TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
BYRNE ACQUISITION GROUP, LLC	2927 Devine St. SUITE 100 Columbia, SC 29205 United States	+1 (803) 851-7388	jbyrne@whhitv.com	Limited Liability Company

Applicant

Address

Phone

Applicant Type

BYRNE ACQUISITION GROUP, LLC

2927 Devine St.

SUITE 100

Columbia, SC 29205

United States

+1 (803) 851-7388

jbyrne@whhitv.com

Limited Liability Company

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
Roy Henn WIFS Chief Engineer Byrne Acquisition Group, LLC	Roy Henn 2814 Syene Road Madison, WI 53713 United States	+1 (608) 270-5940	roy@wi57.tv

Applicant

Address

Phone

Roy Henn

WIFS Chief Engineer

Byrne Acquisition Group, LLC

Roy Henn

2814 Syene Road

Madison, WI 53713

United States

+1 (608) 270-5940

roy@wi57.tv

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	1) Prepare tower transmitter building site. 2) Install new transmitter and related equipment; connect transmitter to combiner. 3) Flash cutover to new channel. 4) Remove old equipment.

Transmitters

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

Auxiliary Transmitter

Add Transmitter Information

Section	Question	Response
Existing Transmitter Description	Type of change	Purchase New
	Use	Auxiliary (Backup)
	Description of Use	Backup transmitter
	Ownership	Owned
	Owner	N/A
	Site	N/A
	Is this transmitter currently shared with another station?	No
	Is this transmitter currently in operating condition?	Yes
Existing Transmitter Manufacturer and Type	Manufacturer
	Model	NV7081E
	Year	2003
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power Capacity	1.2 kW

Auxiliary Transmitter

New Transmitter Costs

Section	Question	Response
New Transmitter	Use	Auxiliary (Backup)
	Change Type	Purchase New
	Is this a request for upgraded equipment?	No
	Manufacturer
	Model	TMU9
	Transmitter Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	1.2 kW
	Justification for New Transmitter	Current backup transmitter cannot be re-channelized

Auxiliary Transmitter

Other Transmitter Costs

Section	Question	Response
Electrical Service	Service Entrance (3 phases 800A 208V)	Yes
	Switchgear (industrial 800 amp)	Yes
	Transformer (480V)	Yes
	Power	150 kVA
	Rigid Conduit and Wiring	Yes
	Size	3 inches
	Length	100.0 feet
	Other Electrical Service	No
	Description	N/A
HVAC Service	Does the replacement transmitter require HVAC Service?	No
	Type	N/A
	Size	N/A
	Other Size	N/A
Transmitter Building Addition/Modification or Leasehold Improvement	Does the Transmitter Building require an addition, modification, other leashold improvement?	No
	Size	N/A
Channel 14 Costs	Is an RF Consulting Engineer needed?	N/A
	Is a channel 14 Mask Filer needed?	N/A
	Is additional field engineering time needed?	N/A
	Number of Days	N/A

Auxiliary Transmitter

Other Transmitter Cost Not Listed

Information not provided.

Primary Transmitter

Existing Transmitter Information

Section	Question	Response
Existing Transmitter Description	Type of change	Purchase New
	Use	Primary (Main)
	Description of Use	N/A
	Ownership	Owned
	Owner	N/A
	Site	N/A
	Is this transmitter currently shared with another station?	No
	Is this transmitter currently in operating condition?	Yes
Existing Transmitter Manufacturer and Type	Manufacturer
	Model	Quantum QX
	Year	2004
	Type	Inductive Output Tube
	IOT Power Type	Single
	Power Capacity	29 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	ULXTE-30
	Transmitter Type	Solid State
	Solid State Cooling	Liquid Cooled
	Solid State Power capacity	19.2 kW
	Justification for New Transmitter	See Attachment 1 to this Form 399.

Primary Transmitter

Other Transmitter Costs

Section	Question	Response
Electrical Service	Service Entrance (3 phases 800A 208V)	Yes
	Switchgear (industrial 800 amp)	Yes
	Transformer (480V)	Yes
	Power	150 kVA
	Rigid Conduit and Wiring	Yes
	Size	2 inches
	Length	200.0 feet
	Other Electrical Service	No
	Description	N/A
HVAC Service	Does the replacement transmitter require HVAC Service?	No
	Type	N/A
	Size	N/A
	Other Size	N/A
Transmitter Building Addition/Modification or Leasehold Improvement	Does the Transmitter Building require an addition, modification, other leashold improvement?	No
	Size	N/A
Channel 14 Costs	Is an RF Consulting Engineer needed?	N/A
	Is a channel 14 Mask Filer needed?	N/A
	Is additional field engineering time needed?	N/A
	Number of Days	N/A

