Go to the Federal Communications Commission homepage at www.fcc.gov

FCC Form 399: Reimbursement Request

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

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

Facility ID:
35525
Service:
DTV
Call Sign:
KQDS-TV
Channel:
18 (UHF)
File Number:
0000027522
FRN:
0003914025
Date Submitted:
06/17/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

KQDS ACQUISITION CORP.

Doing Business As: KQDS ACQUISITION CORP.

Kathy Lau

P. O. BOX 9115

FARGO, ND 58106

United States

+1 (701) 277-1515 KLAU@KVRR.COM Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

The Preparer is same as the reimbursement contact.

 

 

 

Broadcaster Information and Transition Plan

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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 1. Design, engineer and plan. 2. Install interim transmitter and antenna. 3. Decommission existing transmitter and associated appurtenances operating on channel 17. 4. Build new transmitter and associated appurtenances operating on channel 18.

Transmitters

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

Primary Transmitter

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Add 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 DCX Millennium
Year 2006
Type Inductive Output Tube
IOT Power Type Three
Power Capacity 76.1 kW

Primary Transmitter

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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 HPTV-PARLX-U48
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 76.1 kW
Justification for New Transmitter Comark has sent notification that the DCX series has reached end of life status. See attachment "Comark EOL" for details The cost to purchase a solid state transmitter is lower than the cost to replace with IOT. See attachment "Comark IOT Quote"

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) Yes
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring Yes
Size 4 inches
Length 200.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size 15 tons
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

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Other Transmitter Cost Not Listed

Name Description

Telemetry

Monitor and remote control of transmitter

State and Local Taxes

MN State and Local Sales Taxes

Site Visit

Layout and design of installation includes sweep of old feedline

Interim Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Interim
Description of Use N/A
Change Type Purchase
Manufacturer
Model HPTV-PRLX-U12
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 25 kW
Justification for New Transmitter This will minimize service interruption and keep us on the air while the main transmitter is built on the new channel.

Interim Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring Yes
Size 2 inches
Length 50.0 feet
Other Electrical Service Yes
Description Install AC mains feed to the interim transmitter.
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Heating and Cooling
Size 10 tons
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
Inside RF System Is an additional interior RF system required to support this interim transmitter? Yes

Interim Transmitter

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Other Transmitter Cost Not Listed

Name Description

Telemetry

Remote communications with Interim transmitter

State and Local Taxes

MN State and City Sales Taxes

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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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 Full Power
Mounting Top Mount
Antenna position in stack Top
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: 1000.0 kW
Manufacturer
Model TFU-20GTH-R 04
Year 2006

Primary Antenna

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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 Full Power
Mounting Top Mount
Antenna position in stack Top
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: 1000.0 kW
Manufacturer
Model TFU-28GTH O4A
Year 2018
Justification for New Antenna Current antenna is single channel operation on channel 17. We will require an antenna capable of transmitting on channel 18.

Primary Antenna

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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? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 7 3/16 inches inches
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

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Other Antenna Cost Not Listed

Name Description

State and Local Taxes

State and local sales tax, est. 8.375%

Support pole

to maintain current center of radiation

Top Plate Adapter

Top Plate Adapter to match tower top and antenna bolt pattern.

Interim Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Interim
Description of Use N/A
Change Type Purchase New
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Type Class Full Power
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: 612.3 kW
Manufacturer
Model TFU-22JSC/ VP-R C170
Year 2017
Justification for New Antenna This will minimize service interruption and keep us on the air while the main transmitter is built on the new channel.

Interim Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? S
Feed Line Size 6 1/8 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for an antenna? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Interim Antenna

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Other Antenna Cost Not Listed

Name Description

Ice Shield for Interim Antenna

Protect Interim antenna from falling ice and debris

State and Local Taxes

State sales tax, local sales tax. Estimate 8.375%

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? Yes

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Purchase New
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? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 19 1/2 inches
Other Segment Length N/A
Number of parallel runs 1
Length 900 feet per run

Primary Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Type Rigid
Diameter 6 1/8 inches
Other Diameter N/A
Segment Length 20 inches
Other Segment Length N/A
Number of parallel runs 1
Length 40 feet per run
Justification for New Transmission Line Change in line run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Changes to Transmission line run

Addition parts for changes to line runs

State and Local Taxes

state and local sales taxes

Interim Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Rigid
Diameter 6 1/8 inches
Segment Length 19 ½ '
Other Segment Length
Number of parallel runs 1
Length 800 feet per run
Justification for New Transmission Line This will minimize service interruption and keep us on the air while the main transmitter is built on the new channel.

