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:
39738
Service:
DTV
Call Sign:
WXIX-TV
Channel:
15 (UHF)
File Number:
0000024807
FRN:
0018223693
Date Submitted:
02/22/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

GRAY TELEVISION LICENSEE, LLC

Doing Business As: WXIX

4370 PEACHTREE ROAD, NE

ATLANTA, GA 30319

United States

+1 (404) 266-8333 robert.folliard@gray.tv Limited Liability Company

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

The Preparer is same as the reimbursement contact.

 

 

 

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. Yes
Briefly describe transition plan Install interim side mount broadband antenna and line. (WXIX, WPTO) Install new top mounted antenna and connect to existing line. Install new main and backup transmitters

Transmitters

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

Auxiliary Transmitter

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Add Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Auxiliary (Backup)
Description of Use Emergency Backup
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 Ranger
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1.1 kW

Auxiliary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Auxiliary (Backup)
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model UAXTE-2
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.1 kW
Justification for New Transmitter Existing transmitter cannot be re-tuned Manufacturers letter attached NO LONGER PURCHASING THIS TRANSMITTER, NOW PROCURING AN INTERIM. ALL PAYMENTS WILL BE CREDITED TO INTERIM.

Auxiliary 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

Auxiliary Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model DCX
Year 2001
Type Inductive Output Tube
IOT Power Type Single
Power Capacity 20 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model ULXTE-40
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 25.3 kW
Justification for New Transmitter Existing transmitter cannot be retuned Manufacturers statement attached Quote attached Headroom analysis attached

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) Yes
Transformer (480V) Yes
Power 300 kVA
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

Name Description

Primary Transmitter - Other

Primary Transmitter - Other

Primary Transmitter - Removal and Reinstall

Primary Transmitter - Removal and Reinstall

Primary Transmitter - Other - Building Modification

Primary Transmitter - Other - Building Modification

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use N/A
Change Type Purchase
Manufacturer
Model UAXTE-8R44
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 4.8 kW
Justification for New Transmitter Needed to remain on the air during transition.

Interim Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) Yes
Power 150 kVA
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service Yes
Description Electrical work required for operation of interim transmitter
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A
Inside RF System Is an additional interior RF system required to support this interim transmitter? No

Interim Transmitter

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Other Transmitter Cost Not Listed

Name Description

Interim Transmitter - HVAC Relocation

Interim Transmitter - HVAC Relocation

Transmitter-Site Survey

Transmitter-Site Survey

Interim Transmitter - Other

Interim Transmitter - Other

Interim Transmitter - Removal and Reinstall

Interim Transmitter - Removal and Reinstall

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 Full Power
Mounting Top Mount
Antenna position in stack Bottom
Polarization Elliptical
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: 227.0 kW
Manufacturer
Model TFU-14GBH/VP-R6T190
Year 2001

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 Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 164.0 kW
Manufacturer
Model TFU-10GTH/VP-R T190
Year 2019
Justification for New Antenna Existing antenna can not be retuned Station licensed for v-pol

Primary Antenna

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Other Antenna Costs

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

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Interim Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Interim
Description of Use N/A
Change Type Purchase New
Ownership Owned
Owner N/A
Is antenna shared? Yes
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Type Class Full Power
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Slot
Number of Stations Supported 2
Number of Panels/Bays 16
Lower Limit 470.00 MHz
Upper Limit 608.00 MHz
Design power capacity in use 75.0 %
Other Antenna Type N/A
ERP: 450.0 kW
Manufacturer
Model TFU-WB16
Year 2019
Justification for New Antenna Two station interim antenna WXIX, WPTO

Interim Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? 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 an antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Interim Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1000 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 1000 feet per run
Justification for New Transmission Line Existing line sections are 19.5', need 20' sections.

