TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
Board of Regents of the University of Wisconsin System	1730 VAN HISE HALL 1220 LINDEN DRIVE MADISON, WI 53706 United States	+1 (608) 262-2326	board@uwsa.edu	Government Entity

Applicant

Address

Phone

Applicant Type

Board of Regents of the University of Wisconsin System

1730 VAN HISE HALL

1220 LINDEN DRIVE

MADISON, WI 53706

United States

+1 (608) 262-2326

board@uwsa.edu

Government Entity

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	WUWM must shut off its main FM facility on the tower owned by WITI-TV while WITI-TV undergoes repack work. WUWM will broadcast from its licensed auxiliary facility (constructed in anticipation of the repack work) while the main WUWM facility is offair.

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	VS1
	Year	2017
	Type	Solid State
	Solid State Cooling	Air Cooled
	Model Type	Analog
	Solid State Power Capacity	1.4 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?	No
	Manufacturer
	Model	VS1
	Transmitter Type	Solid State
	Solid State Cooling	Air Cooled
	Model Type	Analog
	Solid State Power capacity	1.4 kW
	Justification for New Transmitter	WUWM purchased a new Nautel VS1 transmitter for the auxiliary site because there was no existing transmitter or working spare transmitter available to WUWM.
	Does the transmitter require the purchase of a new HD Importer?	No
	Does the transmitter require the purchase of a new HD Exporter?	No

Primary Transmitter

Other Transmitter Costs

Section	Question	Response
Other Transmitter Costs	Does the transmitter installation require an Additional Exciter?	No
	Does the transmitter installation require any additional transmitter installation costs?	No
	Does the transmitter installation require a Transmitter Building Site Survey/Installation?	No
Electrical Service	Service Entrance (3 phases 800A 208V)	No
	Switchgear (industrial 800 amp)	No
	Transformer (480V)	No
	Rigid Conduit and Wiring	No
	Other Electrical Service	No
HVAC Service	Does the replacement transmitter require HVAC Service?	No
Transmitter Building Addition/Modification or Leasehold Improvement	Does the Transmitter Building require an addition, modification, other leashold improvement?	No
Other Transmitter-Related Expenses	Does the replacement transmitter require a Remote Control?	Yes
	Does the replacement transmitter require an RDS Encoder?	No
	Does the replacement transmitter require Audio Processing?	No

Primary Transmitter

Other Transmitter Cost Not Listed

Information not provided.

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?	No
	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	Circular
	Type	Other
	Other Antenna Type	Retunable Dual Arrow Head Antenna
	ERP:	2.5 kW
	Manufacturer
	Model	6822-1
	Year	2017

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

Facility ID	Call Sign
42669	WYMS

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?	No
	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	Other
	Other Antenna Type	Re-tunable Dual Arrowhead Antenna
	ERP:	2.5 kW
	Manufacturer
	Model	6822-1
	Year	2017
	Justification for New Antenna	New antenna purchased to support frequencies for both WUWM and WYMS combined broadcasting. WYMS had an existing antenna when they were using the space by themselves. WUWM entered into an agreement to share the space requiring a new antenna.

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	88.9 MHz - 89.7 MHz
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?	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
FM Band Pass Filters	Do you require an FM band pass filter?	No
Notch Filter	Do you require a Notch filter?	No
De-Icers	Do you require De-Icers?	No
Radomes	Do you require Radomes?	No

Primary Antenna

Other Antenna Cost Not Listed

Name	Description
Male DIN Dapter	Seven eighth inch to seven sixteenth male din adapter required for installation and connecting to existing section of transmission line.

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	Purchase New
	Use	Primary (Main)
	Ownership	Owned
	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
	Type	Flexible Foam
	Diameter	1/2 inches
	Number of parallel runs	1
	Length	36 feet per run

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

Facility ID	Call Sign
42669	WYMS

Primary Transmission Line

New Transmission Line

Section	Question	Response
New Transmission Line Costs	Use	Primary (Main)
	Change Type	Purchase New
	Is this a request for upgraded equipment?	No
	Type	Flexible Foam
	Diameter	1/2 inches
	Number of parallel runs	1
	Length	36 feet per run
	Justification for New Transmission Line	Purchase for new transmission cable to go from transmitters to combiner and then connect to existing transmission line up the tower.
Interior RF Systems	Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators?	No
Interior RF Systems	Does the Installation of the Transmission Line require additional or replacement Inside RF system elbows, fitting, hangers, etc.?	Yes

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	80
	Explanation	WUWM is a noncommercial public broadcaster with a lean staff without experience in the FCC's reimbursement program.
Outside RF consulting Engineering Services	Prepare engineering section of Form FCC Construction Permit Application	Yes
	For Auxiliary Facility	Yes
	For Main Facility	No
	Prepare engineering section of Form FCC License to Cover Application	Yes
	For Auxiliary Facility	Yes
	For Main Facility	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	Yes
	For Main Facility	No
	Prepare and file Form FCC License to Cover Application	Yes
	For Auxiliary Facility	Yes
	For Main Facility	No
	Prepare request for Special Temporary Authority	No
	Negotiation of Lease and other Matter for Shared Locations	Yes
	Prepare or Review FCC Form 399 for Reimbursement	Yes
	Form 399 assistance or other program management costs	Yes
RF Field Engineering Services	Comprehensive coverage verification via field study	No
	RF exposure measurements	Yes
	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?	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
	1 pair IP-only Codecs for fiber, internet or IP microwave systems	No