Primary Transmitter

Other Transmitter Cost Not Listed

Name	Description
Dummy Load	Dummy load for transmitter testing
Switch	Motorized switch for primary/backup transmitter

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	Retune Existing
	Antenna Use	Primary (Main)
	Description of Use	N/A
	Ownership	Owned
	Owner	N/A
	Site	N/A
	Is the existing antenna shared with another station or stations?	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	Class	Full Power
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Broadband Panel
	Number of Stations Supported	2
	Number of Panels	10
	Design power capacity in use	100.0 %
	Lower Limit	470.00 MHz
	Upper Limit	860.00 MHz
	Other Antenna Type	N/A
	ERP:	200.0 kW
	Manufacturer	Dielectric
	Model	TUA-04-10/40H-1-S-R
	Year	2004

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

Facility ID	Call Sign
6870	WMTV

Primary Antenna

Adjustment to Existing Antenna

Section	Question	Response
Sweep Test of Existing Antenna	Do you need a sweep test of existing antenna?	Yes

Primary Antenna

Other Antenna Costs

Section	Question	Response
Combiner for Shared Antenna	Do you need a Combiner for a Shared Antenna?	Yes
	Type	New
	Number of channels supported	2
	Frequencies of channels supported	Upper and lower frequency
	Frequency	500.0 MHz - 518.0 MHz

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?	Yes

Primary Transmission Line

Existing Transmission Line

Section	Question	Response
Existing Transmission Line Description	Type of change	Utilize Existing
	Use	Primary (Main)
	Description of Use	N/A
	Ownership	Owned
	Owner	N/A
	Site	N/A
	Is the existing transmission line shared with another station or stations?	Yes
	Is Transmission Line in operating condition?	Yes
Existing Transmission Line Manufacturer and Type	Manufacturer	Dielectric
	Type	Rigid
	Diameter	6 1/8 inches
	Other Diameter	N/A
	Segment Length	Broadband
	Other Segment Length	N/A
	Number of parallel runs	2
	Length	1250 feet per run

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

Facility ID	Call Sign
6870	WMTV

Primary Transmission Line

Other Transmission Line Expenses Not Listed

Information not provided.

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?	Yes
	Number of Hours	120
	Explanation	Station's Chief Engineer constitutes the only engineering staff at the company, and does not have sufficient accreditation to professional verify project design.
Outside RF consulting Engineering Services	Perform engineering study for new channel assignment and antenna development	Yes
	Prepare engineering section of Form FCC Construction Permit Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare engineering section of Form FCC License to Cover Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare request for Special Temporary Authority	No
	Quantity	N/A
	Do you have Distributed Transmission System engineering services?	N/A
	Critical Facility	N/A
	Terrain-Shielded Facility	N/A
Attorney and Other Outside Consulting Services	Prepare and file Form FCC Construction Permit Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare and file Form FCC License to Cover Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare request for Special Temporary Authority	No
	Quantity	N/A
	NEPA Section 106 environmental review	No
	Environmental Assessment	No
	ASR Modification	No
	FAA Consultation (including preparation of FAA Form 7460)	No
	Negotiation of Lease and other Matter for Shared Locations	No
	Prepare or Review FCC Form 399 for Reimbursement	Yes
	Address transition timing and coordination issues w/ other stations and wireless providers	Yes
RF Field Engineering Services	Comprehensive coverage verification via field study	No
	RF exposure measurements	No
	Additional Field Engineering Service	No
	Number of Days	N/A
	Justification	N/A

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
Facility Expenses	Name	N/A
	Other Distributed Transmission System Expenses Not listed	N/A
	Name	N/A
	Is Notification of a Medical Facility required as a result of DTV broadcasting?	Yes
Permit and Filing Costs	Local Zoning	No
	Non-zoning permits	Yes
	BLM or NFS Coordination	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
	Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change?	Yes
	Does this relocation require MVPD Notification of a Channel Change?	Yes

