TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
AGAPE BROADCASTERS, INC. Doing Business As: AGAPE BROADCASTERS, INC.	David Thompson P.O. BOX 1469 CROWLEY, LA 70527 United States	+1 (337) 783-1560	davidt@familyvisiontv.com	Corporation

Applicant

Address

Phone

Applicant Type

AGAPE BROADCASTERS, INC.

Doing Business As: AGAPE BROADCASTERS, INC.

David Thompson

P.O. BOX 1469

CROWLEY, LA 70527

United States

+1 (337) 783-1560

davidt@familyvisiontv.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	KFAM is scheduled for Phase 1. At this time it is planned to commence work Monday Nov. 27, 2018 in preparation for commencement of operation on Friday the 28th on CH 30. No temporary facilities are planned at this time, the station has cable coverage.

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)
	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	AT7800
	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?	No
	Manufacturer
	Model	TMU9
	Transmitter Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	1.8 kW
	Justification for New Transmitter	Current transmitter not supported by manufacturer for parts availability.

Primary Transmitter

Other Transmitter Costs

Section	Question	Response
Electrical Service	Service Entrance (3 phases 800A 208V)	No
	Switchgear (industrial 800 amp)	No
	Transformer (480V)	No
	Power	N/A
	Rigid Conduit and Wiring	No
	Size	N/A
	Length	N/A
	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

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)
	Description of Use	N/A
	Ownership	Owned
	Owner	N/A
	Site	N/A
	Is the existing antenna shared with another station or stations?	No
	Is the existing antenna directional?	No
	Is antenna in operating condition?	Yes
	Is antenna located on or in close proximity to an antenna farm?	Yes
Existing Antenna Manufacturer and Type	Class	Class A
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Slotted Coaxial
	Number of Stations Supported	N/A
	Number of Panels	N/A
	Design power capacity in use	N/A
	Lower Limit	N/A
	Upper Limit	N/A
	Other Antenna Type	N/A
	ERP:	15.0 kW
	Manufacturer
	Model	PSILP16OI
	Year	2012

Primary Antenna

New Antenna Costs

Section	Question	Response
New Antenna Description	Use	Primary (Main)
	Description of Use	N/A
	Change Type	Purchase New
	Is this a request for upgraded equipment?	Yes
	Ownership	Owned
	Owner	N/A
	Is antenna shared?	No
	Is antenna directional?	No
	Will antenna be located on or in close proximity to an antenna farm?	Yes
New Antenna Manufacturer and Types	Class	Class A
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Elliptical
	Type	Slotted Coaxial
	Number of Stations Supported	N/A
	Number of Panels/Bays	N/A
	Lower Limit	N/A
	Upper Limit	N/A
	Design power capacity in use	N/A
	Other Antenna Type	N/A
	ERP:	15.0 kW
	Manufacturer
	Model	ATC-BCE416M-V3-24
	Year	2017
	Justification for New Antenna	CURRENT ANTENNA IS SINGLE CHANNEL AND CANNOT BE MOVED FROM CH 14 TO CH 24

Primary Antenna

Other Antenna Costs

Section	Question	Response
Combiner for Shared Antenna	Do you need a Combiner for a Shared Antenna?	No
	Type
	Number of channels supported	N/A
	Frequencies of channels supported	N/A
	Frequency	N/A
	Do you need a combiner output splitter/switcher for dual feed lines?	N/A
Elbow Complex	Do you require the separate purchase of the Elbow Complex?	No
	Broadband or Single Channel?	N/A
	Feed Line Size	N/A
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?	Yes

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	Move Equipment
	Tower Use	Primary (Main)
	Description of Use	N/A
	Ownership	Leased
	Is this tower consider Complex?	No
	Is this tower currently shared with any other stations?	No
	One or more FM, AM or TV radio broadcaster(s)	N/A
	Others Types of Users	N/A
	Is tower documented for structural analysis?	Unknown
	Is tower compliant with Rev G?	Unknown
Existing Tower Structure Registration	Do you have a tower registration number?	Yes
Existing Tower Structure Registration	ASR Number	1209257
Coordinates (NAD83)	Latitude (NAD83)	30° 13' 16.4" N-
	Longitude (NAD83)	093° 18' 40.9" W-
	Overall Structure Height	579.72 feet
	Support Structure Height	579.72 feet
	Ground Elevation Above Mean Sea Level (AMSL)	14.76 feet
	Structure Type	TOWER - Free Standing or Guyed Structure
	Tower Owner	P & P Communications, Inc.
	Date Constructed	06/11/2005

Primary Tower

Tower Rigging Costs

Section	Question	Response
Tower Rigging Costs	Complex Tower	N/A
Helicopter Services Required	Are helicopter services required?	No

Primary Tower

Other Tower Expenses Not Listed

Name	Description
TBD	Remove Existing Antenna and Install New

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	Yes
	Number of Hours	595
	Explanation	Station contract engineer cannot manage entire project due to time limitations. Coordination for lease and rigging, planning and on site installation, other stations, checkout and proof required. Removal of old equipment.
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	Yes
	Quantity	1
	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	Yes
	Quantity	1
	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	Yes
	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	Yes
	Number of Days	5
	Justification	Transmitter install and checkout, proof, antenna system sweep.

