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:
125172
Service:
LPA
Call Sign:
K21OB-D
Channel:
21 (UHF)
File Number:
0000088735
FRN:
0015680614
Eligibility Status:
Eligible
Date Submitted:
04/15/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

WINDSONG COMMUNICATIONS, INC

Applicant

Doing Business As: WINDSONG COMMUNICATIONS, INC

C. Dowen Johnson

104 WOODMONT

MONTGOMERY, TX 77356

United States

+1 (936) 443-4451 windsongcomm@swbell.net Other

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. No
Briefly describe transition plan Replace the transmitter and antenna per the channel reassignment project with reasonable and customary engineering and business practices.

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
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 5SBP2K
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 2 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 TRN-U-2000-FA
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 2.2 kW
Justification for New Transmitter Replace the transmitter per the channel reassignment with reasonable and customary engineering and business practices.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
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

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Other Transmitter Cost Not Listed

Name Description

Shipping

Shipping of Transmitter from manufacturer to site not included in quote.

Decomm

Disconnect and de-install all existing components on old transmitter to prepare for installation of new transmitter.

Tax

Estimated tax on purchase of transmitter not included in quote.

Transmitter Site Prep

Perform work to prepare site for installation of new transmitter.

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)
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 Middle
Polarization Circular
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 3
Design power capacity in use 20.0 %
Lower Limit 14.00 MHz
Upper Limit 69.00 MHz
ERP: 10.0 kW
Manufacturer
Model 955512
Year 2006

Primary Antenna

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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 Middle
Polarization Elliptical
Type Slotted Coaxial
ERP: 5.0 kW
Manufacturer
Model PSILP80I
Year 2019
Justification for New Antenna New antenna for new channel.

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

Taxes

Estimated Taxes not included on antenna quote

Shipping

Estimated shipping costs from manufacturer to site.

Transmission Line

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

Tower Equipment And Rigging Costs

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

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1022634
Coordinates (NAD83) Latitude (NAD83) 30° 18' 43.0" N-
Longitude (NAD83) 093° 20' 15.2" W-
Overall Structure Height 513.12 feet
Support Structure Height 499.99 feet
Ground Elevation Above Mean Sea Level (AMSL) 18.04 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner American Towers, Inc.
Date Constructed 05/03/1996


Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Tower mapping and report for structural engineer
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? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 200
Explanation Required to assist in the turnkey management of the channel relocation project in order that the existing internal personnel can maintain and operate the stations daily operational requirements and plans.
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 Yes
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 Yes
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 Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 5
Justification Estimated field engineering required during transition activities.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Field and Technical Project Management

Field and Technical Project Management

Permit pickup

Flat fee for picking up permit

A and E walk

Site walk coordinated with A&E firm

Building permit application

Flat fee for preparation of BP

Co-location application

Flat fee for preparation of co-location application

Complex zoning

Potential for complex zoning with hearing

Construction drawings

Construction drawings

Fully executed amendment with non-MLA landlord

Flat fee service for completion of amendment

Landlord NTP

Flat fee for landlord approval to proceed

Leasing audit

Entitlement review of existing lease documents

NEPA and SHPO compliance

NEPA/SHPO compliance

Negotiation of co-location lease

Negotiation of co-location lease by telecom consultant

Zoning and permitting determination

Flat fee service for zoning/permitting determination

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Permit and Filing Costs FCC Construction Permit Major Change Yes
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

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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 $115,220.00 $126,020.00 N/A $86,620.00 N/A
Total for all systems $540,951.07 $417,170.57 N/A $167,982.30 N/A
Primary Transmitter TRN-U-2000-FA $115,220.00 $126,020.00 $86,620.00
Shipping $1,120.00 $1,120.00 Estimated shipping costs for transmitter. Actual costs to be determined. $1,120.00 N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $79,800.00 Estimated cost determined from Anywave Transmitter Proposal uploaded on 4.7.20 $79,800.00 N/A
Transmitter Site Prep $5,700.00 $5,700.00 cost determined from quote from attached file $5,700.00 N/A
Tax $8,400.00 $8,400.00 Estimated tax for transmitter. Actual costs to be determined. N/A N/A
Transmitter Building Site Survey/Installation $10,000.00 $25,000.00 3/30/2020- Working to obtain quote which may be delayed due to coronavirus pandemicy. N/A N/A
Decomm $6,000.00 $6,000.00 Disconnect and de-install the existing transmitter to prepare for the installation of new transmitter due to the repack project. N/A N/A

Components

Actual Information Description File Name
Shipping

Component Description:
Shipping and handling for transmitter
Amount:
$1,120.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:
2.2 kW transmitter
Amount:
$79,800.00
Transmitter Site Prep

Component Description:
Requesting amount for Tx installation.
Amount:
$5,700.00
Tax Information not provided.
Transmitter Building Site Survey/Installation Information not provided.
Decomm Information not provided.

