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:
28199
Service:
DCA
Call Sign:
WDNI-CD
Channel:
16 (UHF)
File Number:
0000025424
FRN:
0006584247
Date Submitted:
04/06/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

RADIO ONE OF INDIANA, LLC

Doing Business As: RADIO ONE OF INDIANA, LLC

Sonya M. Hall-Harris

1010 WAYNE AVENUE, 14TH FLOOR

SILVER SPRING, MD 20910

United States

+1 (301) 429-3200 SHARRIS@urban1.COM Limited Liability Company

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

Sonya Harris

Corporate Paralegal

Urban One, Inc.

Sonya Harris

1010 Wayne Avenue

14th Floor

Silver Spring, MD 20910

United States

+1 (301) 429-3200 sharris@urban1.com

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 Purchase aux transmitter, line and new antenna. Run new line below current antenna and move Ch19 antenna to lower height. Mount new antenna at CP height utilizing existing coax. Remove Ch19 antenna and temporary line after on new channel assignment.

Transmitters

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

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Retune Existing
Use Primary (Main)
Ownership Owned
Owner 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 Harris
Model Maxiva UAX
Year 2009
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.25 kW

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed N/A
New Mask Filter
Power 1.5 kW
Other Power N/A
New Exciter Is a new exciter needed? No

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) 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

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Other Transmitter Cost Not Listed

Information not provided.

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 ULXTE-2
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 1.44 kW
Justification for New Transmitter No aux transmitter currently. Need to stay on air while antennas are being removed and replaced. This would be used to maintain Ch19 coverage while Ch16 antenna is installed and the main transmitter is retuned for new frequency.

Interim Transmitter

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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 Yes
Size 1 inches
Length 25.0 feet
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A
Inside RF System Is an additional interior RF system required to support this interim transmitter? No

Interim Transmitter

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Other Transmitter Cost Not Listed

Information not provided.

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? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class 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 SWR-SWCP16OI/19
Year 2009

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? No
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? No
New Antenna Manufacturer and Types Class Class A
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Circular
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: 13.9 kW
Manufacturer
Model SWEDM16OI/16-EP
Year 2017
Justification for New Antenna Need new antenna as current antenna cannot be retuned according to manufacturer.

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? 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? No

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

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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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
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? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users No
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1027512
Coordinates (NAD83) Latitude (NAD83) 39° 48' 00.4" N-
Longitude (NAD83) 086° 04' 37.6" W-
Overall Structure Height 523.29 feet
Support Structure Height 519.68 feet
Ground Elevation Above Mean Sea Level (AMSL) 820.86 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner VB Nimbus, LLC
Date Constructed 10/09/2002

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
28609 WJJK 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 undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Major Reinforcements needed

Primary Tower

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Tower Rigging Costs

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

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Porta Potty

Needed for tower crew workers due to no facilities on site.

Brush clearing

Site and guy wire paths need brush removed for crew to stage equipment and replace guy wires. Land grading necessary to get construction equipment in place.

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 Yes
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

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 Yes
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 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? 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

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Other Expenses Not Listed

Information not provided.

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 $254,280.23 $251,639.44 N/A $146,050.23 N/A
Total for all systems $1,106,963.73 $1,119,259.59 N/A $837,436.93 N/A
Interim Transmitter ULXTE-2 $146,050.23 $146,050.23 $146,050.23
1" Rigid Conduit and Wiring $2,952.92 $2,952.92 The expense was greater due to the fact that electrical also had to be provided to pump stand and to cooling radiators located outside since it is a liquid cooled transmitter. $2,952.92 N/A
UHF - Liquid Cooled Solid State Transmitter 1.44 kW $143,097.31 $143,097.31 The amount is higher due to change orders that came up due to site issues. $143,097.31 This was the total cost and was higher due to a couple change orders due to site requirements.
Primary Transmitter Maxiva UAX $108,230.00 $105,589.21 $0.00
UHF and VHF - minor banding issues $105,200.00 $100,000.00 N/A N/A N/A
1.5 kW mask filter $3,030.00 $5,589.21 That is the price quoted from Gates Air. Please see attached quote for reference. N/A N/A