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Primary Transmission Line - Other Parts

Primary Transmission Line - Other Parts

Primary Transmission Line - Sweep Test

Primary Transmission Line - Additional sweep test of primary transmission line

Interim Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Rigid
Diameter 4 1/16 inches
Segment Length Broadband
Other Segment Length
Number of parallel runs 1
Length 1000 feet per run
Justification for New Transmission Line Broadband interim line for two station interim operation WXIX and WPTO

Interim Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Interim Transmission Line - Other Parts

Interim Transmission Line - Other Parts

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? Yes
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 39° 07' 19.0" N-
Longitude (NAD83) 084° 32' 52.0" W-
Overall Structure Height 1020.98 feet
Support Structure Height 951.76 feet
Ground Elevation Above Mean Sea Level (AMSL) 728.01 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner WXIX, LLC
Date Constructed 01/01/1985

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
72126 WGRR FM
5893 WIZF FM
3142 WRRM FM
25065 WPTO DTV
57353 WOSL 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: Study needed for documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor 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? Yes

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 895
Explanation Pattern analysis Antenna Spec Transmitter Spec Building drawings Installation Supervision Accounting Internal Legal Strategic Support
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility 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
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 Yes
Quantity 1
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations Yes
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 Yes
Number of Days 5
Justification On-site engineering services necessary for transmission line installation

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Name Description

Site Security

Site Security

Equipment Rental

Equipment rental required for repack work.

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 $1,543,007.22 $1,299,929.98 N/A $1,168,679.60 N/A
Total for all systems $3,245,081.50 $2,843,480.83 N/A $2,293,762.95 N/A
Interim Transmitter UAXTE-8R44 $292,664.90 $193,520.80 $107,122.70
Interim Transmitter - Removal and Reinstall $22,516.01 $22,516.01 Please see GatesAir Change Order Q-81980 and actual costs (proportional sales tax) on Invoice US0327386 N/A N/A
Interim Transmitter - Other $441.21 $441.21 Please see WXIX-TV Interim Transmitter - Other Budget Justification Letter $23.73 N/A
Transmitter-Site Survey $2,000.00 $2,000.00 Please see WXIX-TV Interim Transmitter-Site Survey Budget Revision Justification Letter $2,000.00 N/A
Interim Transmitter - HVAC Relocation $920.18 $920.18 Please see WXIX-TV Interim Transmitter HVAC Relocation Budget Justification Letter $920.18 N/A
Transformer 3 phase/480v - 150 KVA $25,550.00 $4,570.06 GatesAir Quote Q-80920r2 $0.00 N/A
Other Electrical Service: Electrical work required for operation of interim transmitter $4,737.50 $4,737.50 Please see WXIX-TV Interim Transmitter-Other Electrical Service Budget Revision Justification Letter $4,737.50 N/A
UHF - Air Cooled Solid State Transmitter 4 - 6 kW $236,500.00 $158,335.84 Please see Estimated Cost Justification WXIX-180-Interim Transmitter - UHF - Air Cooled Solid State Transmitter 4 - 6 kW v1 GatesAir Quote Q-80920r2 Est cost decreased by payments already made towards Aux transmitter no longer needed. $99,441.29 N/A
Primary Transmitter ULXTE-40 $1,124,342.32 $1,093,256.48 $1,048,404.20
Primary Transmitter - Other - Building Modification $81,921.00 $81,921.00 Please see BK Specialty Contractors Estimate # 1004 and WXIX-TV Primary Transmitter - Other - Building Modification Budget Justification Letter $81,921.00 N/A
Primary Transmitter - Removal and Reinstall $19,975.00 $19,975.00 Please see Estimated Cost Justification WXIX-110-1st Primary Transmitter - Removal and Reinstall V0 $19,975.00 N/A
Primary Transmitter - Other $446.32 $446.32 Please see Estimated Cost Justification WXIX-110-1st Primary Transmitter - Other v0 $446.32 N/A
Transformer 3 phase/480v - 300 KVA $36,800.00 $35,000.00 N/A $8,691.22 N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A $17,756.50 N/A
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW $947,000.00 $919,614.16 Please see Estimated Cost Justification WXIX-110-1st Primary Transmitter - UHF - Liquid Cooled Solid State, 21-31 kW v0 Quote attached Headroom analysis attached $919,614.16 N/A
Auxiliary Transmitter UAXTE-2 $126,000.00 $13,152.70 $13,152.70
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $126,000.00 $13,152.70 No longer purchasing an AUX, rather procuring an interim. All payments will be credited towards interim. $13,152.70 N/A