Interim Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

State and Local Taxes

State and local sales tax, est. 8.375%

Dehydrator and RF scout

Keeps line pressure and measures RF levels

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Add Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Owned
Is this tower consider Complex? Candelabra
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
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? No
ASR Number
Coordinates (NAD83) Latitude (NAD83) 46° 47' 37.0" N-
Longitude (NAD83) 092° 07' 04.0" W-
Overall Structure Height 789.03 feet
Support Structure Height 693.56 feet
Ground Elevation Above Mean Sea Level (AMSL) 1236.86 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner KODS ACQUISITION CORP.
Date Constructed 11/09/1999

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID Call Sign Service
65660 KQDS-FM FM

Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Minor Reinforcements needed

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Name Description

State and Local Taxes

State and local sales taxes, est. 8.75%

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? No
Number of Hours N/A
Explanation N/A
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 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 Yes
RF exposure measurements No
Additional Field Engineering Service Yes
Number of Days 2
Justification Sweep Line and confirm re-usability of any existing components.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
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 No
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

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Other Expenses Not Listed

Name Description

Portable Restrooms

Meet requirements for construction site restrooms

Employee Time

Recover salary expenses for time spent on repack project.

Modify Receive Antenna at Translator Site

To increase signal strength received at the remote headend sites, due to low power/interim operation during the transition.

State And Local Taxes

State and local Sales Tax @ 8.375%

Cost Information

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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 $3,485,370.00 $3,018,140.00 N/A $2,922,850.28 N/A
Total for all systems $5,396,320.70 $5,100,463.64 N/A $4,731,206.49 N/A
Interim Transmitter HPTV-PRLX-U12 $1,235,205.00 $833,275.00 $780,951.78
State and Local Taxes $70,505.00 $70,505.00 N/A $58,206.25 N/A
Telemetry $2,000.00 $2,000.00 N/A $353.53 N/A
UHF inside RF system including switching $147,500.00 $140,000.00 N/A $140,000.00 N/A
10 Ton system $38,900.00 $37,000.00 N/A $12,542.00 N/A
Other Electrical Service: Install AC mains feed to the interim transmitter. $13,600.00 $13,600.00 See attachment titled "Electrical Quote KQDS-TV Repack". $13,600.00 N/A
2" Rigid Conduit and Wiring (Cost per foot) $1,300.00 $1,250.00 N/A $1,250.00 N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $13,920.00 Service entrance has to be tied back to transformer $0.00 N/A
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW $947,000.00 $555,000.00 N/A $555,000.00 N/A
Primary Transmitter HPTV-PARLX-U48 $2,250,165.00 $2,184,865.00 $2,141,898.50
Site Visit $16,400.00 $16,400.00 Determine placement, design and installation plan Sweep existing line $16,400.00 N/A
State and Local Taxes $178,965.00 $178,965.00 N/A $169,998.50 N/A
Telemetry $8,000.00 $8,000.00 Meet FCC requirement to monitor and remotely control. Old system not supported. $0.00 N/A
15 Ton system $88,400.00 $26,000.00 N/A $0.00 N/A
4" Rigid Conduit and Wiring (Cost per foot) $20,200.00 $19,200.00 N/A $19,200.00 N/A
Switchgear - industrial 800 amp $38,200.00 $36,300.00 N/A $36,300.00 N/A
UHF - Liquid Cooled Solid State Transmitter 76.1 kW $1,900,000.00 $1,900,000.00 N/A $1,900,000.00 30% Down

Components

Actual Information Description File Name
State and Local Taxes

Component Description:
State tax on 60% of the quote for the interim transmitter
Amount:
$27,888.75

Component Description:
State taxes for down payment of interim transmitter
Amount:
$13,944.38

