TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
KQDS-TV CORP.	KATHY LAU, CHIEF OPERATING OFFICER P. O. BOX 9115 FARGO, ND 58106 United States	+1 (701) 277-1515	KLAU@KVRR.COM	Corporation

Applicant

Address

Phone

Applicant Type

KQDS-TV CORP.

KATHY LAU, CHIEF OPERATING OFFICER

P. O. BOX 9115

FARGO, ND 58106

United States

+1 (701) 277-1515

KLAU@KVRR.COM

Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant	Address	Phone	Email
[Confidential]

Preparer Contact Information

Preparer Contact Name and Information

Applicant	Address	Phone	Email
The Preparer is same as the reimbursement contact.

Broadcaster Information and Transition Plan

Question	Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information.	No
Briefly describe transition plan	Applied for CP for channel 15, Replaced Antenna, filter and retuned transmitter to new frequency.

Transmitters

Section	Question	Response
Transmitter Related Expenses	Do you have transmitter related expenses?	No

Antennas

Section	Question	Response
Antenna Related Expenses	Do you have antenna related expenses?	No

Transmission Line

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

Tower Equipment And Rigging Costs

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

Primary Tower

Existing Tower

Section	Question	Response
Existing Tower Description	Type of change	Move Equipment
	Tower Use	Primary (Main)
	Ownership	Leased
	Is this tower consider Complex?
	Is this tower currently shared with any other stations?	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?	Yes
Existing Tower Structure Registration	ASR Number	1200096
Coordinates (NAD83)	Latitude (NAD83)	46° 35' 23.3" N-
	Longitude (NAD83)	090° 50' 13.3" W-
	Overall Structure Height	416.01 feet
	Support Structure Height	399.93 feet
	Ground Elevation Above Mean Sea Level (AMSL)	700.12 feet
	Structure Type	TOWER - Free Standing or Guyed Structure
	Tower Owner	American Towers LLC
	Date Constructed	09/24/2001

Primary Tower

Tower Rigging Costs

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

Primary Tower

Other Tower Expenses Not Listed

Name	Description
New Antenna	Remove and replace existing antenna with Ch 15 antenna

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	No
Outside RF consulting Engineering Services	Perform engineering study for displacement application	Yes
	Prepare engineering section of Form FCC Construction Permit Application	No
	Prepare engineering section of Form FCC License to Cover Application	No
	Prepare request for Special Temporary Authority	No
	Prepare Form 601	No
Attorney and Other Outside Consulting Services	Prepare and file Form FCC Construction Permit Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare and file Form FCC License to Cover Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare request for Special Temporary Authority	Yes
	Quantity	1
	Negotiation of Lease and other Matter for Shared Locations	No
	Prepare or Review FCC Form 399 for Reimbursement	No
	Form 399 assistance or other program management costs	No
RF Field Engineering Services	Comprehensive coverage verification via field study	No
	RF exposure measurements	No
	Additional Field Engineering Service	No

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

Section	Question	Response
AM Pattern Disturbance	Is an Impact Study needed?	No
AM Pattern Disturbance	Is Remediation needed?	No
Permit and Filing Costs	FCC Construction Permit Major Change	No
	FCC Construction Permit Minor Change	Yes
	FCC License to Cover Application	Yes
	FCC Special Temporary Authority Application	Yes
Other Miscellaneous Expenses	Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)?	No
	Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs?	Yes
	Does this relocation require Equipment Storage?	No
Point to Point Microwave (STL/ICR)	Frequency Coordination for Unidirection System	No
	Frequency Coordination for Bi-Direction System	No
	New Point to Point Microwave System	No

Other Expenses

Other Expenses Not Listed

Name	Description
Band Stop Filter	Off air pick up, main freq is 12 mhz from ch. 15 translator freq.
Shipping Expenses	Equipment delivery charges

Cost Information

Transmitters

Information not provided.

Cost Information

Antennas

Information not provided.

Cost Information

Transmission Line

Information not provided.