Components

Actual Information Description File Name
Interim Transmitter - Removal and Reinstall Information not provided.
Interim Transmitter - Other

Component Description:
WXIX-180-Interim Transmitter - Other
Amount:
$23.73
Transmitter-Site Survey

Component Description:
WXIX-180-Interim Transmitter Site Survey
Amount:
$2,000.00
Interim Transmitter - HVAC Relocation

Component Description:
Transmitter site-relocate AC unit- labor, materials, trip, tools
Amount:
$920.18
Transformer 3 phase/480v - 150 KVA Information not provided.
Other Electrical Service: Electrical work required for operation of interim transmitter

Component Description:
WXIX-180-Interim Transmitter Other Electrical Service
Amount:
$4,737.50
UHF - Air Cooled Solid State Transmitter 4 - 6 kW

Component Description:
UAXTE-8
Amount:
$75,386.78

Component Description:
UAXTE-8
Amount:
$24,054.51
Primary Transmitter - Other - Building Modification

Component Description:
Install three phase 100 amp service disconnect in existing distribution panel including 80 amp fuses.
Amount:
$24,791.44

Component Description:
Help with removing existing 6 inch transmission line and installing new 3 inch during an over night shut down at the tower.
Amount:
$1,540.00

Component Description:
Install three phase 100 amp service disconnect in existing distribution panel including 80 amp fuses.
Amount:
$24,062.28

Component Description:
Install three phase 100 amp service disconnect in existing distribution panel including 80 amp fuses.
Amount:
$24,062.28

Component Description:
Transmitter Building
Amount:
$7,465.00
Primary Transmitter - Removal and Reinstall

Component Description:
Service Call Decom existing transmitter equipment
Amount:
$19,975.00
Primary Transmitter - Other

Component Description:
Coaxial Adapter
Amount:
$23.73

Component Description:
Repack supplies
Amount:
$422.59
Transformer 3 phase/480v - 300 KVA

Component Description:
WXIX-110-1st Primary Transmitter - 3 Phase, 480 V, 300 KVA Transformer
Amount:
$5,931.19

Component Description:
WXIX-110-1st Primary Transmitter - 3 Phase, 480 V, 300 KVA Transformer
Amount:
$661.38

Component Description:
WXIX-110-1st Primary Transmitter - 3 Phase, 480 V, 300 KVA Transformer
Amount:
$2,098.65
Switchgear - industrial 800 amp

Component Description:
"SWITCH S60 6-50 4 PORT 115VAC MOT /CONTROL 8-30VDC-115 & 230 VAC"
Amount:
$17,756.50
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW

Component Description:
ULXTE-40 per Quote Q-70112
Amount:
$87,502.15

Component Description:
ULXTE-40
Amount:
$79,636.25

Component Description:
ULXTE-40 per Quote Q-70112
Amount:
$131,253.23

Component Description:
Repack supplies
Amount:
$336.00

Component Description:
A. Transmitter
Amount:
$423,663.90

Component Description:
ULXTE-40
Amount:
$197,222.63
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
UAXTE-2-E per quote GA-00020798
Amount:
$7,891.62

Component Description:
UAXTE-2-E
Amount:
$5,261.08

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 $428,007.50 $291,237.13 N/A $269,039.13 N/A
Total for all systems $3,245,081.50 $2,843,480.83 N/A $2,293,762.95 N/A
Interim Antenna TFU-WB16 $119,477.50 $119,147.50 $98,494.13
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $6,400.00 N/A
UHF - High Power, Side Mount, basic slot antenna, 16 bay,, 450 kW input, directional,, horizontally polarized $112,747.50 $112,747.50 Quote attached $92,094.13 N/A
Primary Antenna TFU-10GTH/VP-R T190 $308,530.00 $172,089.63 $170,545.00
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,300.00 $1,544.63 Please see Dielectric Quote 44983 and Order Confirmation 69001, less amount already reimbursed under antenna category $1,544.63 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $6,400.00 N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $289,500.00 $164,145.00 Quote attached $162,600.37 N/A