Component Description:
State Taxes 8.375% of 55500 & 14000. Interim
Amount:
$5,820.62

Component Description:
State taxes for interim transmitter inside RF system
Amount:
$3,517.50

Component Description:
State tax on 60% of quote for UHF inside plant system
Amount:
$7,035.00
Telemetry

Component Description:
Telemetry router interim transmitter KQDS
Amount:
$353.53
UHF inside RF system including switching

Component Description:
60% of Comark quote due prior to shipping
Amount:
$84,000.00

Component Description:
30% down of interim transmitter inside RF system
Amount:
$42,000.00

Component Description:
Final 10% KQDS-TV interim Transmitter Hitachi/Comark
Amount:
$14,000.00
10 Ton system

Component Description:
Invoice for work to roll back ice screen during A/C install
Amount:
$3,000.00

Component Description:
50% of the Quote for A/C Gartner Refrigeration
Amount:
$4,771.00

Component Description:
Final payment for A/C installation interim transmitter
Amount:
$4,771.00
Other Electrical Service: Install AC mains feed to the interim transmitter.

Component Description:
50% down payment for electrical work on interim transmitter
Amount:
$6,800.00

Component Description:
Invoice for Hunt Electric interim Quote
Amount:
$6,800.00
2" Rigid Conduit and Wiring (Cost per foot)

Component Description:
50% down for the electrical work on the interim transmitter
Amount:
$625.00

Component Description:
Invoice from Hunt Electric Interim quote.
Amount:
$625.00
Service entrance 3 phase/800 amp/208 volt Information not provided.
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW

Component Description:
30% down payment of Interim transmitter
Amount:
$166,500.00

Component Description:
Final 10% KQDS-TV interim transmitter Hitachi/Comark
Amount:
$55,500.00

Component Description:
60% of quote due prior to shipping interim transmitter
Amount:
$333,000.00
Site Visit

Component Description:
Site Survey
Amount:
$16,400.00
State and Local Taxes

Component Description:
.5% tax adjustment of MN state sales tax for earlier 60% down payment made.
Amount:
$5,700.00

Component Description:
.5% tax adjustment MN sales tax on downpayment of 30%
Amount:
$2,850.00

Component Description:
State tax for down payment of primary transmitter
Amount:
$47,737.50

Component Description:
State Tax
Amount:
$1,373.50

Component Description:
State taxes, 8.875% of 190000. Primary TX KQDS-TV
Amount:
$16,862.50

Component Description:
State tax on 60% of quote for Primary Transmitter
Amount:
$95,475.00
Telemetry

Component Description:
Router for network needed for telemetry Primary KQDS-TV, monitoring is IP based on Main TX
Amount:
$547.21
15 Ton system

Component Description:
50% with order downpayment primary A/C system KQDS-TV
Amount:
$11,849.00
4" Rigid Conduit and Wiring (Cost per foot)

Component Description:
Electrical Work KQDS-TV Primary 4" Rigid Conduit and Wiring
Amount:
$19,200.00
Switchgear - industrial 800 amp

Component Description:
Electrical Work KQDS-TV primary SWITCHGEAR-INDUSTRIAL 800A
Amount:
$36,300.00
UHF - Liquid Cooled Solid State Transmitter 76.1 kW

Component Description:
Final 10% for KQDS-TV main transmitter from Hitachi/Comark
Amount:
$190,000.00

Component Description:
Primary Transmitter
Amount:
$570,000.00

Component Description:
60% of quote due prior to shipping Primary Transmitter
Amount:
$1,140,000.00