Other Expenses

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	$1,027,700.00	$905,200.00	N/A	$0.00	N/A
Total for all systems	$1,208,765.00	$1,074,130.00	N/A	$13,107.50	N/A
Primary Transmitter ULXTE-30	$818,350.00	$780,300.00		$0.00
UHF - Liquid Cooled Solid State Transmitter 14.2 - 20 kW	$684,000.00	$650,000.00	N/A	N/A	N/A
Service entrance 3 phase/800 amp/208 volt	$14,400.00	$13,700.00	N/A	N/A	N/A
Switchgear - industrial 800 amp	$38,200.00	$36,300.00	N/A	N/A	N/A
Transformer 3 phase/480v - 150 KVA	$25,550.00	$24,300.00	N/A	N/A	N/A
2" Rigid Conduit and Wiring (Cost per foot)	$5,200.00	$5,000.00	N/A	N/A	N/A
Switch	$33,000.00	$33,000.00	N/A	N/A	N/A
Dummy Load	$18,000.00	$18,000.00	N/A	N/A	N/A
Auxiliary Transmitter TMU9	$209,350.00	$124,900.00		$0.00
Switchgear - industrial 800 amp	$38,200.00	$0.00	Included in cost estimate related to primary transmitter.	N/A	N/A
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW	$126,000.00	$120,000.00	N/A	N/A	N/A
Service entrance 3 phase/800 amp/208 volt	$14,400.00	$0.00	Included in cost estimate related to primary transmitter.	N/A	N/A
3" Rigid Conduit and Wiring (Cost per foot)	$5,200.00	$4,900.00	N/A	N/A	N/A
Transformer 3 phase/480v - 150 KVA	$25,550.00	$0.00	Included in cost estimate related to primary transmitter.	N/A	N/A

Components

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	$90,930.00	$81,585.00	N/A	$1,500.00	N/A
Total for all systems	$1,208,765.00	$1,074,130.00	N/A	$13,107.50	N/A
Primary Antenna TUA-04-10/40H-1-S-R	$90,930.00	$81,585.00		$1,500.00
New combiner, cost per channel (without antenna)	$84,200.00	$80,000.00	N/A	N/A	N/A
Sweep test of existing antenna	$6,730.00	$1,585.00	N/A	$1,500.00	N/A
UHF - High Power, Side Mount, broadband panel, 10 bay,, 200 kW input, directional,, horizontally polarized	$0.00	$0.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
New combiner, cost per channel (without antenna)	Information not provided.
Sweep test of existing antenna	Component Description: Sweep test of existing antenna using newly assigned repack channel. Amount: $1,500.00
UHF - High Power, Side Mount, broadband panel, 10 bay,, 200 kW input, directional,, horizontally polarized	Information not provided.

Cost Information

Transmission Line

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$0.00	$0.00	N/A	$0.00	N/A
Total for all systems	$1,208,765.00	$1,074,130.00	N/A	$13,107.50	N/A
Primary Transmission Line	$0.00	$0.00		$0.00