Components

Actual Information Description File Name
Sweep test of existing antenna

Component Description:
Interim Antenna - Sweep Test
Amount:
$640.00

Component Description:
WXIX-280-Interim Antenna - Sweep Test
Amount:
$960.00

Component Description:
WXIX-280-Interim Antenna - Sweep Test
Amount:
$3,200.00

Component Description:
WXIX-280-Interim Antenna - Sweep Test
Amount:
$1,600.00
UHF - High Power, Side Mount, basic slot antenna, 16 bay,, 450 kW input, directional,, horizontally polarized

Component Description:
ANTENNA- PURCHASE OF INTERIM ANTENNAS AND/OR REPLACEMENT OF EXISTIING AUXILIARY ANTENNAS ANT TFU-16WB WXIX PRICE SHOWN INCLUDES STANDARD MOUNTING BRACKETS
Amount:
$25,481.25

Component Description:
ANTENNA
Amount:
$4,375.63

Component Description:
"ANTENNA- FOR PURCHASE OF INTERIM ANTENNAS AND/OR REPLACEMENT OF EXISTIING AUXILIARY ANTENNAS ANT TFU-16WB WXIX PRICE SHOWN INCLUDES STANDARD MOUNTING BRACKETS"
Amount:
$50,962.50

Component Description:
Interim Antenna
Amount:
$11,274.75
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
WXIX-210-Primary Antenna - Elbow Complex
Amount:
$1,544.63
Sweep test of existing antenna

Component Description:
WXIX-210-Primary Antenna - Sweep Test
Amount:
$960.00

Component Description:
WXIX-210-Primary Antenna - Sweep Test
Amount:
$1,600.00

Component Description:
WXIX-210-Primary Antenna - Sweep Test
Amount:
$3,200.00

Component Description:
Primary Antenna - Sweep Test
Amount:
$640.00
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized

Component Description:
RIGID TRANSMISSION LINE - COPPER
Amount:
$19,036.74

Component Description:
UHF - HIGH POWER TOP MOUNT (200-1,000 KW)
Amount:
$82,072.50

Component Description:
Primary Antenna and Elbow Complex
Amount:
$16,414.50

Component Description:
UHF-HIGH POWER TOP MOUNT (200-1,000 KW)
Amount:
$41,036.24

Component Description:
FREIGHT AND SHIPPING PAF 48' FLATBED DELIVERY
Amount:
$4,040.39

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 $407,152.86 $281,954.41 N/A $193,476.26 N/A
Total for all systems $3,245,081.50 $2,843,480.83 N/A $2,293,762.95 N/A
Interim Transmission Line $198,334.86 $133,643.56 $45,165.43
Rigid Transmission Line - copper, 4 1/16" broadband $163,000.00 $98,308.70 Quote attached (see interim antenna quote) $9,830.57 N/A
Interim Transmission Line - Other Parts $35,334.86 $35,334.86 Please see Estimated Cost Justification WXIX-380-Interim Transmission Line - Other Parts v2 $35,334.86 N/A
Primary Transmission Line $208,818.00 $148,310.85 $148,310.83
Primary Transmission Line - Sweep Test $6,400.00 $6,400.00 Please see THTV estimate 1022 with sweep test email explanation dated 1-3-21 $6,400.00 N/A
Primary Transmission Line - Other Parts $418.00 $418.00 Please see Estimated Cost Justification WXIX-310-Primary Transmission Line - Other Parts V1 $418.00 N/A
Rigid Transmission Line - copper, 6 1/8" $202,000.00 $141,492.85 per Estimated Cost Justification WXIX-310-Primary Transmission Line - Rigid, Copper V1 $141,492.83 N/A