Cost Information

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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 $687,665.99 $624,065.99 N/A $618,489.21 N/A
Total for all systems $5,396,320.70 $5,100,463.64 N/A $4,731,206.49 N/A
Interim Antenna TFU-22JSC/ VP-R C170 $243,324.00 $239,725.00 $233,970.91
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed) $12,300.00 $13,566.00 Per quote $13,566.00 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $6,400.00 N/A
UHF - High Power, Side Mount, basic slot antenna, 612 kW input, directional,, elliptically or circularly polarized $170,510.00 $170,510.00 ***System Notice: Estimate adjusted and locked because line has been superseded.*** $170,510.00 Wrong Amount submitted on original estimate
Ice Shield for Interim Antenna $8,000.00 $8,000.00 N/A $7,264.00 N/A
State and Local Taxes $22,634.00 $22,634.00 8.375% of estimated costs $17,615.91 N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $23,150.00 $18,615.00 N/A $18,615.00 N/A
Primary Antenna TFU-28GTH O4A $444,341.99 $384,340.99 $384,518.30
Top Plate Adapter $20,740.00 $20,740.00 Unable to re-use the existing antenna adapter plate to mount the new antenna. $20,740.00 N/A
Support pole $83,770.90 $83,770.90 N/A $83,770.89 N/A
State and Local Taxes $29,701.09 $29,701.09 8.375% of estimated costs $29,878.41 Tax rate rose since project started from 8.375 to 8.875
Elbow complex, single channel, at antenna input, per 7 3/16. feedline (if needed) $13,900.00 $15,878.00 Per Quote $15,878.00 N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A $6,400.00 N/A
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized $289,500.00 $227,851.00 Horizontal component only, V pol invoiced directly to KQDS $227,851.00 N/A

Components

Actual Information Description File Name
Elbow complex, single channel, at antenna input, per 6 1/8. feedline (if needed)

Component Description:
Line 23 invoice MAN00546, 45% sales quote 1179002 prior to ship
Amount:
$6,104.70

Component Description:
Line 23 Man1179002, 10% SO 1179002 KQDS-TV repack
Amount:
$1,356.60

Component Description:
45% of Quote line 23
Amount:
$6,104.70
Sweep test of existing antenna

Component Description:
Line 45 invoice MAN00546, 45% sales quote 1179002, prior to ship
Amount:
$2,880.00

Component Description:
Final 10% MAN1179002 line 45
Amount:
$640.00

Component Description:
45% of quote line 45 due upon order
Amount:
$2,880.00
UHF - High Power, Side Mount, basic slot antenna, 612 kW input, directional,, elliptically or circularly polarized

Component Description:
Line 20 invoice MAN00546, sales quote 1179002 45% prior to ship
Amount:
$76,729.50

Component Description:
45% down with order interim antenna line 20 of Invoice
Amount:
$76,729.50

Component Description:
10% Line 20 Dielectric MAN1179002 Side mount interim antenna KQDS-TV
Amount:
$17,051.00
Ice Shield for Interim Antenna

Component Description:
Invoice per quote True North Ice shield for interim antenna KQDS-TV Fabricate and install
Amount:
$7,264.00
State and Local Taxes

Component Description:
MN State and local sales tax KQDS-TV repack
Amount:
$1,855.68

Component Description:
State and local taxes repack KQDS-TV
Amount:
$15,760.23
Side mount brackets for high power antennas (if not included in antenna base cost)

Component Description:
Line 22 of invoice MAN00546, 45% sales quote1179002 prior to ship.
Amount:
$8,376.75

Component Description:
Line 22 MAN1179002, 10% SO 1179002 Repack KQDS-TV
Amount:
$1,861.50

Component Description:
45% of quote line 22 due upon order
Amount:
$8,376.75
Top Plate Adapter

Component Description:
Line #3 invoice MAN00546, sales quote, 1179002, 45% prior to ship
Amount:
$9,333.00

Component Description:
Line 3 SO 1179002 Adapter plate
Amount:
$2,074.00

Component Description:
45% quote line 3 due upon order
Amount:
$9,333.00
Support pole

Component Description:
Line #4 invoice MAN00546, sales quote 1179002, 45% prior to ship
Amount:
$37,696.90

Component Description:
Line 4 invoice MAN1179002, Support Pole for main Antenna 10% KQDS-TV Repack
Amount:
$8,377.09

Component Description:
45% per quote line 4 due upon order
Amount:
$37,696.90
State and Local Taxes

Component Description:
MN State and local taxes KQDS-TV repack
Amount:
$3,147.43

Component Description:
State and Local taxes MN, repack KQDS-TV
Amount:
$26,730.98
Elbow complex, single channel, at antenna input, per 7 3/16. feedline (if needed)