Other Expenses

Other Expenses Not Listed

Name	Description
Higgins Tower	Tower crew to replace old antenna and install new antenna on tower.
IP Codecs	IP Codecs to transmit and receive audio from WUWM studios to WUWM aux transmitter site for broadcasting since no over the air STL can be used.
IT Networking Equipment	Misc IT and networking equipment such as computer, router, switch, and cabling for IP based audio transmissions and networking required since the site does not have an over the air STL.
Audio Hardware	Audio hardware to convert digital to analog signals and analog to digital audio signals and necessary switching hardware to supply the transmitter with audio for broadcast.

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	$10,785.55	$12,665.22	N/A	$12,665.22	N/A
Total for all systems	$90,895.41	$72,198.74	N/A	$37,071.02	N/A
Primary Transmitter VS1	$10,785.55	$12,665.22		$12,665.22
Other Transmitter-Related Expenses Remote Control	$2,400.00	$4,279.67	Burk remote control unit to control and monitor transmitter plus AutoPilot software and Plus Connect for Nautel VS1 transmitter and RSI enabled came in a little higher than original estimate.	$4,279.67	Burk System purchase higher than originally projected cost.
Air Cooled Solid State Transmitter 1.4 kW Analog	$8,385.55	$8,385.55	Nautel VS 1 transmitter with optional Orban audio processor installed.	$8,385.55	N/A

Components

Actual Information Description	File Name
Other Transmitter-Related Expenses Remote Control	Component Description: Burk ARC PLUS TOUCH Remote Control, RSI and AutoPilot System Amount: $4,279.67
Air Cooled Solid State Transmitter 1.4 kW Analog	Component Description: Nautel VS1 1kW Transmitter wEIA Connector, Orban 5500 Option for VS Transmitters, Single Phase Surge Protector for VS Series and Transient Protection Toroid Kit Amount: $8,385.55

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	$23,382.50	$13,035.07	N/A	$5,864.67	N/A
Total for all systems	$90,895.41	$72,198.74	N/A	$37,071.02	N/A
Primary Antenna 6822-1	$23,382.50	$13,035.07		$5,864.67
New FM combiner, cost per channel (depends on power input and min. frequency separation)	$21,782.50	$11,435.07	Estimated cost for a 3 cavitiy Shively 2930-2/3-06-FM combiner installed at Auxiliary site tuned for 88.9Mhz and 89.7Mhz. WUWM and WYMS must combine to use a single antenna and transmission line at the auxiliary site.	$5,864.67	Antenna and FM Combiner higher cost than originally estimated due to custom build and tuning for station frequency and broadcast.
Male DIN Dapter	$200.00	$200.00	Required male DIN adapter to connect antenna to an existing section of transmission line on the tower.	$0.00	N/A
Low Power 1 kW - 2.5 kW Circularly-polarized	$1,400.00	$1,400.00	N/A	$0.00	N/A

Components

Actual Information Description	File Name
New FM combiner, cost per channel (depends on power input and min. frequency separation)	Component Description: Antenna and FM Combiner Payment 2 of 2 remaining balance Amount: $5,864.67 Component Description: Antenna and FM Combiner Amount: $5,570.40
Male DIN Dapter	Information not provided.
Low Power 1 kW - 2.5 kW Circularly-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	$2,820.33	$2,874.33	N/A	$2,694.33	N/A
Total for all systems	$90,895.41	$72,198.74	N/A	$37,071.02	N/A
Primary Transmission Line	$2,820.33	$2,874.33		$2,694.33
Interior RF Systems: Elbows, fitting, hangers, etc.	$2,694.33	$2,694.33	Required fittings and jumper cables to connect and combine two transmitters to the combiner and dummy load and existing transmission line up the tower.	$2,694.33	N/A
Flexible Foam Transmission Line - dielectric, 1/2"	$126.00	$180.00	List price for Andrew half inch foam superflex is $5 per foot. The estimated footage of cable required is 36 feet.	$0.00	N/A

Components

Actual Information Description	File Name
Interior RF Systems: Elbows, fitting, hangers, etc.	Component Description: Jumper Cables and Transmission Adapters Dummy Load Amount: $2,694.33
Flexible Foam Transmission Line - dielectric, 1/2"	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	$27,823.00	$17,540.09	N/A	$4,759.91	N/A
Total for all systems	$90,895.41	$72,198.74	N/A	$37,071.02	N/A
Outside Professional Services	$27,823.00	$17,540.09		$4,759.91
RF Exposure Measurements	$12,100.00	$1,817.09	Estimated cost from engineering contractor	$466.91	N/A
Attorney Fees - Negotiation of Lease and other matters for Shared Locations	$1,280.00	$1,280.00	N/A	$0.00	N/A
Form 399 assistance or other Program Management costs	$4,293.00	$4,293.00	N/A	$4,293.00	N/A
Prepare/ Review 399 reimbursement form	$1,710.00	$1,710.00	\	$0.00	N/A
Project management of the transition	$8,440.00	$8,440.00	N/A	$0.00	N/A

