TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
WORD OF GOD FELLOWSHIP, INC.	Arnold Torres 3901 HIGHWAY 121 BEDFORD, TX 76021 United States	+1 (817) 799-2138	ARNOLD.TORRES@DAYSTAR.COM	Not-for-Profit

Applicant

Address

Phone

Applicant Type

WORD OF GOD FELLOWSHIP, INC.

Arnold Torres

3901 HIGHWAY 121

BEDFORD, TX 76021

United States

+1 (817) 799-2138

ARNOLD.TORRES@DAYSTAR.COM

Not-for-Profit

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant	Address	Phone	Email
[Confidential]

Preparer Contact Information

Preparer Contact Name and Information

Applicant	Address	Phone	Email
Samuel Hariton Widelity, Inc.	Samuel Hariton 4031 University Drive Ste 100 Fairfax, VA 22030 United States	+1 (339) 222-8107	sam.hariton@widelity.com

Applicant

Address

Phone

Samuel Hariton

Widelity, Inc.

Samuel Hariton

4031 University Drive

Ste 100

Fairfax, VA 22030

United States

+1 (339) 222-8107

sam.hariton@widelity.com

Broadcaster Information and Transition Plan

Question	Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information.	No
Briefly describe transition plan	WKDC will transition from channel 50 to channel 16 by changing its antenna and transmitter. WKDC will not change tower sites.

Transmitters

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

Primary Transmitter

Existing Transmitter Information

Section	Question	Response
Existing Transmitter Description	Type of change	Purchase New
	Use	Primary (Main)
	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
	Model	AT7-2K0
	Year	2011
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power Capacity	2 kW

Primary Transmitter

New Transmitter Costs

Section	Question	Response
New Transmitter	Use	Primary (Main)
	Change Type	Purchase New
	Is this a request for upgraded equipment?	Yes
	Manufacturer
	Model	TXUD3600AC-D
	Transmitter Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	3.6 kW
	Justification for New Transmitter	Moving from channel 50 to channel 16 requires the purchase of a new transmitter because the current transmitter cannot be re-channeled to meet the new channel assignment.

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?	Yes
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	Purchase New
	Antenna Use	Primary (Main)
	Ownership	Owned
	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?	Yes
Existing Antenna Manufacturer and Type
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Elliptical
	Type	Slotted Coaxial
	ERP:	15.0 kW
	Manufacturer
	Model	SWLP8WC
	Year	2011

Primary Antenna

New Antenna Costs

Section	Question	Response
New Antenna Description	Use	Primary (Main)
	Change Type	Purchase New
	Ownership	Owned
	Is antenna shared?	No
	Is antenna directional?	Yes
	Will antenna be located on or in close proximity to an antenna farm?	Yes
New Antenna Manufacturer and Types
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Elliptical
	Type	Slotted Coaxial
	ERP:	15.0 kW
	Manufacturer
	Model	SWEDL6WC/16
	Year	2019
	Justification for New Antenna	Existing antenna cannot accommodate channel 16 operations..

Primary Antenna

Other Antenna Costs

Section	Question	Response
Elbow Complex	Do you require the separate purchase of the Elbow Complex?	Yes
	Broadband or Single Channel?	Single Channel
	Feed Line Size	1 5/8 inches inches
Side Mount Brackets	Do you require the separate purchase of side mount brackets for a high power antenna?	No
Pattern Scatter Analysis	Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna?	No
Sweep Test	Do you require the sweep testing of transmission line and antenna?	Yes

Primary Antenna

Other Antenna Cost Not Listed

Name	Description
Antenna removal and installation	Antenna removal and installation

Transmission Line

Section	Question	Response
Transmission Line Related Expenses	Do you have transmission line related expenses?	No