Components

Actual Information Description File Name
1" Rigid Conduit and Wiring

Component Description:
Electrical work to hook up the new transmitter and cooling fans. Reference Meugge-Quote.pdf for quote.
Amount:
$2,952.92

Component Description:
Electrical work to hook up transmitter.
Amount:
$2,952.92
UHF - Liquid Cooled Solid State Transmitter 1.44 kW

Component Description:
Final Transmitter payment. Please reference change orders #Q-82871 and #Q-84737 in attachments.
Amount:
$55,443.79

Component Description:
Final Payment for transmitter to Gates Air, Inc.
Amount:
$55,443.79

Component Description:
1st of 3 payments.
Amount:
$43,826.76

Component Description:
Payment 2 of 3 to Gates Air for transmitter.
Amount:
$43,826.76

Component Description:
2nd of 3 payments.
Amount:
$43,826.76
UHF and VHF - minor banding issues Information not provided.
1.5 kW mask filter Information not provided.

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 $26,300.00 $30,029.95 N/A $0.00 N/A
Total for all systems $1,106,963.73 $1,119,259.59 N/A $837,436.93 N/A
Primary Antenna SWEDM16OI/16-EP $26,300.00 $30,029.95 $0.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic $26,300.00 $30,029.95 Cost for new antenna model number SWEDM16/16 EP. Please see Document in attachments named SWR Antenna Explanation of Costs for breakdown of costs and a list of quotes and documentation. $0.00 Please see attachment named SWR Explanation of Costs for documentation and explanation.

Components

Actual Information Description File Name
UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:
Cost for standard replacement antenna to replace what we had. Please reference the attachment named SWR Explanation of Costs for documentation.
Amount:
$30,029.95

Component Description:
New antenna for channel move. Model SWEDM16/16 EP, (CH. 16).
Amount:
$34,317.15

Component Description:
Shipping cost for antenna.
Amount:
$973.95

Cost Information

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Transmission Line

Information not provided.

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 $673,191.50 $696,691.20 N/A $681,547.70 N/A
Total for all systems $1,106,963.73 $1,119,259.59 N/A $837,436.93 N/A
Primary Tower GTOWER $673,191.50 $696,691.20 $681,547.70
Porta Potty $1,591.50 $1,591.50 N/A $575.00 N/A
Tall Tower (greater than 500') $210,500.00 $12,291.00 N/A $0.00 N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $26,300.00 $17,035.00 N/A $17,035.00 N/A
Brush clearing $13,800.00 $13,800.00 N/A $12,000.00 N/A
Major tower reinforcement/modifications $421,000.00 $651,973.70 This is the cost provided by Electronics Reasearch, Inc. Please reference the attached document named ERI Reinforcement Report for scope of work and document labeled ERI Quote for invoice #WDNI-36676B . $651,937.70 The original quote did not include tax, freight, or inclement weather delay charges.

Components

Actual Information Description File Name
Porta Potty

Component Description:
Porta Potty rental extension for tower crew.
Amount:
$225.00

Component Description:
Porta Potty was stolen from the site and we had to pay to replace the unit.
Amount:
$1,016.50

Component Description:
Total initial payment for porta potty rental for tower crew. Cover letter also attached,
Amount:
$350.00
Tall Tower (greater than 500')

Component Description:
Antenna Installation. Please see attachment named Mileage Cost Correction for Antenna Installation in the attachments for discrepancy.
Amount:
$12,291.00
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study

Component Description:
Design Analysis for tower by ERI. Reference quote file named ERI Agreement for Repack 2019 for reference.
Amount:
$4,250.00

Component Description:
Initial Structural Analysis. Please see attachment named 35-1083384 for the matching quote.
Amount:
$3,500.00

Component Description:
Geotech and foundation mapping by ERI. See quote file named ERI Agreement for Repack 2019 for refeerence.
Amount:
$9,285.00

Component Description:
Geotech and foundation mapping needed for Structural Analysis performed by ERI.
Amount:
$9,285.00

Component Description:
Initial structural analysis performed by ERI.
Amount:
$4,250.00
Brush clearing

Component Description:
Please see attachment named Brush_Clearing_Justification for clarification.
Amount:
$12,000.00