Components

Actual Information Description File Name
Rigid Transmission Line - copper, 4 1/16" broadband

Component Description:
Interim Transmission Line - Rigid, Copper, 4 1/16
Amount:
$9,830.57
Interim Transmission Line - Other Parts

Component Description:
WXIX-380-Interim Transmission Line - Other Parts
Amount:
$15,828.00

Component Description:
WXIX-380-Interim Transmission Line - Other Parts
Amount:
$24.13

Component Description:
other
Amount:
$7,928.20

Component Description:
WXIX-380-Interim Transmission Line - Other Parts
Amount:
$156.99

Component Description:
WXIX-380-Interim Transmission Line - Other Parts
Amount:
$91.59

Component Description:
WXIX-380-Interim Transmission Line - Other Parts
Amount:
$105.95

Component Description:
WXIX-380-Interim Transmission Line - Other Parts
Amount:
$5,124.00

Component Description:
RIGID TRANSMISSION LINE - COPPER
Amount:
$3,514.00

Component Description:
WXIX-380-Interim Transmission Line - Other Parts
Amount:
$2,562.00
Primary Transmission Line - Sweep Test

Component Description:
RF Sweep 6 1/8" transmission line new installation
Amount:
$6,400.00
Primary Transmission Line - Other Parts

Component Description:
WXIX-310-Primary Transmission Line - Other Parts
Amount:
$39.32

Component Description:
Cylinder Billing Nitrogen
Amount:
$24.14

Component Description:
UN1001 ACETYLENE, DISSOLVED
Amount:
$156.98

Component Description:
UN1001 ACETYLENE, DISSOLVED
Amount:
$91.60

Component Description:
4 HOLE CORNER ANGLE ZN PLTD
Amount:
$105.96
Rigid Transmission Line - copper, 6 1/8"

Component Description:
WXIX-310-Primary Transmission Line - Rigid, Copper, 6 1/8"
Amount:
$4,979.98

Component Description:
HANGER VERT 8 3/16 FIXED HEAVY DUTY
Amount:
$1,659.75

Component Description:
WXIX-310-Primary Transmission Line - Rigid, Copper, 6 1/8"
Amount:
$33,233.02

Component Description:
FLANGE ASSY 6 1/8 UHF SOLDER "QS"
Amount:
$1,167.00

Component Description:
WXIX-310-Primary Transmission Line - Rigid, Copper, 6 1/8"
Amount:
$20,297.82

Component Description:
WXIX-310-Primary Transmission Line - Rigid, Copper, 6 1/8"
Amount:
$66,466.05

Component Description:
FLANGE ASSY 6 1/8 UHF SOLDER "QS"
Amount:
$396.00

Component Description:
Primary Antenna - UHF High Power Top Mount, E-POL
Amount:
$13,293.21

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 $495,100.00 $614,405.00 N/A $464,405.00 N/A
Total for all systems $3,245,081.50 $2,843,480.83 N/A $2,293,762.95 N/A
Primary Tower TOWER $495,100.00 $614,405.00 $464,405.00
Tower Helicopter Lift $114,000.00 $114,000.00 Please see Tower King II, Inc. Proposal C-19-011 $114,000.00 N/A
Structural engineering tower load study for well documented tower $12,600.00 $18,000.00 per Tower King II, Inc Proposal C-17-155, FDH Velocitel Proposal P17_1771_001 and FDH Infrastructure Services, LLC Proposal P20_1771_001 $18,000.00 N/A
Tall Tower (greater than 500') $210,500.00 $332,405.00 Please see Tower King II, Inc. Proposal C-20-036 and Tower King II, Inc. Proposal C-19-011 $332,405.00 N/A
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A $0.00 N/A

Components

Actual Information Description File Name
Tower Helicopter Lift

Component Description:
WXIX-410-Existing Primary Tower - Helicopter Lift
Amount:
$39,108.06

Component Description:
WXIX-410-Existing Primary Tower - Helicopter Lift
Amount:
$74,891.94
Structural engineering tower load study for well documented tower

