TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
Holston Valley Broadcasting Corporation	N. David Widener 222 Commerce Street Kingsport, TN 37660 United States	+1 (423) 246-9578	davidw@wtfm.com	Corporation

Applicant

Address

Phone

Applicant Type

Holston Valley Broadcasting Corporation

N. David Widener

222 Commerce Street

Kingsport, TN 37660

United States

+1 (423) 246-9578

davidw@wtfm.com

Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant	Address	Phone	Email
[Confidential]

Preparer Contact Information

Preparer Contact Name and Information

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

Broadcaster Information and Transition Plan

Question	Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information.	No
Briefly describe transition plan	We think we can just purchase a new stringent mask filter for our conversion from channel 21 to channel 23, and the transmitter, antenna, and transmission line should work on our new channel.

Transmitters

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

Antennas

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

Transmission Line

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

Tower Equipment And Rigging Costs

Section	Question	Response
Tower Equipment or Rigging Costs Changes	Do you have tower equipment or rigging costs changes?	No

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	Yes
	Number of Hours	10
	Explanation	Prepare and certify form 387 quarterly reports and special progress reports
Outside RF consulting Engineering Services	Perform engineering study for new channel assignment and antenna development	No
	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	No
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

Name	Description
Other Engineering Services	Engineering services not included in any other OPS section

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	No
	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)?	No
	Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs?	No
	Does this relocation require Equipment Storage?	No
	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

Name	Description
Technalogix Mask Filter	new stringent mask filter for channel 23 replacing our channel 21

Cost Information

Transmitters

Information not provided.

Cost Information

Antennas

Information not provided.

Cost Information

Transmission Line

Information not provided.

Cost Information

Tower Equipment and Rigging Costs

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	$22,570.00	$17,362.00	N/A	$9,340.00	N/A
Total for all systems	$39,937.00	$25,810.00	N/A	$16,718.00	N/A
Outside Professional Services	$22,570.00	$17,362.00		$9,340.00
Other Engineering Services	$6,000.00	$6,000.00	Engineering services not included in any other OPS section	$1,178.00	N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$2,365.00	$1,500.00	N/A	$350.00	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$5,260.00	$2,800.00	N/A	$2,800.00	N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,580.00	$1,000.00	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$3,155.00	$1,500.00	N/A	$450.00	N/A
Prepare and or review reimbursement form	$2,630.00	$2,912.00	The Estimated Cost includes Form 399 submissions including ongoing Actual Cost invoice prep and submission, and amendments as needed.	$2,912.00	N/A
Project management of the transition	$1,580.00	$1,650.00	This component is being used to apply expenses for such tasks as project management and Form 387 Transition Plan Progress Report preparation.	$1,650.00	N/A

