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:
8500
Service:
DCA
Call Sign:
WLCU-CD
Channel:
15 (UHF)
File Number:
0000028953
FRN:
0013180294
Date Submitted:
10/08/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

Campbellsville University

1 University Drive

Campbellsville, KY 42718

United States

+1 (270) 403-0505 hkspears@campbellsville.edu Private Not-for-Profit Educational Institution

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

Lauren Lynch Flick

Esq

Pillsbury Winthrop Shaw Pittman LLP

1200 Seventeenth Street, NW

Washington, DC 20036

United States

+1 (202) 663-8166 lauren.lynch.flick@pillsburylaw.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 The WLCU-CD antenna is side mounted on a short guyed tower. The station will flash-cut to the new channel when its antenna is replaced and new transmitter installed in a new building.

Transmitters

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

Primary Transmitter

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Add 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 Anywave
Model TXR-5X-4-U-C
Year 2015
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity .56 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? Yes
Exciter Type Single frequency agile

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 Yes
Description Increase capacity
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size Other tons
Other Size 3 tons
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 12.0 square feet
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

Retuning

Required retuning, work, installation, commissioning and proof of performance

Primary Transmitter

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Add 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 TXR-5X-4-U-C
Year 2015
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity .56 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? No
Manufacturer
Model TXR-5X-4-U-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity .56 kW
Justification for New Transmitter Existing transmitter cannot be re-tuned.

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 Yes
Description 400A and backup generator
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size Other
Other Size 12 tons
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? Yes
Size 600.0 square feet
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

Transmitter Project Management

Labor & expenses associated with transmitter survey, planning, receiving, install & testing

Exciter

Anywave 5x plus Exciter

Mask Filter

Dielectric UHF Channel 15 Mask Bandpass Filter with Couplers

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 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: 3.0 kW
Manufacturer
Model SL-8
Year 2015

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? No
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: 2.48 kW
Manufacturer
Model SL-8
Year 2018
Justification for New Antenna Existing antenna will not function on new channel and cannot be retuned.

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? 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? No

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Antenna Data Lines

Install Antenna Data lines between antenna & building

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 Flexible Air
Diameter 7/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 0
Length 114 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 Flexible Foam
Diameter 7/8 inches
Other Diameter N/A
Segment Length N/A
Other Segment Length N/A
Number of parallel runs 0
Length 200 feet per run
Justification for New Transmission Line Old line could not be used, was not long enough

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

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 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? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 37° 20' 39.0" N-
Longitude (NAD83) 085° 21' 34.0" W-
Overall Structure Height 167.00 feet
Support Structure Height 167.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 833.00 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner Campbellsville University
Date Constructed 02/01/2011

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
176645 WLCU FM

Primary Tower

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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

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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? No
Number of Hours N/A
Explanation N/A
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development No
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority No
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 Yes
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

Form 399 Assistance

Form 399 Assistance

Legal Fees for Preparation of Transition Progress Reporting

Legal Fees for Preparation of Transition Progress Reporting

Technical Services

David Greenlee

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 No
FCC Special Temporary Authority Application No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? No
Does this relocation require Equipment Storage? No
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

Information not provided.