Component Description:
Final PMT 50%
Amount:
$3,750.00

Component Description:
Down PMT 50%
Amount:
$3,750.00

Component Description:
Engineering structural analysis
Amount:
$2,500.00

Component Description:
Mapping of WXIX Facility ID # 39738
Amount:
$5,500.00

Component Description:
Engineering - structural analysis
Amount:
$2,500.00
Tall Tower (greater than 500')

Component Description:
Tower Service- Final invoice
Amount:
$116,608.06

Component Description:
Tower Service
Amount:
$60,891.94

Component Description:
TOWER SERVICE
Amount:
$100,000.00

Component Description:
Final Balance to complete the WXIX post transition work.
Amount:
$54,905.00
Minor tower reinforcement/modifications 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 $269,095.00 $261,030.39 N/A $132,124.05 N/A
Total for all systems $3,245,081.50 $2,843,480.83 N/A $2,293,762.95 N/A
Outside Professional Services $269,095.00 $261,030.39 $132,124.05
Additional Field Engineering Service, 5 Days $11,195.00 $11,195.00 Please see WXIX-TV RF Eng-Additional Field Engineering Service, 5 days Budget Revision Justification Letter. The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $11,195.00 N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A $1,579.17 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 N/A $273.86 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $1,319.55 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $1,319.55 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A $207.50 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $1,750.00 N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,087.50 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $7,087.50 N/A
Prepare and or review reimbursement form $2,630.00 $3.34 Please see WXIX-TV Prepare and or Review Reimbursement Form Budget Revision Justification Letter $3.34 N/A
Project management of the transition $141,410.00 $144,675.00 Widelity Quote $107,437.30 N/A
Prepare request for Special Temporary Authorization $2,050.00 $1,500.00 N/A $1,270.83 N/A

Components

Actual Information Description File Name
Additional Field Engineering Service, 5 Days

Component Description:
On Site Engineering
Amount:
$10,250.00

Component Description:
August 19 Remove old equipment
Amount:
$945.00
Comprehensive coverage verification via field study, if needed

Component Description:
WXIX-580-Field Engineering Service - Comprehensive Coverage Verification
Amount:
$1,579.17
Attorney Fees - Prepare and File request for Special Temporary Authorization

Component Description:
WXIX-550-Attorney - Special Temporary Authroization
Amount:
$26.58

Component Description:
WXIX-550-Attorney - Special Temporary Authorization
Amount:
$53.62

Component Description:
For Professional Services Rendered Through August 31, 2019
Amount:
$193.66
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
For Professional Services Rendered Through October 31, 2019
Amount:
$222.00

Component Description:
For professional-services rendered in connection with the above referenced matter through December 31, 2018
Amount:
$27.86

Component Description:
Professional Services Rendered
Amount:
$29.90

Component Description:
Professional Services Rendered
Amount:
$10.65

Component Description:
Professional Services Rendered
Amount:
$6.64

Component Description:
Legal Services
Amount:
$297.53

Component Description:
Professional Services Rendered
Amount:
$70.14

Component Description:
Professional Services Rendered
Amount:
$49.50

Component Description:
Professional Services Rendered
Amount:
$191.81

Component Description:
Professional Services Rendered
Amount:
$203.35

Component Description:
Professional Services Rendered
Amount:
$51.28

Component Description:
Professional Services Rendered
Amount:
$44.94

Component Description:
Professional Services Rendered
Amount:
$94.02

Component Description:
Legal Services
Amount:
$19.93
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
WXIX-550-Attorney - License to Cover Application (Main) ($207.50)
Amount:
$207.50
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 Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
RF Eng- Preparation of engineering section of FCC Form 2100
Amount:
$1,750.00
Perform engineering study for new channel assignment and antenna development

Component Description:
Repack Engineering
Amount:
$3,362.50

Component Description:
Engineering study work for new channel assignment and antenna development
Amount:
$1,000.00

