude (NAD83) 088° 14' 35.0" W-
Overall Structure Height 349.08 feet
Support Structure Height 330.38 feet
Ground Elevation Above Mean Sea Level (AMSL) 734.24 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner TAK COMMUNICATIONS LLC DBA = WKIO FM
Date Constructed 01/11/1998


Other Types of Users

Users
LPFM
Cellular

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: No 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

Information not provided.

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 200
Explanation Applicant has no internal resources capable of overseeing, identifying, purchasing, installing and commissioning this repack project. It will rely solely on outside services to manage all work required.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority 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 No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
Quantity N/A
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations No
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers No
RF Field Engineering Services Comprehensive coverage verification via field study Yes
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

MSW reports

MSW technical services preparing FCC post-repack reports

Progress Reporting

Prepare and file 9 required progress reports on FCC Form 2100, Schedule 387 on a quarterly basis with the FCC.

Fletcher, Heald and Hildreth

FCC Attorney fees for repack planning, reporting and submitting docs.

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 Yes
Non-zoning permits Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application Yes
FCC Special Temporary Authority Application No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? 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? No

Other Expenses

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Other Expenses Not Listed

Name Description

MSW reports

MSW technical services preparing FCC post-repack reports

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 $108,230.00 $18,179.80 N/A $18,179.80 N/A
Total for all systems $442,251.25 $265,562.40 N/A $195,088.92 N/A
Primary Transmitter TXUD1000 $108,230.00 $18,179.80 $18,179.80
UHF and VHF - minor banding issues $105,200.00 $15,000.00 N/A $15,000.00 Two invoices have been submitted, the second is a duplicate with the quote document attached as requested.
1.5 kW mask filter $3,030.00 $3,179.80 The estimate was outdated and did not include freight expense. $3,179.80 The original $2,800 estimate was based on information from the vendor at the time we created the 399. The actual cost nearly 2 years later increased due to manufacturing expense increases. Note freight is included on the invoice but not the estimate.

Components

Actual Information Description File Name
UHF and VHF - minor banding issues

Component Description:
TRANSMITTER MINOR BANDING SERVICES
Amount:
$15,000.00

Component Description:
transmitter services. Two invoices have been submitted, the second is a duplicate with the quote document attached as requested.
Amount:
$15,000.00
1.5 kW mask filter

Component Description:
NEW CHANNEL 18 MASK FILTER
Amount:
$3,179.80

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 $33,030.00 $30,059.25 N/A $30,059.25 N/A
Total for all systems $442,251.25 $265,562.40 N/A $195,088.92 N/A
Primary Antenna TLP-16H (SP) $33,030.00 $30,059.25 $30,059.25
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $25,559.25 N/A $25,559.25 N/A
Sweep test of existing antenna $6,730.00 $4,500.00 N/A $4,500.00 Two invoices have been submitted, the second is a duplicate with the quote document attached as requested.

Components

Actual Information Description File Name
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
UHF - LOW POWER SIDE MOUNT ANTENNA AND MOUNT TLP 16H
Amount:
$23,365.50

Component Description:
freight and shipping expense
Amount:
$2,193.75
Sweep test of existing antenna

Component Description:
sweep test services, inve with quote attached
Amount:
$4,500.00

Component Description:
SWEEP TEST
Amount:
$4,500.00

Cost Information

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Transmission Line

Information not provided.

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 $110,500.00 $88,000.00 N/A $63,000.00 N/A
Total for all systems $442,251.25 $265,562.40 N/A $195,088.92 N/A
Primary Tower TOWER $110,500.00 $88,000.00 $63,000.00
Short Tower (less than 500') $84,200.00 $63,000.00 N/A $63,000.00 Two invoices have been submitted, the second is a duplicate with the quote document attached as requested.
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $25,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Short Tower (less than 500')

Component Description:
tower antenna services Two invoices have been submitted, the second is a duplicate with the quote document attached as requested.
Amount:
$63,000.00

Component Description:
TOWER ANTENNA SERVICES
Amount:
$63,000.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study Information not provided.