Component Description:
line 5 Quote MAN1179002, 10% Dielectric Elbow complex KQDS-tv Repack
Amount:
$1,587.80

Component Description:
Line # 5, invoice MAN00546, sales quote 1179002, 45% prior to ship
Amount:
$7,145.10

Component Description:
45% quote line 5 due upon order
Amount:
$7,145.10
Sweep test of existing antenna

Component Description:
Final 10% SO 1179002, Line 19 invoice MAN1179002
Amount:
$640.00

Component Description:
Line # 19, invoice MAN00546, sales quote 1179002, 45% prior to ship
Amount:
$2,880.00

Component Description:
45% of quote line 45 due upon order
Amount:
$2,880.00
UHF - High Power Top Mount (200-1000 kW), One station antenna , elliptically or circularly polarized

Component Description:
45% of quote line 1 due upon order
Amount:
$102,532.95

Component Description:
Line 1 of invoice MAN1179002. Final 10% Dielectric
Amount:
$22,785.10

Component Description:
Line #1, invoice MAN00546, sales quote 1179002, prior to ship
Amount:
$102,532.95

Cost Information

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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 $218,843.27 $201,591.21 N/A $200,149.56 N/A
Total for all systems $5,396,320.70 $5,100,463.64 N/A $4,731,206.49 N/A
Interim Transmission Line $196,224.87 $179,696.07 $179,384.73
Dehydrator and RF scout $20,536.87 $20,536.87 N/A $20,536.87 Line 49 of SO1179002 was not added into estimate. It changed when line17 became line 49.
State and Local Taxes $14,088.00 $14,088.00 8.375% total estimate $13,776.67 N/A
Rigid Transmission Line - copper, 6 1/8" $161,600.00 $145,071.20 per updated quote $145,071.19 N/A
Primary Transmission Line $22,618.40 $21,895.14 $20,764.83
Changes to Transmission line run $11,784.40 $11,784.40 N/A $11,784.42 Rounding error on 45% payments. Should have been 5302.98. Accounts for the difference, of .02.
State and Local Taxes $2,754.00 $2,754.00 N/A $1,623.67 N/A
Rigid Transmission Line - copper, 6 1/8" $8,080.00 $7,356.74 N/A $7,356.74 Part needed during actual activation process.

Components

Actual Information Description File Name
Dehydrator and RF scout

Component Description:
Lines 13-16, 49 invoice MAN1179002, sales quote 1179002, 10% final
Amount:
$2,053.69

Component Description:
Lines 13-16, 49 invoice MAN00546, sales quote 1179002, 45% prior to ship
Amount:
$9,241.59

Component Description:
45% of quote lines 13-16, 49
Amount:
$9,241.59
State and Local Taxes

Component Description:
Mn State and local taxes KQDS-TV repack
Amount:
$1,451.25

Component Description:
State and local taxes MN, repack KQDS-TV
Amount:
$12,325.42
Rigid Transmission Line - copper, 6 1/8"

Component Description:
Line #'s 24 - 28, invoice MAN00546, sales quote 1179002, 45% prior to ship
Amount:
$64,343.00

Component Description:
10% Lines 24-28 Dielectric SO1179002. MAn1179002 Lines 24-28 KQDS-TV repack off by .01 due to rounding
Amount:
$14,298.44

Component Description:
45% of quote, lines 24 & 28 due upon order
Amount:
$64,343.00

Component Description:
Final cut Transmission Line Interim KQDS-TV
Amount:
$2,086.75
Changes to Transmission line run

Component Description:
Final 10% SO1179002 line 6, Dielectric Invoice MAN1179002 KQDS-TV
Amount:
$1,001.64

Component Description:
Line #'s 8-11 invoice MAN1179002, sales quote 1179002, 10% final
Amount:
$176.80

Component Description:
Line #'s 6, 8-11 invoice MAN00546, sales quote 1179002, 45% prior to ship
Amount:
$5,302.99

Component Description:
45% of Quote, lines 6, 8-11 due upon order
Amount:
$5,302.99
State and Local Taxes

Component Description:
State Tax KQDS-TV invoice 864017
Amount:
$217.64

Component Description:
State and Local taxes for inv 864017 Dielectric
Amount:
$217.64