Component Description:
Engineering study work for new channel assignment and antenna development.
Amount:
$125.00

Component Description:
WXIX-530-RF Eng - Engineering Study for New Channel Assignment
Amount:
$2,250.00

Component Description:
WXIX-530-RF Eng - Engineering Study for New Channel Assignment
Amount:
$350.00
Prepare and or review reimbursement form

Component Description:
WXIX-550-Attorney - Prepare and or review reimbursement form
Amount:
$3.34
Project management of the transition

Component Description:
Project Management
Amount:
$56.46

Component Description:
Project Management
Amount:
$1,696.00

Component Description:
Project Management
Amount:
$2,544.95

Component Description:
Project Management
Amount:
$1,935.90

Component Description:
Project Management
Amount:
$89.83

Component Description:
Project Management
Amount:
$30.80

Component Description:
Project Management
Amount:
$3,611.80

Component Description:
Project management
Amount:
$2,329.40

Component Description:
Project Management
Amount:
$579.35

Component Description:
Project Management
Amount:
$2,999.95

Component Description:
Project Management
Amount:
$2,918.30

Component Description:
Project Management
Amount:
$2,570.75

Component Description:
Project Management
Amount:
$1,673.48

Component Description:
Project Management
Amount:
$1,993.50

Component Description:
WXIX-510-Project Management
Amount:
$1,771.00

Component Description:
Project Management
Amount:
$2,210.65

Component Description:
Project Management
Amount:
$3,293.35

Component Description:
Project Management
Amount:
$1,606.90

Component Description:
Project Management
Amount:
$3,193.25

Component Description:
Project Management
Amount:
$7,795.45

Component Description:
Project Management
Amount:
$924.00

Component Description:
Project Management
Amount:
$3,220.05

Component Description:
Project Management
Amount:
$2,269.10

Component Description:
Project Management
Amount:
$4,288.40

Component Description:
Project Management
Amount:
$1,918.75

Component Description:
Project Management
Amount:
$932.65

Component Description:
Project Management
Amount:
$7,821.35

Component Description:
Project Management
Amount:
$609.95

Component Description:
Project Management
Amount:
$2,499.55

Component Description:
Project Management
Amount:
$2,216.05

Component Description:
Project Management
Amount:
$3,135.05

Component Description:
Project Management
Amount:
$1,209.10

Component Description:
Project Management
Amount:
$1,573.15

Component Description:
Project Management
Amount:
$1,951.95

Component Description:
Project Management
Amount:
$2,984.95

Component Description:
Project Management
Amount:
$1,965.45

Component Description:
Project Management
Amount:
$3,799.10

Component Description:
Project Management
Amount:
$2,444.00

Component Description:
Project Management
Amount:
$46.20

Component Description:
Project Management
Amount:
$1,937.15

Component Description:
Project Management
Amount:
$2,670.55

Component Description:
Project Management
Amount:
$2,438.50

Component Description:
Project Management
Amount:
$2,025.15

Component Description:
Project Management
Amount:
$561.30

Component Description:
Project Management
Amount:
$5,046.15

Component Description:
Project Management
Amount:
$1,897.20

Component Description:
Project Management
Amount:
$151.43
Prepare request for Special Temporary Authorization

Component Description:
WXIX-530-RF Eng - Special Temporary Authorization
Amount:
$920.83

Component Description:
Develop technical parameters for Interim broadband side-mount antenna
Amount:
$350.00