Tower Equipment And Rigging Costs

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

Primary Tower

Existing Tower

Section	Question	Response
Existing Tower Description	Type of change	Modify Existing
	Tower Use	Primary (Main)
	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)	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
Existing Tower Structure Registration	ASR Number	1055358
Coordinates (NAD83)	Latitude (NAD83)	34° 06' 58.4" N-
	Longitude (NAD83)	080° 45' 49.9" W-
	Overall Structure Height	1764.09 feet
	Support Structure Height	1695.85 feet
	Ground Elevation Above Mean Sea Level (AMSL)	284.77 feet
	Structure Type	GTOWER - Guyed Structure Used for Communication Purposes
	Tower Owner	American Towers LLC
	Date Constructed	03/05/2001

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
19199	WACH	DTV
40902	WKTC	DTV
60963	WOLO-TV	DTV

Primary Tower

Tower Modification Costs

Section	Question	Response
Engineering Study	Please what type of engineering study is required, if any:	No study needed
Tower Reinforcements	Please select whether tower reinforcements are needed:	No reinforcements needed

Primary Tower

Tower Rigging Costs

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

Primary Tower

Other Tower Expenses Not Listed

Name	Description
Tower - Construction Drawings	Tower - Construction Drawings
Tower - Structural Analysis	Tower - Structural Analysis

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	Yes
	Number of Hours	254
	Explanation	WKDC-LD does not have sufficient resource capacity and expertise in house to handle all activities necessary for completion of the station's build by the construction deadline. WKDC-LD will hire an outside firm to facilitate a timely transition.
Outside RF consulting Engineering Services	Perform engineering study for displacement application	Yes
	Prepare engineering section of Form FCC Construction Permit Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare engineering section of Form FCC License to Cover Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare request for Special Temporary Authority	Yes
	Quantity	1
	Prepare Form 601	No
Attorney and Other Outside Consulting Services	Prepare and file Form FCC Construction Permit Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare and file Form FCC License to Cover Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare request for Special Temporary Authority	Yes
	Quantity	1
	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	Yes
	Additional Field Engineering Service	Yes
	Number of Days	4
	Justification	Transmitter, antenna, and additional equipment adjustments required to complete necessary repack work.

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	Yes
	FCC License to Cover Application	Yes
	FCC Special Temporary Authority Application	Yes
Other Miscellaneous Expenses	Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)?	Yes
	Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs?	Yes
	Does this relocation require Equipment Storage?	Yes
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

Information not provided.

Cost Information

Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$116,300.00	$106,757.20	N/A	$250.00	N/A
Total for all systems	$377,399.82	$184,477.32	N/A	$43,997.86	N/A
Primary Transmitter TXUD3600AC-D	$116,300.00	$106,757.20		$250.00
Transmitter Building Site Survey/Installation	$10,000.00	$6,000.00	N/A	$250.00	N/A
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW	$106,300.00	$100,757.20	Please see Elettronika America Estimate 6534	N/A	N/A

Components

Actual Information Description	File Name
Transmitter Building Site Survey/Installation	Component Description: "Retune Comtech Channel 28 2.5 kW 1-5/8 EIA. Model A-TV6D140C-KK, SN1414-172028. Retune filter from Channel 28 to Channel 16" Amount: $250.00
UHF - Air Cooled Solid State Transmitter 2.501 - 3.999 kW	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	$27,090.78	$16,123.28	N/A	$14,623.28	N/A
Total for all systems	$377,399.82	$184,477.32	N/A	$43,997.86	N/A
Primary Antenna SWEDL6WC/16	$27,090.78	$16,123.28		$14,623.28
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical	$14,460.78	$14,460.78	Please see Estimated Cost Justification WKDC-LD-210-Primary Antenna - UHF Low Power Side Mount, E-POL v1	$14,460.78	N/A
Sweep test of transmission line and antenna	$5,730.00	$162.50	The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time.	$162.50	N/A
Antenna removal and installation	$0.00	$0.00	Previously approved antenna removal and installation budget moved to appropriate tower rigging category	N/A	N/A
Elbow complex, single channel, 1 5/8” input (if needed)	$6,900.00	$1,500.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical	Component Description: Low power digital TV transmit antenna Amount: $14,460.78
Sweep test of transmission line and antenna	Component Description: WKDC-LD-210-Primary Antenna - Sweep Test Amount: $162.50
Antenna removal and installation	Information not provided.
Elbow complex, single channel, 1 5/8” input (if needed)	Information not provided.