Component Description:
MN State and Local sales tax KQDS-TV repack
Amount:
$148.11

Component Description:
State and local taxes MN, Repack KQDS-TV
Amount:
$1,257.92
Rigid Transmission Line - copper, 6 1/8"

Component Description:
Special cut section for the final piece to connect the RF line for KQDS-TV build.
Amount:
$2,452.25

Component Description:
Line #7, invoice MAN00546, sales quote 1179002, 45% prior to ship
Amount:
$2,207.02

Component Description:
final 10% PCA 1179002 Line 7 Kqds-tv repack total of invoices short .01 due to rounding down on other two 45% payments
Amount:
$490.45

Component Description:
45% quote line 7 due upon order
Amount:
$2,207.02

Cost Information

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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 $628,315.00 $887,265.00 N/A $779,019.30 N/A
Total for all systems $5,396,320.70 $5,100,463.64 N/A $4,731,206.49 N/A
Primary Tower TOWER $628,315.00 $887,265.00 $779,019.30
Minor tower reinforcement/modifications $158,000.00 $150,000.00 N/A $87,000.00 N/A
State and Local Taxes $36,715.00 $36,715.00 8.375% of quote cost $31,214.30 N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $421,000.00 $697,050.00 Tower reinforcement, stacked antenna and Interim side mount plus removal of existing stack, multiple crews and companies will be doing this work. Due to multiple issues with construction crews and timing Helicopter lift added. Change orders added. $657,305.00 N/A
Structural engineering tower load study for well documented tower $12,600.00 $3,500.00 N/A $3,500.00 N/A

Components

Actual Information Description File Name
Minor tower reinforcement/modifications

Component Description:
Down payment for KQDS top tower guy for tower reinforcment
Amount:
$43,500.00

Component Description:
Final invoice for guy reinforcement
Amount:
$43,500.00
State and Local Taxes

Component Description:
State and local taxes MN, repack KQDS-TV
Amount:
$31,214.30
Complex Tower (includes, for example, those with candelabras and/or stacked antennas)

Component Description:
2nd and final 50% of Quote 03081802 for removal of tower attachments
Amount:
$3,500.00

Component Description:
45% due prior to ship lines 1 - 3. Sales quote 1229002
Amount:
$186,354.00

Component Description:
2nd invoice for installation of cross bracing on KQDS tower
Amount:
$6,250.00

Component Description:
Invoice for Helicopter lift of main antenna KQDS-TV per change orders 03022020 and 07142020
Amount:
$251,262.00

Component Description:
45% of quote lines 1-3 due upon order
Amount:
$186,354.00

Component Description:
Cross Braces for tower reinforcement for Rev G compliance per proposal 19598
Amount:
$13,835.00

Component Description:
50% of Quote 03081802 for removal of tower attachments
Amount:
$3,500.00

Component Description:
50% of installation of tower support cross bracing per proposal
Amount:
$6,250.00
Structural engineering tower load study for well documented tower

Component Description:
Invoice for quote 19583 for Structural analysis
Amount:
$3,500.00

Cost Information

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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 $123,910.00 $117,750.00 N/A $42,721.00 N/A
Total for all systems $5,396,320.70 $5,100,463.64 N/A $4,731,206.49 N/A
Outside Professional Services $123,910.00 $117,750.00 $42,721.00
Additional Field Engineering Service, 2 Days $9,000.00 $9,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A $42,721.00 N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,680.00 $3,500.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A 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 N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 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 $2,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Additional Field Engineering Service, 2 Days Information not provided.
Comprehensive coverage verification via field study, if needed

Component Description:
Drone Based (ITU 10m/FCC 9.1m) Field Strength Measurements KQDS-TV Main Antenna coverage, quote # QU-17186 in attachments
Amount:
$17,406.00

Component Description:
Drone-Based Antenna Pattern Reconstitution, ERP, Azimuth and Elevation. Quote # QU-17185 in attachments. patterns, KQDS-TV
Amount:
$25,315.00
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
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 Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
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 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