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 $102,718.92 $94,923.92 N/A $66,038.91 N/A
Total for all systems $3,245,081.50 $2,843,480.83 N/A $2,293,762.95 N/A
Other Expenses $102,718.92 $94,923.92 $66,038.91
Site Security $16,948.08 $16,948.08 Please see Estimate Cost Justification WXIX-610-Site Security v0 $16,948.07 N/A
MVPD Notification of Channel Change $0.00 $0.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $2,850.00 $2,850.00 estimate for on air rescan announcement production. Quote attached N/A N/A
Equipment Delivery and Handling Charges $37,447.47 $37,447.47 please see Estimated Cost Justification WXIX-610-Equipment Delivery and Handling v4 $37,447.47 N/A
Equipment Rental $2,429.97 $2,429.97 Please see the attached WXIX-TV - Equipment Rental - Budget Revision Justification Letter $2,429.97 N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $200.00 Please see WXIX-TV FCC Filing Fees STA Budget Revision Justification Letter $200.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 Please see WXIX-TV FCC Filing Fees License to Cover Budget Revision Justification Letter $335.00 N/A
DTV Medical Facility Notification $11,550.00 $3,750.00 Group quote attached $3,750.00 N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $463.40 $463.40 Please see Estimated Cost Justification WXIX-610-Disposal v0 $463.40 N/A
Equipment Storage $30,500.00 $30,500.00 Estimate for Dielectric on site antenna storage Dielectric letter attached $4,465.00 N/A

Components

Actual Information Description File Name
Site Security

Component Description:
Police OT Salaries- September 2019
Amount:
$1,173.02

Component Description:
September 2019- Transmitter grounds during re-pac project
Amount:
$6,809.53

Component Description:
July 2020 - Transmitter repack project. On site to make rounds
Amount:
$2,305.42

Component Description:
August 2020 - Transmitter repack project. On site to make rounds
Amount:
$4,802.96

Component Description:
August 2019- transmitter grounds during re-pac project.
Amount:
$1,857.14
MVPD Notification of Channel Change Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
Equipment Delivery and Handling Charges

Component Description:
other
Amount:
$4,061.04

Component Description:
FREIGHT AND SHIPPING
Amount:
$2,497.50

Component Description:
WXIX-610-Equipment Delivery and Handling
Amount:
$4,692.71

Component Description:
FORKLIFT, TELESCOPIC
Amount:
$5,200.20

Component Description:
FORKLIFT, TELESCOPIC
Amount:
$4,090.85

Component Description:
other
Amount:
$872.69

Component Description:
FREIGHT AND SHIPPING
Amount:
$3,491.99

Component Description:
OTHER
Amount:
$817.78

Component Description:
SCISSOR LIFT 19'x32"
Amount:
$640.93

Component Description:
WXIX-610-Equipment Delivery and Handling
Amount:
$10,715.84

Component Description:
Forklift Industrial 5,000
Amount:
$365.94
Equipment Rental

Component Description:
SCISSOR LIFT 19x 32 -Electric-
Amount:
$555.33

Component Description:
Scissor Lift
Amount:
$491.13

Component Description:
Scissor Lift
Amount:
$828.18

Component Description:
SCISSOR LIFT
Amount:
$555.33
FCC Filing Fees - Special Temporary Authorization request

Component Description:
WXIX-610-FCC Filing Fees - Special Temporary Authorization request ($200.00)
Amount:
$200.00
FCC Filing Fees - Form 2100 license to cover application

Component Description:
WXIX-610-FCC Filing Fees - Form 2100 license to cover application ($335.00)
Amount:
$335.00
DTV Medical Facility Notification

Component Description:
Medical Notification
Amount:
$3,750.00
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
1 Waste Container 30 Cu Yd, on Call Service
Amount:
$318.22

Component Description:
1 Waste Container 30 Cu Yd, On Call Service
Amount:
$145.18
Equipment Storage

Component Description:
WXIX-610-Equipment Storage
Amount:
$1,595.00

Component Description:
Storage
Amount:
$2,870.00

Component Description:
WXIX-610-Equipment Storage
Amount:
$2,870.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $3,245,081.50 $2,843,480.83 $2,293,762.95

Reimbursement Status

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

Certification

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Section Question Response
Submission of Estimated Expenses Statements

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

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

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

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

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

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

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

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

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

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

Robert Folliard , III .

Assistant Secretary


02/22/2022

Certification

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Section Question Response
Submission of Actual Cost Documentation Statements

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

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

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

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

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

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

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

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

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

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

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

Robert Folliard , III .

Assistant Secretary


02/22/2022

Attachments

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