TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
MOHAVE COUNTY BOARD OF SUPERVISORS Applicant Doing Business As: MOHAVE COUNTY BOARD OF SUPERVISORS	Barbara Spoonhour PO BOX 7000 KINGMAN, AZ 86402 United States	+1 (928) 753-0729	spoonb@mohave.gov	Other

Applicant

Address

Phone

Applicant Type

MOHAVE COUNTY BOARD OF SUPERVISORS

Applicant

Doing Business As: MOHAVE COUNTY BOARD OF SUPERVISORS

Barbara Spoonhour

PO BOX 7000

KINGMAN, AZ 86402

United States

+1 (928) 753-0729

spoonb@mohave.gov

Other

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.	Yes
Briefly describe transition plan	Transition complete required based on T-Mobile/FCC Repackaging

Question	Response
Sharee Station Facility ID	43401
Call Sign	K18LZ-D
Type
Licensee Name	MOHAVE COUNTY BOARD OF SUPERVISORS
Status	LICENSED
DTS	No
Community of License	KINGMAN, AZ
Pre-auction RF Channel	18
Post-auction RF Channel
Neilsen DMA
Network Affiliation

Question	Response
Sharee Station Facility ID	43415
Call Sign	K10RM-D
Type
Licensee Name	MOHAVE COUNTY BOARD OF SUPERVISORS
Status	LICENSED
DTS	No
Community of License	KINGMAN, AZ
Pre-auction RF Channel	10
Post-auction RF Channel
Neilsen DMA
Network Affiliation

Question	Response
Sharee Station Facility ID	43386
Call Sign	K35MX-D
Type
Licensee Name	MOHAVE COUNTY BOARD OF SUPERVISORS
Status	LICENSED
DTS	No
Community of License	KINGMAN, AZ
Pre-auction RF Channel	35
Post-auction RF Channel
Neilsen DMA
Network Affiliation

Question	Response
Sharee Station Facility ID	43379
Call Sign	K33OD-D
Type
Licensee Name	MOHAVE COUNTY BOARD OF SUPERVISORS
Status	LICENSED
DTS	No
Community of License	KINGMAN, AZ
Pre-auction RF Channel	33
Post-auction RF Channel
Neilsen DMA
Network Affiliation

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?	Yes

Primary Antenna

Existing Antenna Information

Section	Question	Response
Existing Antenna Description	Type of change	Purchase New
	Antenna Use	Primary (Main)
	Ownership	Owned
	Is the existing antenna shared with another station or stations?	Yes
	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
	Mounting	Top Mount
	Antenna position in stack	Top
	Polarization	Horizontal
	Type	Broadband Panel
	Number of Stations Supported	3
	Number of Panels	12
	Design power capacity in use	25.0 %
	Lower Limit	560.00 MHz
	Upper Limit	566.00 MHz
	ERP:	100.0 W
	Manufacturer
	Model	BCA/MJ
	Year	2019

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID	Call Sign
43386	K35MX-D
43379	K33OD-D

Primary Antenna

New Antenna Costs

Section	Question	Response
New Antenna Description	Use	Primary (Main)
	Change Type	Purchase New
	Ownership	Owned
	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 Types
	Mounting	Top Mount
	Antenna position in stack	Top
	Polarization	Horizontal
	Type	Broadband Panel
	Number of Stations Supported	3
	Number of Panels/Bays	12
	Lower Limit	560.00 MHz
	Upper Limit	566.00 MHz
	Design power capacity in use	25.0 %
	ERP:	100.0 W
	Manufacturer
	Model	BCA/MJ
	Year	2019
	Justification for New Antenna	T-Mobile/Re-Pack required. New channel assignments required combined antenna due to no available tower space.

Primary Antenna

Other Antenna Costs

Section	Question	Response
Combiner for Shared Antenna	Do you need a Combiner for a Shared Antenna?	No
Elbow Complex	Do you require the separate purchase of the Elbow Complex?	No
Pattern Scatter Analysis	Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna?	No
Sweep Test	Do you require the sweep testing of transmission line and antenna?	No
Power Dividers	Does the panel antenna require power dividers?	Yes
Power Dividers	Number of Power Dividers	2
Cable Harness	Does the panel antenna require cable harness?	No

Primary Antenna

Other Antenna Cost Not Listed

Information not provided.

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?	No

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	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare engineering section of Form FCC License to Cover Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare request for Special Temporary Authority	No
	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	No
	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	No
	FCC License to Cover Application	No
	FCC Special Temporary Authority Application	No
Other Miscellaneous Expenses	Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)?	No
	Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs?	No
	Does this relocation require Equipment Storage?	No
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	Yes
	Type	6/11 GHz Licensed Part 101

Other Expenses

Other Expenses Not Listed

Name	Description
Hayden to Goat Hill	Required due to co-channeling of Rx/Tx frequencies in proximity.
Staff expenses	8 hours at 63.90
Technical staff expenxe	2 hours at 33.95
Construction expense	Antenna removal, install, cabling, dressing and grounding.

Cost Information

Transmitters

Information not provided.