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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 $252,216.44 $251,651.44 N/A $167,977.14 N/A
Total for all systems $5,396,320.70 $5,100,463.64 N/A $4,731,206.49 N/A
Other Expenses $252,216.44 $251,651.44 $167,977.14
State And Local Taxes $17,327.00 $17,327.00 per current quotes and estimates $9,708.83 N/A
Modify Receive Antenna at Translator Site $5,000.00 $5,000.00 N/A N/A N/A
Employee Time $25,263.57 $25,263.57 Project was done without outside project management. Internal labor ran higher than expected (approx $5,263.57 due to this. It saved up to $50,000 in foutside project managment costs, as a result.. $25,263.57 repack project for KQDS-TV did not use outside project management which could have cost $50,000. Ended up exceeding internal labor cost, but saved quite a bit on management costs overall.
MVPD Notification of Channel Change $3,000.00 $3,000.00 N/A $1,463.70 N/A
Develop and air announcement of upcoming channel change $44,705.00 $44,705.00 See attached advertising schedule titled "KQDS Channel Reassignment Notification". Also, shooting, editing and production of notifications. $0.00 N/A
Equipment Storage $29,307.81 $29,307.81 Additional Storage do to delay in build of Main Antennea. Kqds-tv $16,056.31 Security of on site storage during installation of interim antenna at KQDS-TV tower site.
Equipment Delivery and Handling Charges $95,000.00 $95,000.00 Includes both Comark and Dielectric quotes that total this amount. The additional expense is due to Antennas and transmission line being shipped in two different orders. Interim first, then main. $93,270.33 There were additional costs during the actual building phase of the main antenna that arose as actual onsite issues, where additional shipping of materials were needed
Disposal Costs (for equipment and other waste, net of any salvage value) $20,233.06 $20,233.06 Additional disposal cost for KQDS-TV Main Transmitter site $20,233.06 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 $325.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $1,895.50 N/A
Portable Restrooms $300.00 $300.00 N/A $85.84 N/A

Components

Actual Information Description File Name
State And Local Taxes

Component Description:
.5% tax adjustment on MN sales tax increase on 60% downpayment shipping cost during repack process
Amount:
$71.02

Component Description:
.5% tax adjustment on MN sales tax increase on 60% downpayment disposal cost during repack process
Amount:
$60.00

Component Description:
.5% tax adjustment on MN sales tax increase on 30% downpayment shipping cost during repack process
Amount:
$35.51

Component Description:
.5% tax adjustment on MN sales tax increase on 30% downpayment disposal cost during repack process
Amount:
$30.00

Component Description:
State and local taxes MN, repack KQDS-TV
Amount:
$3,994.88

Component Description:
State taxes on invoice 866022
Amount:
$161.94

Component Description:
Invoice has wrong total. Dielectric will issue new invoice once corrected.
Amount:
N/A

Component Description:
Taxes 8.875% Delivery Interim Comark. KQDS-TV
Amount:
$117.25

Component Description:
State tax on 60% of quote for disposal costs
Amount:
$1,005.00

Component Description:
State taxes for 30% down of disposal costs of transmitters-primary, interim & interim RF
Amount:
$502.50

Component Description:
State and local sales tax KQDS-TV repack
Amount:
$470.38

Component Description:
Taxes 8.375% Delivery Comark KQDS-TV
Amount:
$210.09

Component Description:
Taxes 8.875% for disposal costs. Comark. KQDS-TV
Amount:
$177.50

Component Description:
State tax of 30% down for delivery & handling of transmitters-primary, interim, & interim RF
Amount:
$946.50

Component Description:
State Tax on invoice 851022
Amount:
$33.24

Component Description:
State Tax for 60% of quote for shipping and handling
Amount:
$1,893.02
Modify Receive Antenna at Translator Site Information not provided.
Employee Time

Component Description:
KQDS-TV personnel labor repack - Steve Schuyler
Amount:
$4,784.69

Component Description:
Employee Chris Drovdal labor 399 repack KQDS-TV
Amount:
$4,748.40

Component Description:
Employee Labor KQDS-TV repack - Chris Drovdal, CE
Amount:
$8,574.95

Component Description:
Employee Labor repack KQDS-TV Steven Schuyler
Amount:
$7,155.53