Components

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	$43,940.00	$41,750.00	N/A	$11,607.50	N/A
Total for all systems	$1,208,765.00	$1,074,130.00	N/A	$13,107.50	N/A
Outside Professional Services	$43,940.00	$41,750.00		$11,607.50
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$2,365.00	$2,250.00	N/A	$0.00	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$5,260.00	$5,000.00	N/A	$2,608.50	N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,580.00	$1,500.00	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$3,155.00	$3,000.00	N/A	$2,250.00	N/A
Perform engineering study for new channel assignment and antenna development	$7,360.00	$7,000.00	N/A	$1,250.00	N/A
Address transition timing and coordination issues w/ other stations and wireless	$2,630.00	$2,500.00	N/A	N/A	N/A
Prepare and or review reimbursement form	$2,630.00	$2,500.00	N/A	$5,499.00	As a small independent station with no qualified professional in-house legal or engineering staff, WIFS (fka WBUW) required more than Widelity estimated to correctly complete the legal and technical engineering aspects of the repack.
Project management of the transition	$18,960.00	$18,000.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	Component Description: Line item #5) Telephone conference w/ G. Masters, J. Byrne, and R. Henn re: repack reimbursement issues Amount: $372.50 Component Description: Line item #1) Preparatory work on Form 2100, Schedule A; consult w/ client re: Form 1876 Amount: $643.50 Component Description: Line item #6) Email correspondence w/ J. Byrne re: call sign discrepancy in auction system; conference w/ B. Claydon re: resolution of same. Amount: $178.75 Component Description: Line item #3) Conference w/ G. Masters re: auction repack matters; Form 1876 and modification application Amount: $39.00 Component Description: Line item #2) Finalize and file WIFS modification application Amount: $195.00 Component Description: Line item #5) Follow up w/ A. Meltzer re: Form 1876 and issue of incorrect call sign in Commission's system Amount: $97.50 Component Description: Line item #6) Consultation and communication w/ client in connection w/ construction permit application and reimbursement form Amount: $1,144.00 Component Description: Line item #1) Email correspondence w/ J. Byrne re: repack filings Amount: $143.00 Component Description: Line item #2) Email correspondence w/ J. Byrne re: FRN for repack filings Amount: $71.50
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	Component Description: Auction Repack Work: Engineering study work for new channel assignment including antenna development and preparation of the engineering section of FCC Form 2100 Amount: $2,250.00
Perform engineering study for new channel assignment and antenna development	Component Description: WI Janesville WIFS Auction Repack Work Amount: $250.00 Component Description: WI Janesville WIFS Auction Repack Work Amount: $250.00 Component Description: Auction Repack Work: Engineering study work for new channel assignment and antenna development Amount: $1,250.00
Address transition timing and coordination issues w/ other stations and wireless	Information not provided.
Prepare and or review reimbursement form	Component Description: Line item #1) Email correspondence w/ J. Byrne re: repack reimbursement process Amount: $357.50 Component Description: Line item #4) Email correspondence w/ J. Byrne re: Form 1876; conference w/ B. Claydon re: same Amount: $143.00 Component Description: Line item #11) Email correspondence w/ client re: Form 399 Amount: $71.50 Component Description: Line item #7) Correspondence to client re: Form 1876 submission for spectrum auction Amount: $78.00 Component Description: Line item #4) Conference w/ G. Masters re: auction issues and call sign change for station; telephone conference with Commission staff re: same Amount: $97.50 Component Description: Line item #6) Work on preparation of Form 399 Amount: $1,001.00 Component Description: Line item #5) Review correspondence from client re: Form 1876; follow up w/ client re: questions re: same Amount: $195.00 Component Description: Line item #7) Telephone conference w/ Commission staff/Wireless Bureau re: issue of call sign change for auction related submissions Amount: $97.50 Component Description: Line item #3) Email correspondence w/ J. Byrne, R. Henn et al. re: FCC Form 399 Amount: $214.50 Component Description: Line item #10) Communication w/ client re: FCC Form 399 Amount: $143.00 Component Description: Line item #9) Follow up matters re: Form 399 for WIFS(TV) Amount: $78.00 Component Description: Line item #4) Communication w/ client and preparation of FCC Form 399 Amount: $643.50 Component Description: Line item #8) Work on preparation of FCC Form 399 Amount: $2,574.00 Component Description: Line item #1) Email correspondence w/ J. Byrne re: repack reimbursement preparation Amount: $178.75
Project management of the transition	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	$46,195.00	$45,595.00	N/A	$0.00	N/A
Total for all systems	$1,208,765.00	$1,074,130.00	N/A	$13,107.50	N/A
Other Expenses	$46,195.00	$45,595.00		$0.00
Equipment Delivery and Handling Charges	$16,700.00	$16,700.00	N/A	N/A	N/A
Disposal Costs (for equipment and other waste, net of any salvage value)	$6,000.00	$6,000.00	N/A	N/A	N/A
Non-zoning permits	$2,500.00	$2,500.00	N/A	N/A	N/A
FCC Filing Fees - Form 2100 license to cover application	$335.00	$325.00	N/A	N/A	N/A
MVPD Notification of Channel Change	$1,000.00	$1,000.00	N/A	N/A	N/A
Develop and air announcement of upcoming channel change	$2,000.00	$2,000.00	N/A	N/A	N/A
Equipment Storage	$5,000.00	$5,000.00	N/A	N/A	N/A
FCC Filing Fees - Form 2100 minor change CP application	$1,110.00	$1,070.00	N/A	N/A	N/A
DTV Medical Facility Notification	$11,550.00	$11,000.00	N/A	N/A	N/A

Components

Information not provided.

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$1,208,765.00	$1,074,130.00	$13,107.50

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.	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

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.	Roy Henn Chief Engineer 04/12/2018

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.

Roy Henn

Chief Engineer

04/12/2018

(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

Auxiliary Transmitter

Add Transmitter Information

Auxiliary Transmitter

New Transmitter Costs

Auxiliary Transmitter

Other Transmitter Costs

Auxiliary Transmitter

Other Transmitter Cost Not Listed

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

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

Primary Antenna

Adjustment to Existing Antenna

Primary Antenna

Other Antenna Costs

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Primary Transmission Line

Existing Transmission Line

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

Primary Transmission Line

Other Transmission Line Expenses Not Listed

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

Components

Cost Information

Antennas

Components

Cost Information

Transmission Line

Components

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

Attachments