Cost Information

Antennas

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$23,600.00	$6,532.65	N/A	$6,532.65	N/A
Total for all systems	$67,686.93	$29,478.40	N/A	$29,478.40	N/A
Primary Antenna BCA/MJ	$23,600.00	$6,532.65		$6,532.65
UHF Broadband panel antenna (per panel), horizontally-polarized	$21,000.00	$6,532.65	Actual cost	$6,532.65	N/A
Power Dividers (each, for panel antenna system, if not included in antenna cost)	$2,600.00	$0.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
UHF Broadband panel antenna (per panel), horizontally-polarized	Component Description: Purchase of antennas. Amount: $6,532.65
Power Dividers (each, for panel antenna system, if not included in antenna cost)	Information not provided.

Cost Information

Transmission Line

Information not provided.

Cost Information

Tower Equipment and Rigging Costs

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	$9,557.50	$5,175.09	N/A	$5,175.09	N/A
Total for all systems	$67,686.93	$29,478.40	N/A	$29,478.40	N/A
Outside Professional Services	$9,557.50	$5,175.09		$5,175.09
Perform engineering study for displacement application	$1,800.00	$0.00	N/A	N/A	N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$1,577.50	$890.37	Actual.	$890.37	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$3,025.00	$0.00	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,052.50	$4,284.72	Actual cost	$4,284.72	N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$2,102.50	$0.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Perform engineering study for displacement application	Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Component Description: Legal services. Amount: $8.50 Component Description: Legal services. Amount: $107.67 Component Description: Legal services. Amount: $28.33 Component Description: Legal services. Amount: $132.50 Component Description: Legal services. Amount: $138.89 Component Description: Legal services. Amount: $8.83 Component Description: Legal services. Amount: $8.83 Component Description: Legal services. Amount: $181.10 Component Description: Legal services. Amount: $9.33 Component Description: Legal services. Amount: $222.22 Component Description: Legal services. Amount: $44.17
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: Engineering assistance with FCC questions. Amount: $34.72 Component Description: Preparation and submittal of license. This is a flat fee. Amount: $250.00 Component Description: Engineering portion of applications (early launch) for displacement; engineering portions of requests for Special Temporary Authority including engineering support for requests for waiver. Amount: $3,000.00 Component Description: Study of Mohave County's overall channel plan compatibility and antenna designs required due to FCC's recent incentive Auction. Amount: $1,000.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit 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	$34,529.43	$17,770.66	N/A	$17,770.66	N/A
Total for all systems	$67,686.93	$29,478.40	N/A	$29,478.40	N/A
Other Expenses	$34,529.43	$17,770.66		$17,770.66
Technical staff expenxe	$60.43	$60.43	Actual Costs.	$60.43	04/14/22: Uploaded corrected memo for invoice 30253 04/22/22: Uploaded corrected memo for invoice 30253.
Staff expenses	$529.00	$529.00	Actual internal labor costs.	$529.00	04/14/22: Uploaded corrected memo for invoice 1.
Construction expense	$5,440.00	$5,440.00	Actual	$5,440.00	N/A
Hayden to Goat Hill	$0.00	$0.00	N/A	N/A	N/A
New Point to Point Microwave System: 6/11 GHz Licensed Part 101	$28,500.00	$11,741.23	Actual cost for microwave.	$11,741.23	Purchase of microwaves was needed to remove interference and allow the County to continue serving its customers.

Components

Actual Information Description	File Name
Technical staff expenxe	Component Description: Technical staff charges to assist with applications. Amount: $60.43 Component Description: Technical staff charges to work on applications. Amount: $60.73 Component Description: Technical staff charges to assist with repackaging applications. Amount: $60.43
Staff expenses	Component Description: Internal staff charges to work on applications. Amount: $529.00 Component Description: Internal staff charges for repackaging. Amount: $529.00
Construction expense	Component Description: TV maintenance labor for repackaging. Amount: $5,440.00
Hayden to Goat Hill	Information not provided.
New Point to Point Microwave System: 6/11 GHz Licensed Part 101	Component Description: Purchase of microwaves. Needed to reduce interference from repackaging. Amount: $11,741.23

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$67,686.93	$29,478.40	$29,478.40

Reimbursement Status

Question	Response
The facility has ceased operating on its pre-auction channel.	No
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.	Barbara Jo Spoonhour Administrative Services Director 08/18/2022

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.

Barbara Jo Spoonhour

Administrative Services Director

08/18/2022

Certification

Section	Question	Response
Submission of Actual Cost Documentation Statements	WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).
The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) . The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Barbara Jo Spoonhour Administrative Services Director 08/18/2022

Section

Question

Response

Submission of Actual Cost Documentation Statements

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

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

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

Barbara Jo Spoonhour

Administrative Services Director

08/18/2022

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.	Barbara J Spoonhour Administrative Services Director 08/18/2022

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.

Barbara J Spoonhour

Administrative Services Director

08/18/2022

(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

Primary Antenna

Existing Antenna Information

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Primary Antenna

New Antenna Costs

Primary Antenna

Other Antenna Costs

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Tower Equipment And Rigging Costs

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

Components

Cost Information

Transmission Line

Cost Information

Tower Equipment and Rigging Costs

Cost Information

Outside Professional Services

Components

Cost Information

Other Expenses

Components

Cost Information

Grand Total

Reimbursement Status

Certification

Certification

Certification

Attachments