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 $170,290.23 $169,010.23 N/A $136,858.03 N/A
Total for all systems $322,423.50 $249,325.47 N/A $204,173.27 N/A
Primary Transmitter TXR-5X-4-U-C $24,080.00 $22,800.00 $0.00
1.5 kW mask filter $3,030.00 $2,800.00 ***System Notice: Estimate adjusted and locked because line has been superseded.***Existing equipment cannot operate on new channel. $0.00 N/A
Single frequency agile exciter $21,050.00 $20,000.00 ***System Notice: Estimate adjusted and locked because line has been superseded.***Existing exciter is at capacity/marginal for station's current operation. Any loss in efficiency due to on-site retuning of transmitter not likely to be withstood. First phase assignment necessitates replacement over repair. $0.00 N/A
Primary Transmitter TXR-5X-4-U-C $146,210.23 $146,210.23 $136,858.03
Transmitter Project Management $14,702.79 $14,702.79 N/A $14,702.79 N/A
Other -- Building Addition Size: 600.0 $34,155.24 $34,155.24 N/A $34,155.24 N/A
Other -- HVAC Service Type: H Size:12 (Other) $6,400.00 $6,400.00 N/A $6,400.00 N/A
Other Electrical Service: 400A and backup generator $17,352.20 $17,352.20 N/A $8,000.00 N/A
UHF - Air Cooled Solid State Transmitter .56 kW $50,800.00 $50,800.00 N/A $50,800.00 N/A
Exciter $20,000.00 $20,000.00 Exciter is necessary as it is sold separately than the transmitter. $20,000.00 N/A
Mask Filter $2,800.00 $2,800.00 N/A $2,800.00 N/A

Components

Actual Information Description File Name
1.5 kW mask filter

Component Description:
Dielectric UHF Channel 15 Mask Bandpass Filter with Couplers
Amount:
$2,800.00
Single frequency agile exciter

Component Description:
Anywave 5 Exciter/Frequency Agile with options PQM, TSoIP, PSIP, EAS
Amount:
$20,000.00
Transmitter Project Management

Component Description:
Transmitter project management
Amount:
$14,702.79
Other -- Building Addition Size: 600.0

Component Description:
Building Construction
Amount:
$7,786.38

Component Description:
Building Construction
Amount:
$1,982.37

Component Description:
Building Electrical & generator
Amount:
$8,800.00

Component Description:
Building Construction
Amount:
$5,040.12

Component Description:
Building Construction
Amount:
$9,256.88

Component Description:
Dense Grade Aggregate
Amount:
$220.90

Component Description:
Dense Grade Aggregate
Amount:
$198.59

Component Description:
Removing & installing new gas line
Amount:
$870.00
Other -- HVAC Service Type: H Size:12 (Other)

Component Description:
AC Unit
Amount:
$6,400.00
Other Electrical Service: 400A and backup generator

Component Description:
Electrical Work
Amount:
$8,000.00
UHF - Air Cooled Solid State Transmitter .56 kW

Component Description:
Transmitter
Amount:
$50,800.00
Exciter

Component Description:
Anywave Exciter
Amount:
$20,000.00
Mask Filter

Component Description:
Mask Filter
Amount:
$2,800.00

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 $26,626.91 $7,526.91 N/A $7,526.91 N/A
Total for all systems $322,423.50 $249,325.47 N/A $204,173.27 N/A
Primary Antenna SL-8 $26,626.91 $7,526.91 $7,526.91
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $7,200.00 N/A $7,200.00 N/A
Antenna Data Lines $326.91 $326.91 N/A $326.91 N/A

Components

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

Component Description:
Scala Antenna OMNI, SCA-SL8
Amount:
$7,200.00
Antenna Data Lines

Component Description:
Cat6 Data Lines
Amount:
$326.91

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 $0.00 $1,287.00 N/A $1,287.00 N/A
Total for all systems $322,423.50 $249,325.47 N/A $204,173.27 N/A
Primary Transmission Line $0.00 $1,287.00 $1,287.00
Flexible Foam Transmission Line - dielectric, 7/8" $0.00 $1,287.00 N/A $1,287.00 N/A

Components

Actual Information Description File Name
Flexible Foam Transmission Line - dielectric, 7/8"

Component Description:
transmission line
Amount:
$1,287.00

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 $84,200.00 $18,730.00 N/A $18,730.00 N/A
Total for all systems $322,423.50 $249,325.47 N/A $204,173.27 N/A
Primary Tower GTOWER $84,200.00 $18,730.00 $18,730.00
Short Tower (less than 500') $84,200.00 $18,730.00 N/A $18,730.00 N/A