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 $26,564.00 $26,564.00 N/A $0.00 N/A
Total for all systems $540,951.07 $417,170.57 N/A $167,982.30 N/A
Primary Antenna PSILP80I $26,564.00 $26,564.00 $0.00
UHF-Low Power, Side Mount, Slotted Coaxial, 5.0kW input, Elliptical $13,474.00 $13,474.00 Cost determined by invoice. $0.00 N/A
Sweep test of transmission line and antenna $5,730.00 $5,730.00 N/A N/A N/A
Shipping $735.00 $735.00 Cost determined by invoices. $0.00 N/A
Side Mount antenna brackets $4,625.00 $4,625.00 3/30/2020- Working to obtain quote which may be delayed due to coronavirus pandemic N/A N/A
Taxes $2,000.00 $2,000.00 Estimated taxes for antenna. Actual costs to be determined. N/A N/A

Components

Actual Information Description File Name
UHF-Low Power, Side Mount, Slotted Coaxial, 5.0kW input, Elliptical

Component Description:
Cost of antenna
Amount:
$13,474.00
Sweep test of transmission line and antenna Information not provided.
Shipping

Component Description:
Cost of shipping
Amount:
$735.00
Side Mount antenna brackets Information not provided.
Taxes Information not provided.

Cost Information

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Transmission Line

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $228,750.00 $93,125.00 N/A $23,625.00 N/A
Total for all systems $540,951.07 $417,170.57 N/A $167,982.30 N/A
Primary Tower TOWER $228,750.00 $93,125.00 $23,625.00
Tower mapping and report for structural engineer $21,000.00 $21,000.00 3/30/2020- Working to obtain quote which may be delayed due to coronavirus pandemic $1,500.00 N/A
Minor tower reinforcement/modifications $50,000.00 $50,000.00 3/30/2020- Working to obtain quote which may be delayed due to coronavirus pandemic N/A N/A
Tower Rigging Tall Tower (greater than 500') $157,750.00 $22,125.00 Cost determined by invoices. Subject to change. $22,125.00 Actual costs submitted

Components

Actual Information Description File Name
Tower mapping and report for structural engineer

Component Description:
Structural
Amount:
$1,500.00
Minor tower reinforcement/modifications Information not provided.
Tower Rigging Tall Tower (greater than 500')

Component Description:
25% Upon contract acceptance. All rates are flat fees.
Amount:
$5,875.00

Component Description:
Antenna installation
Amount:
$12,500.00

Component Description:
Antenna Installation
Amount:
$3,750.00

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 $154,832.30 $155,876.80 N/A $56,467.30 N/A
Total for all systems $540,951.07 $417,170.57 N/A $167,982.30 N/A
Outside Professional Services $154,832.30 $155,876.80 $56,467.30
NEPA and SHPO compliance $2,500.00 $2,500.00 N/A N/A N/A
Leasing audit $625.00 $625.00 N/A N/A N/A
Landlord NTP $1,000.00 $1,000.00 N/A N/A N/A
Fully executed amendment with non-MLA landlord $4,000.00 $4,000.00 N/A N/A N/A
Construction drawings $3,500.00 $3,500.00 N/A N/A N/A
Complex zoning $5,000.00 $5,000.00 N/A N/A N/A
Co-location application $700.00 $700.00 N/A N/A N/A
Building permit application $1,500.00 $1,500.00 N/A N/A N/A
A and E walk $4,500.00 $4,500.00 N/A N/A N/A
Permit pickup $700.00 $700.00 N/A N/A N/A
Additional Field Engineering Service, 5 Days $5,000.00 $5,000.00 Estimated field engineering required during transition activities. Actual costs to be determined. N/A N/A
Prepare Form 601 $755.00 $755.00 3/30/2020- Working to obtain quote which may be delayed due to coronavirus pandemic N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $3,025.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A $1,000.00 N/A
Prepare request for Special Temporary Authorization $1,280.00 $1,280.00 N/A N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $2,500.00 Per attached Anywave proposal PR1910-0543 dated 10/18/19. $2,500.00 N/A
Zoning and permitting determination $650.00 $650.00 N/A N/A N/A
Negotiation of co-location lease $1,750.00 $1,750.00 N/A N/A N/A
Perform engineering study for displacement application $1,800.00 $1,800.00 N/A $1,500.00 N/A
Form 399 assistance or other Program Management costs $23,476.80 $23,476.80 Cost determined by invoices. $23,476.80 Estimate is same as sub-total
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,000.00 N/A $0.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $2,235.00 $2,235.00 3/30/2020- Working to obtain quote which may be delayed due to coronavirus pandemic N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $3,262.50 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A N/A N/A
Field and Technical Project Management $7,430.50 $7,430.50 Cost determined by invoices. $7,430.50 N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $43,732.00 Per-attached quote number 723-R for Coverage Verification $15,750.00 N/A
Project management of the transition $21,100.00 $30,800.00 Estimated 200 hours at $154/hr. $4,810.00 N/A