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	Yes
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	$126,000.00	$81,561.05	N/A	$81,560.45	N/A
Total for all systems	$574,650.00	$313,932.05	N/A	$185,327.70	N/A
Primary Transmitter TMU9	$126,000.00	$81,561.05		$81,560.45
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW	$126,000.00	$81,561.05	SJ Ramer Associates Quote 1819R. Revised estimated cost to reflect actual invoice.	$81,560.45	N/A

Components

Actual Information Description	File Name
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW	Component Description: Contract Engineering Services Amount: $10,925.00 Component Description: Repack related invoice for KFAM post transition Channel 24. Amount: $31,710.45 Component Description: FCC Repack Related Invoice - Broadcast Transmitter System TMU9-3 1800W UHF transmitter. Amount: $38,925.00 Component Description: Installation of transmitter and other equipment for Repack Amount: $4,843.08

Actual Information Description

File Name

UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW

Component Description:: Contract Engineering Services
Amount:: $10,925.00

Component Description:: Repack related invoice for KFAM post transition Channel 24.
Amount:: $31,710.45

Component Description:: FCC Repack Related Invoice - Broadcast Transmitter System TMU9-3 1800W UHF transmitter.
Amount:: $38,925.00

Component Description:: Installation of transmitter and other equipment for Repack
Amount:: $4,843.08

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	$33,030.00	$34,113.00	N/A	$20,950.00	N/A
Total for all systems	$574,650.00	$313,932.05	N/A	$185,327.70	N/A
Primary Antenna ATC-BCE416M-V3-24	$33,030.00	$34,113.00		$20,950.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic	$26,300.00	$28,113.00	LRC Wireless Invoice #20742	$20,950.00	N/A
Sweep test of existing antenna	$6,730.00	$6,000.00	N/A	$0.00	N/A

Components

Actual Information Description	File Name
UHF - Lower Power Side Mount, Class A One Station antenna -- basic	Component Description: Antenna - ATC -BCH416M-24 H-POL Coaxial Slot Antenna Amount: $12,025.00 Component Description: Antenna - ATCBCH416M-24 H-POL Coaxial Slot Antenna Amount: $8,925.00 Component Description: Agape Broadcasting KFAM Antenna Replacement Amount: $7,163.00
Sweep test of existing antenna	Information not provided.

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	$230,500.00	$27,163.00	N/A	$7,163.00	N/A
Total for all systems	$574,650.00	$313,932.05	N/A	$185,327.70	N/A
Primary Tower TOWER	$230,500.00	$27,163.00		$7,163.00
TBD	$20,000.00	$20,000.00	TOWER RIGGING	N/A	N/A
Tall Tower (greater than 500')	$210,500.00	$7,163.00	LRC Wireless 20742	$7,163.00	a

Components

Actual Information Description	File Name
TBD	Information not provided.
Tall Tower (greater than 500')	Component Description: Replaced existing antenna with customer supplied new antenna. Amount: $7,163.00