Components

Actual Information Description	File Name
RF Exposure Measurements	Component Description: RF Exposure Measurements supplies Amount: $15.18 Component Description: RF Exposure Measurements Amount: $153.76 Component Description: RF Exposure Measurements supplies Amount: $179.88 Component Description: RF Exposure Measurements supplies Amount: $41.38 Component Description: RF Exposure Measurements supplies Amount: $91.89 Component Description: RF Exposure Measurements supplies Amount: $1,335.00
Attorney Fees - Negotiation of Lease and other matters for Shared Locations	Information not provided.
Form 399 assistance or other Program Management costs	Component Description: Gray Miller Persh LLP legal counsel for WUWM FM Reimbursement for Repack Disruptions Amount: $404.00 Component Description: Gray Miller Persh LLP legal counsel for WUWM FM Reimbursement for Repack Disruptions Amount: $656.50 Component Description: Gray Miller Persh LLP legal counsel for WUWM FM Reimbursement for Repack Disruptions Amount: $353.50 Component Description: Gray Miller Persh LLP legal counsel for WUWM FM Reimbursement for Repack Disruptions Amount: $101.00 Component Description: Gray Miller Persh LLP legal counsel for WUWM FM Reimbursement for Repack Disruptions Amount: $303.00 Component Description: Gray Miller Persh LLP legal counsel for WUWM FM Reimbursement for Repack Disruptions Amount: $2,475.00
Prepare/ Review 399 reimbursement form	Information not provided.
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	$26,084.03	$26,084.03	N/A	$11,086.89	N/A
Total for all systems	$90,895.41	$72,198.74	N/A	$37,071.02	N/A
Other Expenses	$26,084.03	$26,084.03		$11,086.89
IT Networking Equipment	$2,639.03	$2,639.03	Costs for required computer, router and swtiches, equipment rack and rack components.	$293.39	N/A
IP Codecs	$15,000.00	$15,000.00	Required IP codecs to transmit audio from main studios to transmitter site. Traditional over the air STL cannot be used at the site.	$7,848.50	N/A
Higgins Tower	$2,945.00	$2,945.00	Tower crew required to climb tower and take down old antenna not capable of dual station broadcasting and replacing with the new Shively antenna.	$2,945.00	N/A
Equipment Delivery and Handling Charges	$3,000.00	$3,000.00	Estimated freight and shipping for delivery of all materials required.	$0.00	N/A
Audio Hardware	$2,500.00	$2,500.00	Required audio hardware to convert analog to digital and / or digital to analog signals as well as audio switching hardware to feed audio to transmitter.	$0.00	N/A

Components

Actual Information Description	File Name
IT Networking Equipment	Component Description: Keyboard for Required Computer Amount: $27.72 Component Description: Racks Shelves Panels Fan Tray and Power distribution strip for tech at transmitter site. Amount: $1,519.33 Component Description: Costs for required computer and monitor. Amount: $749.59 Component Description: DataFig Slide on Nut, for Hold Punched Rack Rails Amount: $78.39 Component Description: Required Ubiquiti Networks Router for Transmitter site. Amount: $49.00 Component Description: Required switches for Aux site Amount: $215.00
IP Codecs	Component Description: Partial Intraplex IP Audio CODEC package Amount: $3,011.63 Component Description: Partial Intraplex IP Audio CODEC package Amount: $183.87 Component Description: Partial Intraplex IP Audio CODEC package Amount: $739.53 Component Description: Partial Intraplex IP Audio CODEC package Amount: $7,108.97 Component Description: Partial Intraplex IP Audio CODEC package Amount: $3,956.00
Higgins Tower	Component Description: Replace existing antenna and decom remove existing antennas and transmission down to base of tower. Amount: $2,945.00
Equipment Delivery and Handling Charges	Information not provided.
Audio Hardware	Information not provided.

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$90,895.41	$72,198.74	$37,071.02

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.	Cheryl Locher , Locher . Interim General Manager Manager of Finance and Adm 09/04/2022

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.

Cheryl Locher , Locher .

Interim General Manager Manager of Finance and Adm

09/04/2022

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.	Cheryl Locher Interim General Manager Manager of Finance and Adm 09/04/2022

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.

Cheryl Locher

Interim General Manager Manager of Finance and Adm

09/04/2022

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.	Cheryl Locher Interim General Manager Manager of Finance and Adm 09/04/2022

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.

Cheryl Locher

Interim General Manager Manager of Finance and Adm

09/04/2022

(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

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

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

New Transmission Line

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

Certification

Certification

Attachments