TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
HC2 STATION GROUP, INC.	295 MADISON AVENUE, 12TH FLOOR NEW YORK, NY 10017 United States	+1 (212) 339-5864	RGORBAL@HC2BROADCASTING.COM	Corporation

Applicant

Address

Phone

Applicant Type

HC2 STATION GROUP, INC.

295 MADISON AVENUE, 12TH FLOOR

NEW YORK, NY 10017

United States

+1 (212) 339-5864

RGORBAL@HC2BROADCASTING.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.	Yes
Briefly describe transition plan	This displaced facility is currently in the process of complying with its new displacement construction permit as part of the repack program.

Question	Response
Sharee Station Facility ID	66781
Call Sign	KIRO-TV
Type	Commercial
Licensee Name	KIRO-TV, Inc.
Status	LICENSED
DTS	No
Community of License	SEATTLE, WA
Pre-auction RF Channel	23
Post-auction RF Channel	23
Neilsen DMA	Seattle-Tacoma
Network Affiliation

Transmitters

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

Primary Transmitter

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	TXUD1000A
	Year	2009
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power Capacity	1 kW

Primary Transmitter

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	TMV9/4
	Transmitter Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	2.9 kW
	Justification for New Transmitter	The applicant plans on replacing the existing transmitter because of its age and lack of current support. This facility is relocating from the UHF band to the VHF band. The Hpol power is 1.45kW.

Primary Transmitter

Other Transmitter Costs

Section	Question	Response
Other Transmitter Costs
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	Yes
	Description	Minor Electrical Work.
HVAC Service	Does the replacement transmitter require HVAC Service?	Yes
	Type	Cooling Only
	Size	5 tons
Transmitter Building Addition/Modification or Leasehold Improvement	Does the Transmitter Building require an addition, modification, other leashold improvement?	No

Primary Transmitter

Other Transmitter Cost Not Listed

Name	Description
UHF Inside RF System Including Switching	UHF Inside RF System Including Switching
Additional Field Engineering Time	Additional Field Engineering Time

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?	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
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Other
	Other Antenna Type	Panel UHF
	ERP:	15.0 kW
	Manufacturer
	Model	SWR SWLP8EC
	Year	2009

Primary Antenna

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?	No
New Antenna Manufacturer and Types
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Circular
	Type	Broadband Panel
	Number of Stations Supported	1
	Number of Panels/Bays	1
	Lower Limit	174.00 MHz
	Upper Limit	216.00 MHz
	Design power capacity in use	100.0 %
	ERP:	3.0 kW
	Manufacturer
	Model	2x3 750 00085
	Year	2019
	Justification for New Antenna	The applicant plans on replacing the existing antenna to support the new displacement construction permit. Facility is relocating from UHF band to VHF band.

Primary Antenna

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
Power Dividers	Does the panel antenna require power dividers?	Yes
Power Dividers	Number of Power Dividers	3
Cable Harness	Does the panel antenna require cable harness?	Yes
Cable Harness	Number of Cable Harnesses	3

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?	Yes

Primary Tower

Existing Tower

Section	Question	Response
Existing Tower Description	Type of change	Modify Existing
	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?	Yes
	Is tower compliant with Rev G?	Yes
Existing Tower Structure Registration	Do you have a tower registration number?	Yes
Existing Tower Structure Registration	ASR Number	1056094
Coordinates (NAD83)	Latitude (NAD83)	47° 30' 16.3" N-
	Longitude (NAD83)	121° 58' 10.0" W-
	Overall Structure Height	310.04 feet
	Support Structure Height	270.01 feet
	Ground Elevation Above Mean Sea Level (AMSL)	2838.88 feet
	Structure Type	LTOWER - Lattice Tower
	Tower Owner	American Towers LLC
	Date Constructed	12/01/1998

Primary Tower

Tower Modification Costs

Section	Question	Response
Engineering Study	Please what type of engineering study is required, if any:	Study need for guyed or free-standing tower
Tower Reinforcements	Please select whether tower reinforcements are needed:	No reinforcements needed

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
PE Letter	PE Letter

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	Yes
	Number of Hours	200
	Explanation	Outside consulting engineering, legal work, and accounting services, as well as project management for regional and comprehensive repack execution.
Outside RF consulting Engineering Services	Perform engineering study for displacement application	No
	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	No
	Prepare and file Form FCC License to Cover Application	No
	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	Yes
	Form 399 assistance or other program management costs	Yes
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

Name	Description
Internal Time Costs	Internal Time Costs

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	No
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

Other Expenses Not Listed

Information not provided.