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 $162,806.25 $108,198.35 N/A $79,421.87 N/A
Total for all systems $442,251.25 $265,562.40 N/A $195,088.92 N/A
Outside Professional Services $162,806.25 $108,198.35 $79,421.87
Fletcher, Heald and Hildreth $5,000.00 $5,000.00 N/A $2,894.58 N/A
Prepare and or review reimbursement form $2,630.00 $4,173.75 The initial estimate was outdated and the actual expense exceeded the estimate. $4,173.75 N/A
Progress Reporting $18,000.00 $18,000.00 Prepare and file 9 required progress reports on FCC Form 2100, Schedule 387 on a quarterly basis with the FCC. $1,192.50 N/A
MSW reports $1,656.25 $1,656.25 N/A $728.75 N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $30,000.00 N/A $30,000.00 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A $582.29 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $0.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $2,981.25 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,618.35 Due to antenna availability concerns we modeled multiple antennas and we were ready to transition early thus needed to confirm not up or down stream interference concerns. $7,618.75 Due to antenna availability concerns we modeled multiple antenna options. Further we were ready ahead of the scheduled transition date and need to confirm no up or down stream interference issues.
Project management of the transition $31,600.00 $30,000.00 N/A $29,250.00 N/A

Components

Actual Information Description File Name
Fletcher, Heald and Hildreth

Component Description:
FCC Attorney Fees
Amount:
$68.75

Component Description:
FCC Attorney Fees
Amount:
$214.58

Component Description:
FCC Attorney Fees
Amount:
$250.00

Component Description:
FCC Attorney Fees
Amount:
$62.50

Component Description:
FCC Attorney Fees
Amount:
$125.00

Component Description:
corrected which stations were invoiced and corrected requested amounts.
Amount:
$66.67

Component Description:
FCC Attorney Fees
Amount:
$187.50

Component Description:
FCC Attorney Fees
Amount:
$20.83

Component Description:
FCC Attorney Fees
Amount:
$51.04

Component Description:
FCC Attorney Fees
Amount:
$395.83

Component Description:
FCC Attorney Fees
Amount:
$62.50

Component Description:
FCC Attorney Fees
Amount:
$100.00

Component Description:
corrected which stations were invoiced and corrected requested amounts.
Amount:
$116.46

Component Description:
FCC Attorney Fees
Amount:
$406.25

Component Description:
FCC Attorney Fees
Amount:
$31.25

Component Description:
FCC Attorney Fees
Amount:
$712.50

Component Description:
FCC Attorney Fees
Amount:
$329.17

Component Description:
FCC Attorney Fees
Amount:
$120.83

Component Description:
FCC Attorney Fees
Amount:
$208.33

Component Description:
FCC Attorney Fees
Amount:
$333.33

Component Description:
FCC Attorney Fees
Amount:
$204.17

Component Description:
FCC Attorney Fees
Amount:
$92.71
Prepare and or review reimbursement form

Component Description:
PrepareTechnicalPortionsofFCCForm2100 ConstructionPermitApplicationandEngineeringExhibitsrequiredtobefiledwithInitialRepackChannel ConstructionPermitApplicationFCCForm2100fortheinitialfilingwindow
Amount:
$4,173.75
Progress Reporting

Component Description:
Prepare FCC Form 387 Repack Progress Report Filing. WBXC-CD
Amount:
$1,192.50
MSW reports

Component Description:
Technical services to prepare and file FCC updated forms and construction permits.
Amount:
$728.75
Comprehensive coverage verification via field study, if needed

Component Description:
COMPREHENSIVE FIELD TESTING
Amount:
$30,000.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
attorney fees
Amount:
$582.29

Component Description:
WBXC-CD Champaign, IL Prepare initial budgets, equipment lists, and determine equipment replacement for new repack channel; Prepare FCC Form 2100 Schedule 399 Budget and Narrative for initial Construction Permit Filing Window. 15.75 hours
Amount:
$4,173.75
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
RF Consulting Services - WBXC-CD Champaign, IL Prepare technical portions of FCC Form 2100 Construction Permit Application and Engineering Exhibits required to be filed with initial repack Construction Permit Application - filing window. 11.5 hours
Amount:
$2,981.25
Perform engineering study for new channel assignment and antenna development

Component Description:
Analyze potential early transition for WBXC-CD Champaign, IL. TVStudy and Analysis of Upstream and Downstream Station interference and impacts.
Amount:
$1,391.25

Component Description:
RF Consulting Services - WBXC-CD Champaign, IL Conduct TVStudy analysis of initial channel assignment and analyze interference issues with new repack channel. 12.25 hours
Amount:
$4,438.75