Components

Actual Information Description File Name
NEPA and SHPO compliance Information not provided.
Leasing audit Information not provided.
Landlord NTP Information not provided.
Fully executed amendment with non-MLA landlord Information not provided.
Construction drawings Information not provided.
Complex zoning Information not provided.
Co-location application Information not provided.
Building permit application Information not provided.
A and E walk Information not provided.
Permit pickup Information not provided.
Additional Field Engineering Service, 5 Days Information not provided.
Prepare Form 601 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

Component Description:
Request amount for License to cover.
Amount:
$1,000.00
Prepare request for Special Temporary Authorization Information not provided.
Prepare/ Review 399 reimbursement form

Component Description:
399 Submission. FLAT FEE
Amount:
$2,500.00
Zoning and permitting determination Information not provided.
Negotiation of co-location lease Information not provided.
Perform engineering study for displacement application

Component Description:
Requesting amount for Displacement filings
Amount:
$1,500.00
Form 399 assistance or other Program Management costs

Component Description:
Form 399 Assistance. FLAT FEE
Amount:
$500.00

Component Description:
399 Follow Up Work
Amount:
$308.00

Component Description:
Aug 2021 PM - Anywave - FA2109-1084
Amount:
$1,031.80

Component Description:
Paperwork PM
Amount:
$1,001.00

Component Description:
Paperwork PM
Amount:
$1,563.10

Component Description:
Paperwork PM
Amount:
$1,047.20

Component Description:
PM Paperwork
Amount:
$1,848.00

Component Description:
Oct 2021 PM - Anywave - INV FA2112-1217
Amount:
$1,031.80

Component Description:
PM Paperwork
Amount:
$1,232.00

Component Description:
399 Follow Up Work
Amount:
$693.00

Component Description:
PM Paperwork
Amount:
$1,078.00

Component Description:
PM Paperwork
Amount:
$1,201.20

Component Description:
PM Paperwork
Amount:
$1,355.20

Component Description:
Sept 2021 PM - Anywave - INV FA2110-1159
Amount:
$1,078.00

Component Description:
Aug Paperwork PM
Amount:
$569.80

Component Description:
Paperwork PM
Amount:
$1,647.80

Component Description:
Nov 2021 PM - Anywave - INV FA2202-1275
Amount:
$154.00

Component Description:
July Paperwork PM
Amount:
$2,233.00

Component Description:
July 2021 PM - Anywave - INV FA2109-1109
Amount:
$939.40

Component Description:
399 Follow Up Work
Amount:
$1,524.60

Component Description:
PM Paperwork
Amount:
$939.40

Component Description:
Dec 2021 PM - Anywave - INV FA2202-1261
Amount:
$500.50
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Invoice moved to the correct Component list. Please delete.
Amount:
N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Field and Technical Project Management

Component Description:
July 2021 Tech PM - QComm - INV 120010
Amount:
$308.00

Component Description:
Aug 2021 Tech PM - QComm - INV 230036
Amount:
$770.00

Component Description:
Technical assistance - Qcomm - INV 2022012
Amount:
$616.00

Component Description:
Technical PM Service
Amount:
$770.00

Component Description:
Technical PM Service
Amount:
$1,540.00

Component Description:
Technical Project Management.
Amount:
$770.00

Component Description:
Sept 2021 Tech PM - QComm - INV 230047
Amount:
$308.00

Component Description:
Technical PM Service
Amount:
$462.00

Component Description:
Technical Project Management.
Amount:
$1,886.50
Comprehensive coverage verification via field study, if needed

Component Description:
Field measurements
Amount:
$15,750.00
Project management of the transition

Component Description:
Technical PM and 399 assistance - 02.22
Amount:
$755.00

Component Description:
Technical PM and 399 assistance - 03.22
Amount:
$4,055.00

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 $15,584.77 $15,584.77 N/A $1,270.00 N/A
Total for all systems $540,951.07 $417,170.57 N/A $167,982.30 N/A
Other Expenses $15,584.77 $15,584.77 $1,270.00
Equipment Storage $5,000.00 $5,000.00 Expecting multiple staggered equipment deliveries from different vendors and need to store and stage new equipment prior to installation date. Anticipate from 6-24 months of storage time. 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 minor change CP application $1,110.00 $1,110.00 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
FCC Filing Fees - Form 2100 Major change CP application $4,960.00 $4,960.00 3/30/2020- Working to obtain quote which may be delayed due to coronavirus pandemic N/A N/A
Equipment Delivery and Handling Charges $2,500.00 $2,500.00 Transport, forklift rental and handling fees from staging area to transmitter site. N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $1,374.77 $1,374.77 Disposal costs per Clean Sweeps estimate uploaded - split 50/50 between KAOB and K21OB $1,270.00 N/A

Components

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

Component Description:
Haul away and disposal split 50/50 with KAOB
Amount:
$1,270.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $540,951.07 $417,170.57 $167,982.30

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.

Chuck Johnson

COO


04/15/2022

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.

Chuck Johnson

COO


04/15/2022

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