Cost Information

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	$137,257.14	$89,733.38	N/A	$59,483.38	N/A
Total for all systems	$259,646.40	$210,522.64	N/A	$136,155.26	N/A
Primary Transmitter TMV9/4	$137,257.14	$89,733.38		$59,483.38
Other Electrical Service: Minor Electrical Work.	$1,568.14	$1,568.14	N/A	$1,568.14	N/A
UHF Inside RF System Including Switching	$2,339.00	$2,339.00	N/A	$2,339.00	N/A
Additional Field Engineering Time	$2,100.00	$2,100.00	N/A	$2,100.00	N/A
Transmitter Building Site Survey/Installation	$10,000.00	$10,000.00	N/A	N/A	N/A
5 Ton system	$20,250.00	$20,250.00	N/A	N/A	N/A
High VHF - Air Cooled Solid State Transmitter 1.1 - 4.4 kW	$101,000.00	$53,476.24	N/A	$53,476.24	N/A

Components

Actual Information Description	File Name
Other Electrical Service: Minor Electrical Work.	Component Description: Electrical connection labor and materials. #2072 Amount: $1,299.94 Component Description: Relocate receptacles. #2072-A Amount: $268.20
UHF Inside RF System Including Switching	Component Description: Jumper, down payment. #PO000535-INV Amount: $1,464.00 Component Description: Jumper, balance. #1999 Amount: $875.00
Additional Field Engineering Time	Component Description: Additional field engineering work to set up a new transmitter. Amount: $450.00 Component Description: Additional field engineering comprising replacing a defective filter and continued fabricating of the RF system. Amount: $450.00 Component Description: Additional field engineering comprising continued fabricating of the RF system. Amount: $300.00 Component Description: Continue transmitter installation. #08032020 Amount: $900.00
Transmitter Building Site Survey/Installation	Information not provided.
5 Ton system	Information not provided.
High VHF - Air Cooled Solid State Transmitter 1.1 - 4.4 kW	Component Description: Transmitter tax. #9500102978 Amount: $4,861.52 Component Description: Transmitter cost, 50% balance. #9500102976 Amount: $24,307.36 Component Description: Transmitter cost, 50% down. #9500101707 Amount: $24,307.36

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	$49,402.00	$47,802.00	N/A	$32,147.00	N/A
Total for all systems	$259,646.40	$210,522.64	N/A	$136,155.26	N/A
Primary Antenna 2x3 750 00085	$49,402.00	$47,802.00		$32,147.00
Cable harness (each, for panel antenna system, if not included in antenna cost)	$3,000.00	$4,000.00	N/A	N/A	N/A
Power Dividers (each, for panel antenna system, if not included in antenna cost)	$3,900.00	$1,300.00	N/A	N/A	N/A
Side Mount antenna brackets	$4,625.00	$4,625.00	N/A	N/A	N/A
Sweep test of transmission line and antenna	$5,730.00	$5,730.00	N/A	N/A	N/A
High VHF-Low Power, Side Mount, Broadband Panel, 1 bay, 3.0kW input, Circular	$32,147.00	$32,147.00	N/A	$32,147.00	N/A

Components

Actual Information Description	File Name
Cable harness (each, for panel antenna system, if not included in antenna cost)	Information not provided.
Power Dividers (each, for panel antenna system, if not included in antenna cost)	Information not provided.
Side Mount antenna brackets	Information not provided.
Sweep test of transmission line and antenna	Information not provided.
High VHF-Low Power, Side Mount, Broadband Panel, 1 bay, 3.0kW input, Circular	Component Description: Balance payment for new H-Pol side mount panel array antenna. #1999 Amount: $16,073.50 Component Description: Down payment for a new H-Pol side mount panel array antenna. #PO000535-INV Amount: $16,073.50