Cost Information

Transmission Line

Information not provided.

Cost Information

Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$164,250.00	$13,000.00	N/A	$13,000.00	N/A
Total for all systems	$377,399.82	$184,477.32	N/A	$43,997.86	N/A
Primary Tower GTOWER	$164,250.00	$13,000.00		$13,000.00
Tower - Construction Drawings	$2,500.00	$2,500.00	Please see American Tower PO request dated 12-4-20, line 2	$2,500.00	N/A
Tower Rigging Tall Tower (greater than 500')	$157,750.00	$6,500.00	Please see Vertical Technology Services, LLC Quote dated 5/28/2020	$6,500.00	N/A
Tower - Structural Analysis	$4,000.00	$4,000.00	Please see WKDC-LD Tower - Structural Analysis Budget Revision Justification Letter	$4,000.00	N/A

Components

Actual Information Description	File Name
Tower - Construction Drawings	Component Description: PO Line #2 Construction Drawings Amount: $2,500.00
Tower Rigging Tall Tower (greater than 500')	Component Description: Tower Rigging Amount: $3,250.00 Component Description: 50% down upon award pre VTS Proposal 20096SC - 5.28.20 Amount: $3,250.00 Component Description: Completion of Project - per VTS Proposal 20096SC Amount: $3,250.00 Component Description: Tower Rigging Amount: $3,250.00
Tower - Structural Analysis	Component Description: PO Line 1 - FID: 168565 KDPHChannel 13 PE Amount: $4,000.00

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	$57,009.04	$35,856.84	N/A	$15,986.84	N/A
Total for all systems	$377,399.82	$184,477.32	N/A	$43,997.86	N/A
Outside Professional Services	$57,009.04	$35,856.84		$15,986.84
Additional Field Engineering Service, 4 Days	$2,329.54	$2,329.54	Please see WKDC-LD RF Eng Additional Field Engineering Service Budget Revision Justification Letter. The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time.	$2,329.54	N/A
RF Exposure Measurements	$12,100.00	$5,000.00	N/A	N/A	N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization	$2,235.00	$2,235.00	N/A	N/A	N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$1,577.50	$1,500.00	N/A	N/A	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$3,025.00	$3,000.00	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,052.50	$1,000.00	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$2,102.50	$2,000.00	N/A	N/A	N/A
Prepare request for Special Temporary Authorization	$1,280.00	$1,200.00	N/A	N/A	N/A
Form 399 assistance or other Program Management costs	$1,000.00	$1,000.00	N/A	N/A	N/A
Prepare/ Review 399 reimbursement form	$1,710.00	$1,500.00	N/A	N/A	N/A
Project management of the transition	$26,797.00	$13,592.30	The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time.	$13,592.30	N/A
Perform engineering study for displacement application	$1,800.00	$1,500.00	N/A	$65.00	N/A

Components

Actual Information Description	File Name
Additional Field Engineering Service, 4 Days	Component Description: Work performed by FTM Amount: $1,527.50 Component Description: Expenses incurred by FTM Amount: $802.04
RF Exposure Measurements	Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization	Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	Information not provided.
Prepare request for Special Temporary Authorization	Information not provided.
Form 399 assistance or other Program Management costs	Information not provided.
Prepare/ Review 399 reimbursement form	Information not provided.
Project management of the transition	Component Description: Project Management Amount: $1,678.50 Component Description: Project Management Amount: $381.80 Component Description: Project management Amount: $1,296.75 Component Description: Project Management Amount: $1,985.40 Component Description: Project Management Amount: $1,683.85 Component Description: Project Management Amount: $1,503.85 Component Description: Project Management Amount: $554.20 Component Description: Project management Amount: $525.65 Component Description: Project Management Amount: $395.90 Component Description: Project Management Amount: $411.20 Component Description: Project management Amount: $410.05 Component Description: Project management Amount: $1,154.30 Component Description: Project Management Amount: $504.15 Component Description: Project Management Amount: $31.25 Component Description: Project management Amount: $377.40 Component Description: Project Management Amount: $51.25 Component Description: Project Management Amount: $646.80
Perform engineering study for displacement application	Component Description: Work performed by Frederick T Moore Amount: $65.00