Component Description:
Quote OOO33 in attachments. Only $1800 for rut repair and seeding is for this item. Please see attachment named Rut Repair and Seeding Explanation.
Amount:
$1,800.00

Component Description:
Brush clearing of tower base and guy wire paths. Also leveling site for heavy equipment.
Amount:
$12,000.00
Major tower reinforcement/modifications

Component Description:
Payment 1 of 2 to ERI for tower reinforcement which represents 50% down as vendor has requested.
Amount:
$312,260.50

Component Description:
Payment 1 of 2 to ERI for tower reinforcement. Reference document ERI Quote for invoice #WDNI-36676B.pdf
Amount:
$312,260.50

Component Description:
Payment 2 of 2 to ERI for tower reinforcement. Cost includes tax and freight which were not in original quote.
Amount:
$320,177.20

Component Description:
Second payment to ERI for structural work to bring tower up to G standard. Cost includes tax and freight which were not in original quote.
Amount:
$320,177.20

Component Description:
Inclement weather delay for 4/7/21, 4/8/21, 4/9/21, 4/10/21, and 4/12/21 for ERI tower crew.
Amount:
$14,950.00

Component Description:
Inclement weather delay charge for tower crew on 3/15/21 and 3/18/21.
Amount:
$4,550.00

Component Description:
Inclement weather delay charge for tower crew on 4/7/21, 4/9/21, 4/10/21, and 4/12/21.
Amount:
$14,950.00

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 $135,960.00 $128,500.00 N/A $0.00 N/A
Total for all systems $1,106,963.73 $1,119,259.59 N/A $837,436.93 N/A
Outside Professional Services $135,960.00 $128,500.00 $0.00
RF Exposure Measurements $21,050.00 $20,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A N/A 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 $2,000.00 N/A $0.00 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A 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 $0.00 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
RF Exposure Measurements Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
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

Component Description:
Preparation and filing of Form 2100.
Amount:
$2,000.00
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

Component Description:
Preparation of engineering section of FCC form 2100.
Amount:
$2,000.00
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 $17,232.00 $12,399.00 N/A $9,839.00 N/A
Total for all systems $1,106,963.73 $1,119,259.59 N/A $837,436.93 N/A
Other Expenses $17,232.00 $12,399.00 $9,839.00
MVPD Notification of Channel Change $3,067.00 $3,067.00 This was the amount charged by the vendor for the notifications. $3,067.00 We outsourced this to DTV Notifications and this is what they charged for the service. Please see attachment named DTV INV 002274 Quote for reason for no attached quote. Please delete the component for the amount of $0.00 as it is a duplicate.
Develop and air announcement of upcoming channel change $250.00 $250.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $525.00 $525.00 N/A $0.00 N/A
Local Zoning $200.00 $200.00 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 $325.00 N/A N/A N/A
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,070.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $6,772.00 N/A $6,772.00 N/A

Components

Actual Information Description File Name
MVPD Notification of Channel Change

Component Description:
This was cost to notify all of the MVPDs as required. Please see attachment named DTV INV 002274 Quote for reason for no attached quote.
Amount:
$3,067.00

Component Description:
Please delete this line item as it was accidentally entered twice.
Amount:
N/A
Develop and air announcement of upcoming channel change Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value)

Component Description:
Dumpster is only the charges of $400 and the $125 daily rental amounts from this invoice. Reference quote in attachments named JPB Quote OOO33.
Amount:
$525.00

Component Description:
Dumpster Rental for trash from tower reinforcement and packaging. Cost to grade and reseed from ruts caused by dumpster.
Amount:
$3,120.00
Local Zoning Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
DTV Medical Facility Notification

Component Description:
This was the cost incurred to have the services performed. Refer to quote in attachments named DTV EST-001645.
Amount:
$6,772.00

Component Description:
Notification to Medical facilities as required.
Amount:
$6,772.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $1,106,963.73 $1,119,259.59 $837,436.93

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. Yes

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.

John Takach

Chief Engineer


04/06/2022

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.

John Takach

Chief Engineer


04/06/2022

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.

John Takach

Chief Engineer


04/06/2022

Attachments

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