Cost Information

Tower Equipment and Rigging Costs

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$2,000.00	$2,000.00	N/A	$2,000.00	N/A
Total for all systems	$15,752.50	$17,282.30	N/A	$6,617.36	N/A
Primary Tower TOWER	$2,000.00	$2,000.00		$2,000.00
New Antenna	$2,000.00	$2,000.00	N/A	$2,000.00	N/A
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas)	$0.00	$0.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
New Antenna	Component Description: Installation of new antenna for Ashland, WI site Repack Displacement Ch 45 to Ch 15 Amount: $2,000.00
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas)	Information not provided.

Cost Information

Outside Professional Services

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$8,637.50	$10,177.30	N/A	$3,477.30	N/A
Total for all systems	$15,752.50	$17,282.30	N/A	$6,617.36	N/A
Outside Professional Services	$8,637.50	$10,177.30		$3,477.30
Perform engineering study for displacement application	$1,800.00	$3,477.30	Actual cost per invoice from consulting engineer	$3,477.30	N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization	$2,235.00	$2,200.00	N/A	N/A	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$3,025.00	$3,000.00	N/A	N/A	N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$1,577.50	$1,500.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Perform engineering study for displacement application	Component Description: Consulting Engineer for displacement application W45CI-D Ashland, WI Amount: $3,477.30
Attorney Fees - Prepare and File request for Special Temporary Authorization	Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Information not provided.

Cost Information

Other Expenses

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$5,115.00	$5,105.00	N/A	$1,140.06	N/A
Total for all systems	$15,752.50	$17,282.30	N/A	$6,617.36	N/A
Other Expenses	$5,115.00	$5,105.00		$1,140.06
Shipping Expenses	$2,000.00	$2,000.00	N/A	$0.00	N/A
Equipment Delivery and Handling Charges	$1,000.00	$1,000.00	N/A	$775.06	N/A
Band Stop Filter	$365.00	$365.00	N/A	$365.00	N/A
FCC Filing Fees - Form 2100 minor change CP application	$1,110.00	$1,100.00	N/A	N/A	N/A
FCC Filing Fees - Form 2100 license to cover application	$335.00	$335.00	N/A	N/A	N/A
FCC Filing Fees - Special Temporary Authorization request	$305.00	$305.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Shipping Expenses	Component Description: Shipping costs antenna W45CI-D. LPTV displacement, KQDS-TV. Amount: $679.59
Equipment Delivery and Handling Charges	Component Description: Invoice for shipping antenna for W15EE-D. Amount: $679.59 Component Description: Invoice for shipping mask filter for W15EE-D Amount: $95.47
Band Stop Filter	Component Description: Band Stop Filter CH 15 Amount: $365.00
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 - Special Temporary Authorization request	Information not provided.

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$15,752.50	$17,282.30	$6,617.36

Reimbursement Status

Question	Response
The facility has ceased operating on its pre-auction channel.	Yes
Construction of final facilities or all necessary modifications are complete.	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.	Yes

Certification

Section	Question	Response
Submission of Estimated Expenses Statements	WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.
The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD). The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Kathy l COO 06/08/2022

Section

Question

Response

Submission of Estimated Expenses Statements

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

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

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

Kathy l

COO

06/08/2022

Certification

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.
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. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Kathy Lau COO 06/08/2022

Section

Question

Response

Submission of Final Allocation or Accounting Information Statements

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.
The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.
The above-named entity certifies that all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates.
The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.
The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.
The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

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

Kathy Lau

COO

06/08/2022

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

Applicant Information

Applicant Name, Type, and Contact Information

Reimbursement Contact Information

Reimbursement Contact Name and Information

Preparer Contact Information

Preparer Contact Name and Information

Broadcaster Information and Transition Plan

Transmitters

Antennas

Transmission Line

Tower Equipment And Rigging Costs

Primary Tower

Existing Tower

Primary Tower

Tower Rigging Costs

Primary Tower

Other Tower Expenses Not Listed

Outside Professional Services Costs

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Other Expenses

Other Expenses

Other Expenses Not Listed

Cost Information

Transmitters

Cost Information

Antennas

Cost Information

Transmission Line

Cost Information

Tower Equipment and Rigging Costs

Components

Cost Information

Outside Professional Services

Components

Cost Information

Other Expenses

Components

Cost Information

Grand Total

Reimbursement Status

Certification

Certification

Attachments