Cost Information

Other Expenses

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$12,750.00	$12,740.00	N/A	$137.74	N/A
Total for all systems	$377,399.82	$184,477.32	N/A	$43,997.86	N/A
Other Expenses	$12,750.00	$12,740.00		$137.74
Equipment Delivery and Handling Charges	$5,000.00	$5,000.00	N/A	$137.74	N/A
Disposal Costs (for equipment and other waste, net of any salvage value)	$5,000.00	$5,000.00	N/A	N/A	N/A
FCC Filing Fees - Form 2100 minor change CP application	$1,110.00	$1,100.00	N/A	N/A	N/A
FCC Filing Fees - Special Temporary Authorization request	$305.00	$305.00	N/A	N/A	N/A
FCC Filing Fees - Form 2100 license to cover application	$335.00	$335.00	N/A	N/A	N/A
Equipment Storage	$1,000.00	$1,000.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Equipment Delivery and Handling Charges	Component Description: Expenses incurred by FTM Amount: $137.74
Disposal Costs (for equipment and other waste, net of any salvage value)	Information not provided.
FCC Filing Fees - Form 2100 minor change CP application	Information not provided.
FCC Filing Fees - Special Temporary Authorization request	Information not provided.
FCC Filing Fees - Form 2100 license to cover application	Information not provided.
Equipment Storage	Information not provided.

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$377,399.82	$184,477.32	$43,997.86

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.	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

Section	Question	Response
Submission of Estimated Expenses Statements	WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.
The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD). The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Arnold Torres Business Administrator 10/01/2021

Section

Question

Response

Submission of Estimated Expenses Statements

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

The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.
The above-named entity acknowledges that all certifications and attached documentation are considered material representations.
The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.
The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).
The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.
The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.
The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.
The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

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

Arnold Torres

Business Administrator

10/01/2021

Certification

Section	Question	Response
Submission of Actual Cost Documentation Statements	WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).
The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) . The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Arnold Torres Business Administrator 10/01/2021

Section

Question

Response

Submission of Actual Cost Documentation Statements

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

The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.
The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.
The above-named entity acknowledges that all certifications and attached documentation are considered material representations.
The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.
The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .
The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.
The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.
The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.
The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.

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

Arnold Torres

Business Administrator

10/01/2021

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

Applicant Information

Applicant Name, Type, and Contact Information

Reimbursement Contact Information

Reimbursement Contact Name and Information

Preparer Contact Information

Preparer Contact Name and Information

Broadcaster Information and Transition Plan

Transmitters

Primary Transmitter

Existing Transmitter Information

Primary Transmitter

New Transmitter Costs

Primary Transmitter

Other Transmitter Costs

Primary Transmitter

Other Transmitter Cost Not Listed

Antennas

Primary Antenna

Existing Antenna Information

Primary Antenna

New Antenna Costs

Primary Antenna

Other Antenna Costs

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Tower Equipment And Rigging Costs

Primary Tower

Existing Tower

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

Primary Tower

Tower Modification Costs

Primary Tower

Tower Rigging Costs

Primary Tower

Other Tower Expenses Not Listed

Outside Professional Services Costs

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Other Expenses

Other Expenses

Other Expenses Not Listed

Cost Information

Transmitters

Components

Cost Information

Antennas

Components

Cost Information

Transmission Line

Cost Information

Tower Equipment and Rigging Costs

Components

Cost Information

Outside Professional Services

Components

Cost Information

Other Expenses

Components

Cost Information

Grand Total

Reimbursement Status

Certification

Certification

Attachments