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	$136,430.00	$125,000.00	N/A	$69,795.62	N/A
Total for all systems	$574,650.00	$313,932.05	N/A	$185,327.70	N/A
Outside Professional Services	$136,430.00	$125,000.00		$69,795.62
Additional Field Engineering Service, 5 Days	$7,500.00	$7,500.00	N/A	$0.00	N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization	$3,680.00	$3,500.00	N/A	$157.00	N/A
Attorney Fees - Negotiation of lease and other matters for shared locations	$4,210.00	$4,000.00	N/A	$608.07	N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$2,365.00	$2,250.00	N/A	$435.50	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$5,260.00	$5,000.00	N/A	N/A	N/A
Prepare request for Special Temporary Authorization	$2,050.00	$1,500.00	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,580.00	$1,500.00	N/A	$1,500.00	N/A
Project management of the transition	$94,010.00	$90,750.00	Widelity quote KFAM_Widelity_Quote_SS uploaded to LMS	$67,095.05	N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$3,155.00	$2,500.00	N/A	N/A	N/A
Perform engineering study for new channel assignment and antenna development	$7,360.00	$2,500.00	N/A	N/A	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	$1,500.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Additional Field Engineering Service, 5 Days	Component Description: Field Engineering Amount: $4,743.85
Attorney Fees - Prepare and File request for Special Temporary Authorization	Component Description: KFAM-550-Attorney - Special Temporary Authorization Amount: $157.00
Attorney Fees - Negotiation of lease and other matters for shared locations	Component Description: KFAM-CD FCC Reimbursement of Repack Expenses Amount: $608.07
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Component Description: KFAM-550-Attorney - License to Cover Application (Main) Amount: $435.50
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	Information not provided.
Prepare request for Special Temporary Authorization	Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	Component Description: Antenna manufacture, Local engineer, Transmitter installation engineer Amount: $1,500.00
Project management of the transition	Component Description: Project Management Amount: $2,895.70 Component Description: Project Management Amount: $1,045.85 Component Description: Project Management Amount: $641.40 Component Description: Project Management Amount: $62.50 Component Description: Cost Reconciliation Amount: $1,640.40 Component Description: Project Management Amount: $1,989.60 Component Description: Project Management Amount: $2,100.50 Component Description: Project Management Amount: $276.30 Component Description: Project Management Amount: $610.30 Component Description: Project Management Amount: $2,995.10 Component Description: Project Management Amount: $1,152.50 Component Description: Project Management Amount: $587.45 Component Description: Project manager for the repack of KFAM Amount: $7,500.00 Component Description: Project Management Amount: $3,170.20 Component Description: Project Management Amount: $1,931.25 Component Description: Project Management Amount: $810.70 Component Description: Please deny this invoice.Invoice moved to correct cost category Amount: N/A Component Description: Project Management Amount: $1,656.20 Component Description: Project management Amount: $3,440.15 Component Description: Project Management Amount: $1,977.25 Component Description: Project Management Amount: $2,704.75 Component Description: Project Management Amount: $3,199.30 Component Description: Project Management Amount: $1,548.60 Component Description: Project Management Amount: $3,485.15 Component Description: Project Management Amount: $2,372.10 Component Description: Project Management Amount: $2,004.95 Component Description: Project Management Amount: $1,297.55 Component Description: Project Management Amount: $3,171.65 Component Description: Project Management Amount: $448.60 Component Description: Project Management Amount: $2,057.60 Component Description: Project Management Amount: $1,069.15 Component Description: Project mgt Amount: $2,712.95 Component Description: Project Management Amount: $1,813.50 Component Description: Project Management Amount: $1,662.10 Component Description: Project management Amount: $1,063.75
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	Information not provided.
Perform engineering study for new channel assignment and antenna development	Information not provided.
Address transition timing and coordination issues w/ other stations and wireless	Information not provided.
Prepare and or review reimbursement form	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	$48,690.00	$46,095.00	N/A	$5,858.63	N/A
Total for all systems	$574,650.00	$313,932.05	N/A	$185,327.70	N/A
Other Expenses	$48,690.00	$46,095.00		$5,858.63
Develop and air announcement of upcoming channel change	$4,500.00	$4,500.00	N/A	N/A	N/A
Equipment Storage	$3,500.00	$3,500.00	N/A	N/A	N/A
Equipment Delivery and Handling Charges	$10,000.00	$10,000.00	N/A	N/A	N/A
Disposal Costs (for equipment and other waste, net of any salvage value)	$5,000.00	$5,000.00	N/A	N/A	N/A
Non-zoning permits	$5,000.00	$5,000.00	N/A	N/A	N/A
FCC Filing Fees - Special Temporary Authorization request	$195.00	$190.00	N/A	N/A	N/A
FCC Filing Fees - Form 2100 license to cover application	$335.00	$335.00	Pillsbury Invoice #8246903	$335.00	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	$9,000.00	N/A	$4,023.63	N/A
MVPD Notification of Channel Change	$7,500.00	$7,500.00	N/A	$1,500.00	N/A

Components

Actual Information Description	File Name
Develop and air announcement of upcoming channel change	Information not provided.
Equipment Storage	Information not provided.
Equipment Delivery and Handling Charges	Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)	Information not provided.
Non-zoning permits	Information not provided.
FCC Filing Fees - Special Temporary Authorization request	Information not provided.
FCC Filing Fees - Form 2100 license to cover application	Component Description: KFAM-610-FCC Filing Fee - License to Cover Application Amount: $335.00
FCC Filing Fees - Form 2100 minor change CP application	Information not provided.
DTV Medical Facility Notification	Component Description: "Print and mail a two page, black and white generically addressed letter" Amount: $4,023.63
MVPD Notification of Channel Change	Component Description: MVPD Notification Amount: $1,500.00

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$574,650.00	$313,932.05	$185,327.70

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.	David Thompson Station Manager 12/16/2020

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.

David Thompson

Station Manager

12/16/2020

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.	David Thompson Station Manager 12/16/2020

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.

David Thompson

Station Manager

12/16/2020

(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 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

Attachments