Components

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

Component Description:
Tower Safety Work
Amount:
$10,530.00

Component Description:
Remobilization of Tower Crew
Amount:
$8,200.00

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 $24,058.36 $42,184.33 N/A $31,684.33 N/A
Total for all systems $322,423.50 $249,325.47 N/A $204,173.27 N/A
Outside Professional Services $24,058.36 $42,184.33 $31,684.33
Technical Services $350.36 $350.36 N/A $350.36 N/A
Legal Fees for Preparation of Transition Progress Reporting $3,013.00 $3,013.00 Costs not included in estimate. See attached invoice entries marked Other-Progress Reporting $3,013.00 Costs not included in estimate. See entries on invoice marked Other-Progress Reporting
Form 399 Assistance $3,075.00 $3,075.00 N/A $3,075.00 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $4,253.50 Costs exceeded estimate. See attached invoice entries labeled Prepare and file license to cover. $4,253.50 Costs exceeded estimate. See entries marked Prepare and file license to cover on attached invoice.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A $1,500.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $19,492.47 The rebuild had changed beyond out control, therefore adding more time spent on legal assistance on preparing and reviewing the reimbursement form. $19,492.47 Costs exceeded estimate. See entries marked Preparing or reviewing Form 399 on attached invoice.
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Technical Services

Component Description:
Technical Services
Amount:
$350.36
Legal Fees for Preparation of Transition Progress Reporting

Component Description:
Legal Fees for Preparation of Transition Progress Reporting
Amount:
$3,013.00
Form 399 Assistance

Component Description:
Form 399 Assistance
Amount:
$3,075.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Legal Fees for Preparation of License to Cover Application filing.
Amount:
$4,253.50
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

Component Description:
Prep of engineering portion of Form 2100
Amount:
$1,500.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare and or review reimbursement form

Component Description:
Legal fees to prepare Form 399 submissions.
Amount:
$2,863.00

Component Description:
Services thru 7-31-20
Amount:
$10,055.50

Component Description:
Assistance with Prep of Form 399
Amount:
$1,125.00

Component Description:
Services thru 9-30-20
Amount:
$1,774.50

Component Description:
Services thru 4-30-20
Amount:
$1,229.47

Component Description:
Professional Services Thru Jan 31, 2020
Amount:
$2,445.00
Address transition timing and coordination issues w/ other stations and wireless Information not provided.

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 $17,248.00 $10,587.00 N/A $8,087.00 N/A
Total for all systems $322,423.50 $249,325.47 N/A $204,173.27 N/A
Other Expenses $17,248.00 $10,587.00 $8,087.00
MVPD Notification of Channel Change $3,198.00 $3,198.00 Estimate based on catalogue. Actual cost higher than catalogue. See attached Estimate and comprehensive statement of actual costs incurred attached hereto. $3,198.00 Estimate was based on catalogue. Actual costs were higher. See attached Estimate.
Develop and air announcement of upcoming channel change $2,500.00 $2,500.00 Development and airing of announcement to ensure that over-the-air viewers are properly advised of channel change and requirements for continued service. N/A N/A
DTV Medical Facility Notification $11,550.00 $4,889.00 Actual cost as billed. See Attached Estimate. $4,889.00 Estimate based on catalogue. Actual cost based on invoice. See attached Estimate.

Components

Actual Information Description File Name
MVPD Notification of Channel Change

Component Description:
Actual cost for Notification of MPVD Providers
Amount:
$3,198.00
Develop and air announcement of upcoming channel change Information not provided.
DTV Medical Facility Notification

Component Description:
Actual cost of medical facilities notifications as billed by vendor.
Amount:
$4,889.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $322,423.50 $249,325.47 $204,173.27

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.

Jeannie S. Clark

General Manager


10/08/2021

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.

Jeannie S Clark

General Manager


10/08/2021

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.

Jeannie S Clark

General Manager


10/08/2021

Attachments

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