Component Description:
KQDS-TV personnel labor for repack
Amount:
$4,748.40
MVPD Notification of Channel Change

Component Description:
Invoice MVPD Notification KQDS per quote EST-001255 for Repack
Amount:
$1,463.70
Develop and air announcement of upcoming channel change Information not provided.
Equipment Storage

Component Description:
Invoice 881005 Storage for main antenna KQDS-TV. Credit is a result of the reconciliation, which is attached
Amount:
$7,801.50

Component Description:
Storage for Aux antenna and other aux material
Amount:
$3,395.00

Component Description:
Security for KQDS-TV site. Delivery and installation of main antenna and transmitter site.
Amount:
$2,985.09

Component Description:
Security for on site storage during interim antenna installation
Amount:
$1,171.70

Component Description:
Invoice for Security of the premises during off loading and construction.
Amount:
$703.02
Equipment Delivery and Handling Charges

Component Description:
line item 51 1179002 Rev
Amount:
$1,569.67

Component Description:
line 50 quote 1179002 revised Kqds-tv
Amount:
$66.87

Component Description:
Final section special cut, next day delivery. Crew was at site needed immediately.
Amount:
$1,824.70

Component Description:
Line # 44, invoice MAN00546, sales quote 1179002, 45% prior to ship
Amount:
$11,925.00

Component Description:
Line #18 invoice MAN00546, sales quote 1179002, 45% prior to ship
Amount:
$11,925.00

Component Description:
30% down of delivery of primary, interim, & interim RF system transmitters
Amount:
$11,301.60

Component Description:
Final 10% SO1179002 line 18, Dielectric invoice MAN1179002
Amount:
$2,650.00

Component Description:
Final 10% delivery and handling KQDS-TV Hitachi/Comark
Amount:
$2,367.20

Component Description:
45% of quote line 44 due upon order
Amount:
$11,925.00

Component Description:
Final 10% per SO1179002, Invoice 1179002, line 44
Amount:
$2,650.00

Component Description:
60% of quote due prior to shipping
Amount:
$22,603.20

Component Description:
Memo attached KQDS-TV overnight during final activation
Amount:
$374.53

Component Description:
45% of quote line 18 due upon order
Amount:
$11,925.00

Component Description:
Shipping overnight for final cut piece KQDS-TV main
Amount:
$1,824.70

Component Description:
Final 10% Delivery and handling Interim transmitter KQDS-TV
Amount:
$1,400.00

Component Description:
Equipment rental for off loading shipment
Amount:
$399.10

Component Description:
Shipping overnight Coupler needed to be EHT coated. Crew was on site at $1500 per day. Crews are hard to keep on site.
Amount:
$374.53
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
Roll off dumpsters for KQDS-TV main transmitter site.
Amount:
$233.06

Component Description:
30% down of Disposal Costs
Amount:
$6,000.00

Component Description:
Final 10% Disposal Costs KQDS-TV Hitachi/Comark
Amount:
$2,000.00

Component Description:
60% of quote due prior to shipping
Amount:
$12,000.00
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
DTV Medical Facility Notification

Component Description:
Invoice Medical Facilities Notification KQDS per attached quote EST-001254
Amount:
$1,895.50
Portable Restrooms

Component Description:
Requirement for construction site in MN
Amount:
$85.84

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $5,396,320.70 $5,100,463.64 $4,731,206.49

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. Yes
Construction of final facilities or all necessary modifications are complete. Yes
All receipts for reimbursement have been submitted no further costs are expected to be incurred. Note this will lock the Form 399 from further editing and begin close-out procedures with the Fund Administrator. No

Certification

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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.

  1. 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.

  2. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  3. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  4. 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).

  5. 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.

  6. 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.

  7. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  8. 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.

Kathy Lau

COO


06/17/2021

Certification

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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).

  1. 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.

  2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

  3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  4. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  5. 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) .

  6. 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.

  7. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

  8. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  9. 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.

Kathy Lau

COO


06/17/2021

Certification

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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.

  1. 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.

  2. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  3. 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.

  4. 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.

  5. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  6. 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.

Kathy Lau

COO


06/17/2021

Attachments

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