Component Description:
RF Consulting Services - WBXC-CD Champaign, IL Develop Azimuth antenna patterns and determine antenna required for FCC Form 2100 Construction Permit Application for initial Repack Channel CP Filing. 4.5 hours
Amount:
$1,192.50

Component Description:
Due to availability concerns we had to Analyze Potential use of ERI Antenna alternative and Pattern for WBXC-CD
Amount:
$1,788.75
Project management of the transition

Component Description:
Project Management services, research and coordination w/rf engineering, equipment vendors and site owners
Amount:
$750.00

Component Description:
PROJECT MANAGEMENT SERVICES
Amount:
$6,000.00

Component Description:
REPACK PROJECT MANAGEMENT SERVICES. RESEARCH AND COORDINATION W/RF ENGINEERING, ATTORNEY, EQUIPMENT VENDORS AND SITE OWNER
Amount:
$3,000.00

Component Description:
PROJECT MANAGEMENT
Amount:
$3,000.00

Component Description:
PROJECT MANAGEMENT
Amount:
$3,000.00

Component Description:
REPACK PROJECT MANAGEMENT SERVICES. RESEARCH AND COORDINATION W/RF ENGINEERING, ATTORNEY, EQUIPMENT VENDORS AND SITE OWNER
Amount:
$3,000.00

Component Description:
PROJECT MANAGEMENT SERVICES
Amount:
$2,250.00

Component Description:
PROJECT MANAGEMENT SERVICES
Amount:
$3,000.00

Component Description:
Project Management services, research and coordination w/rf engineering, equipment vendors and site owners
Amount:
$2,250.00

Component Description:
PROJECT MANAGEMENT
Amount:
$1,500.00

Component Description:
PROJECT MANAGEMENT SERVICES
Amount:
$4,500.00

Component Description:
project management services
Amount:
$3,000.00

Component Description:
PROJECT MANAGEMENT SERVICES
Amount:
$3,000.00

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 $27,685.00 $21,125.00 N/A $4,428.00 N/A
Total for all systems $442,251.25 $265,562.40 N/A $195,088.92 N/A
Other Expenses $27,685.00 $21,125.00 $4,428.00
MSW reports $800.00 $800.00 N/A $0.00 N/A
Develop and air announcement of upcoming channel change $2,500.00 $2,500.00 It is required that the applicant give notification to viewers of the repack channel change. Applicant has limited internal resources to create and produce such notifications and will most likely have to obtain the services from an outside vendor. N/A N/A
Equipment Storage $2,500.00 $2,500.00 Applicant may receive antenna and transmitter parts prior to set installation dates. There is no on-site storage available and applicant may be forced to use outside temporary storage facilities. $0.00 N/A
Equipment Delivery and Handling Charges $5,000.00 $5,000.00 There will be shipping charges for the antenna and transmitter costs. Precise costs will not be known until the carrier issues an invoice. Currently, applicant does not estimate costs to be more than this estimate. N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $1,000.00 $1,000.00 Applicant will be required to dispose of the current pre-repack antenna and parts that were replaced for transmitter retuning. The exact costs are not known at this time. N/A N/A
Non-zoning permits $2,000.00 $2,000.00 It is currently unknown what the city or county may levy on applicant in terms of a building permit to perform the tower work required. It is felt this estimate should cover the associated costs for any required permits. N/A N/A
Local Zoning $2,000.00 $2,000.00 It is currently unknown what the local zoning authority or city/county may levy on applicant to perform the tower work required. It is felt this estimate should cover the associated costs for any required permits. N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $5,000.00 N/A $4,428.00 N/A

Components

Actual Information Description File Name
MSW reports

Component Description:
Technical reporting services.
Amount:
$728.75
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage

Component Description:
temporary antenna storage
Amount:
$1,170.00
Equipment Delivery and Handling Charges Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Non-zoning permits Information not provided.
Local Zoning Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
DTV Medical Facility Notification

Component Description:
DTV Notification Service Notification of Medical Facilities Transmitter Medical Facility Notification per proposal
Amount:
$4,428.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $442,251.25 $265,562.40 $195,088.92

Reimbursement Status

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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

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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.

Tim Wolak

Director


06/10/2021

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.

Tim Wolak

Director


06/10/2021

Certification

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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.

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

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

  3. 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.

  4. 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.

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

  6. 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.

Tim Wolak

Director


06/10/2021

Attachments

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