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	$36,675.00	$36,675.00	N/A	$27,975.00	N/A
Total for all systems	$259,646.40	$210,522.64	N/A	$136,155.26	N/A
Primary Tower LTOWER	$36,675.00	$36,675.00		$27,975.00
PE Letter	$750.00	$750.00	N/A	$750.00	N/A
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas)	$27,225.00	$27,225.00	N/A	$27,225.00	N/A
Study needed for guyed or free-standing tower	$8,700.00	$8,700.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
PE Letter	Component Description: PE letter. #A192670 Amount: $750.00
Complex Tower (includes, e.g., towers with candelabras and/or stacked antennas)	Component Description: Tower work, balance. #2864 Amount: $11,137.50 Component Description: Down payment for installation of a new antenna, and removal and disposal of the existing antenna. #2864Deposit Amount: $16,087.50
Study needed for guyed or free-standing tower	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	$26,778.86	$26,778.86	N/A	$11,461.48	N/A
Total for all systems	$259,646.40	$210,522.64	N/A	$136,155.26	N/A
Outside Professional Services	$26,778.86	$26,778.86		$11,461.48
Internal Time Costs	$1,468.86	$1,468.86	N/A	$1,468.86	N/A
Prepare/ Review 399 reimbursement form	$1,710.00	$1,710.00	N/A	N/A	N/A
Project management of the transition	$21,100.00	$21,100.00	N/A	$9,992.62	N/A
Form 399 assistance or other Program Management costs	$2,500.00	$2,500.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Internal Time Costs	Component Description: Internal labor cost. #IL-HC2-08252020-RI Amount: $617.65 Component Description: Portion of general repack matter invoice attributable to this station - divided by 44 stations. #IL-HC2-08202020-IM Amount: $304.01 Component Description: Internal labor cost. #IL-HC2-10042020-RH Amount: $72.10 Component Description: Portion of general repack matter invoice attributable to this station - divided by 42 stations. #IL-HC2-08202020-DD Amount: $170.90 Component Description: Portion of general repack matter invoice attributable to this station - divided by 44 stations. #IL-HC2-08202020-AG Amount: $304.20
Prepare/ Review 399 reimbursement form	Information not provided.
Project management of the transition	Component Description: Portion of general repack matter invoice attributable to this station - divided by 12 stations. #478 Amount: $3,593.75 Component Description: Portion of general repack matter invoice attributable to this station - divided by 9 stations. #223 Amount: $870.00 Component Description: Portion of general repack matter invoice attributable to this station - divided by 13 stations. #160 Amount: $213.84 Component Description: Portion of general repack matter invoice attributable to this station - divided by 9 stations. #146 Amount: $75.55 Component Description: Portion of general repack matter invoice attributable to this station - divided by 12 stations. #204 Amount: $1,643.75 Component Description: Portion of general repack matter invoice attributable to this station - divided by 40 stations. #477015 Amount: $406.37 Component Description: Portion of general repack matter invoice attributable to this station - divided by 25 stations. #181 Amount: $632.00 Component Description: Portion of general repack matter invoice attributable to this station - divided by 29 stations. #188 Amount: $656.55 Component Description: Portion of general repack matter invoice attributable to this station - divided by 40 stations. #1149 Amount: $302.67 Component Description: Portion of general repack matter invoice attributable to this station - divided by 9 stations. #480847 Amount: $71.88 Component Description: Portion of general repack matter invoice attributable to this station - divided by 23 stations. #174 Amount: $551.95 Component Description: Portion of general repack matter invoice attributable to this station - divided by 22 stations. #191 Amount: $974.31
Form 399 assistance or other Program Management costs	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	$9,533.40	$9,533.40	N/A	$5,088.40	N/A
Total for all systems	$259,646.40	$210,522.64	N/A	$136,155.26	N/A
Other Expenses	$9,533.40	$9,533.40		$5,088.40
Equipment Storage	$1,445.00	$1,445.00	N/A	$1,445.00	N/A
Equipment Delivery and Handling Charges	$3,643.40	$3,643.40	N/A	$3,643.40	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 minor change CP application	$1,110.00	$1,110.00	N/A	N/A	N/A
Disposal Costs (for equipment and other waste, net of any salvage value)	$3,000.00	$3,000.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Equipment Storage	Component Description: Storage of a panel array antenna and mounting kit. #30615401 Amount: $1,445.00
Equipment Delivery and Handling Charges	Component Description: Shipping costs of a Central Cast Rack for a new antenna. #05609363824 Amount: $960.76 Component Description: TL and antenna freight. #1999 Amount: $2,037.64 Component Description: Equipment delivery and handling of a panel array antenna and mounting kit. #30615401 Amount: $645.00
FCC Filing Fees - Form 2100 license to cover application	Information not provided.
FCC Filing Fees - Form 2100 minor change CP application	Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)	Information not provided.

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$259,646.40	$210,522.64	$136,155.26

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.	Michael Voge Director of Engineering Operations 09/06/2022

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.

Michael Voge

Director of Engineering Operations

09/06/2022

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.	Michael Voge Director of Engineering Operations 09/06/2022

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.

Michael Voge

Director of Engineering Operations

09/06/2022

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.	Michael Voge Director of Engineering Operations 09/06/2022

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.

Michael Voge

Director of Engineering Operations

09/06/2022

(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

Primary Transmitter

Existing Transmitter Information

Primary Transmitter

New Transmitter Costs

Primary Transmitter

Other Transmitter Costs

Primary Transmitter

Other Transmitter Cost Not Listed

Antennas

Primary Antenna

Existing Antenna Information

Primary Antenna

New Antenna Costs

Primary Antenna

Other Antenna Costs

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Tower Equipment And Rigging Costs

Primary Tower

Existing Tower

Primary Tower

Tower Modification Costs

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

Components

Cost Information

Antennas

Components

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

Certification

Attachments