Components

Actual Information Description	File Name
Other Engineering Services	Component Description: OPS OES Actual Cost Invoice WAPW Amount: $53.00 Component Description: RF design for possible 399 amendment for WAPW Amount: $1,125.00
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Component Description: D Kelly 1272 v200819jgv1 Amount: $350.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	Component Description: FCC Form 2100 Main Amount: $2,800.00
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: Engineering for CP application for WAPW Amount: $450.00
Prepare and or review reimbursement form	Component Description: KGA 964-148 v200605jgv1 Amount: $75.00 Component Description: KGA 964-168 v200813jgv1 Amount: $375.00 Component Description: KGA inv #964-41 AC invs RG Feb 2019 UL20190429jgv1 Amount: $75.00 Component Description: KGA 964-142 v200506jgv1 Amount: $875.00 Component Description: KGA 964-109 v200211jgv1 Amount: $75.00 Component Description: KGA 964-95 v191222jgv1 Amount: $75.00 Component Description: KGA 964-80 v191021jgv1 Amount: $50.00 Component Description: KGA 964-104 v200114jgv1 Amount: $75.00 Component Description: KGA 964-124 v200407jgv1 Amount: $75.00 Component Description: KGA 964-67 v190708jgv1 Amount: $120.00 Component Description: KGA 964-118 v200311jgv1 Amount: $100.00 Component Description: KGA 964-58 v190513pmv1 Amount: $312.00 Component Description: KGA 964-63 v190610pmv1 Amount: $105.00 Component Description: KGA 964-154 v200708jgv1 Amount: $175.00 Component Description: KGA 964-71 v190816jgv1 Amount: $75.00 Component Description: KGA 964-91 v191112jgv1 Amount: $200.00 Component Description: KGA 964-76 v190914jgv1 Amount: $75.00
Project management of the transition	Component Description: KGA 964-164 v200710jgv1 Amount: $150.00 Component Description: KGA 964-163 v200710jgv1 Amount: $150.00 Component Description: KGA inv #964-50 Form 387 2019 Q1 UL20190429jgv1 Amount: $150.00 Component Description: Progress Report 4Q2018 Amount: $150.00 Component Description: KGA 964-84 v191028jgv1 Amount: $150.00 Component Description: KGA 964-114 v200211jgv1 Amount: $150.00 Component Description: KGA 964-129 v200413jgv1 Amount: $150.00 Component Description: KGA 964-88 v191028jgv1 Amount: $150.00 Component Description: Prog Rpt Form 387 3Q2018 Amount: $150.00 Component Description: KGA 964-159 v200710jgv1 Amount: $150.00 Component Description: FCC form 387 for 2Q18 WAPW Amount: $150.00

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	$17,367.00	$8,448.00	N/A	$7,378.00	N/A
Total for all systems	$39,937.00	$25,810.00	N/A	$16,718.00	N/A
Other Expenses	$17,367.00	$8,448.00		$7,378.00
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	$2,671.00	See attached / uploaded PDF file titled "KGA 964-136 v200414jgv1.pdf"	$2,671.00	N/A
Technalogix Mask Filter	$2,620.00	$2,620.00	See attached / uploaded PDF file titled "Technalogix WAPW1 v200420jgv1.pdf"	$2,620.00	N/A
FCC Filing Fees - Form 2100 license to cover application	$335.00	$335.00	N/A	$335.00	N/A
MVPD Notification of Channel Change	$1,752.00	$1,752.00	See attached / uploaded PDF file titled "KGA 964-137 v200414jgv1.pdf"	$1,752.00	N/A
Develop and air announcement of upcoming channel change	$0.00	$0.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
FCC Filing Fees - Form 2100 minor change CP application	Information not provided.
DTV Medical Facility Notification	Component Description: KGA 964-136 v200414jgv1 Amount: $2,671.00
Technalogix Mask Filter	Component Description: Technalogix WAPW1 v200420jgv1 Amount: $2,620.00
FCC Filing Fees - Form 2100 license to cover application	Component Description: FCC 0000116775 v200819jgv1 Amount: $335.00
MVPD Notification of Channel Change	Component Description: KGA 964-137 v200414jgv1 Amount: $1,752.00
Develop and air announcement of upcoming channel change	Information not provided.

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$39,937.00	$25,810.00	$16,718.00

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.	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.	Jeffrey C Gehman Engineering Associate 08/19/2020

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.

Jeffrey C Gehman

Engineering Associate

08/19/2020

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.	Jeffrey C Gehman Engineering Associate 08/19/2020

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.

Jeffrey C Gehman

Engineering Associate

08/19/2020

FCC Form 399: Reimbursement Request

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

Applicant Information

Applicant Name, Type, and Contact Information

Reimbursement Contact Information

Reimbursement Contact Name and Information

Preparer Contact Information

Preparer Contact Name and Information

Broadcaster Information and Transition Plan

Transmitters

Antennas

Transmission Line

Tower Equipment And Rigging Costs

Outside Professional Services Costs

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Other Expenses

Other Expenses

Other Expenses Not Listed

Cost Information

Transmitters

Cost Information

Antennas

Cost Information

Transmission Line

Cost Information

Tower Equipment and Rigging Costs

Cost Information

Outside Professional Services

Components

Cost Information

Other Expenses

Components

Cost Information

Grand Total

Reimbursement Status

Certification

Certification

Attachments