TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
NBC TELEMUNDO LICENSE LLC	Margaret L. Tobey 300 NEW JERSEY AVE, N.W. SUITE 700 WASHINGTON, DC 20001 United States	+1 (202) 524-6401	MARGARET.TOBEY@NBCUNI.COM	Limited Liability Company

Applicant

Address

Phone

Applicant Type

NBC TELEMUNDO LICENSE LLC

Margaret L. Tobey

300 NEW JERSEY AVE, N.W.

SUITE 700

WASHINGTON, DC 20001

United States

+1 (202) 524-6401

MARGARET.TOBEY@NBCUNI.COM

Limited Liability Company

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
Margaret L Tobey NBCUniversal, LLC	300 New Jersey Ave. NW Suite 700 Washington, DC 20001 United States	+1 (202) 524-6401	Margaret.Tobey@nbcuni.com

Applicant

Address

Phone

Margaret L Tobey

NBCUniversal, LLC

300 New Jersey Ave. NW

Suite 700

Washington, DC 20001

United States

+1 (202) 524-6401

Margaret.Tobey@nbcuni.com

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	Shutdown transmitter on current channel. Remove and replace antenna at the same location on the same tower. Tune transmitter and filter to the new channel. Resume broadcasting after channel change is complete.

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	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	GatesAir
	Model	UAXT-1AT
	Year	2015
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	0.9 kW

Primary Transmitter

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

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

Name	Description
Retune and test transmitter	Rechannel transmitter and perform proof of performance testing with retuned filter.

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?	Yes
	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	ALP16 SPECIAL PATTERN
	Year	1999

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?	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?	Yes
New Antenna Manufacturer and Types	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/Bays	N/A
	Lower Limit	N/A
	Upper Limit	N/A
	Design power capacity in use	N/A
	Other Antenna Type	N/A
	ERP:	5.5 kW
	Manufacturer
	Model	TLP-16P (SP)-R
	Year	2018
	Justification for New Antenna	Existing antenna is a slot antenna built for channel 50 that cannot be used on the new channel 21.

Primary Antenna

Other Antenna Costs

Section	Question	Response
Combiner for Shared Antenna	Do you need a Combiner for a Shared Antenna?
	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?	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?	No

Primary Antenna

Other Antenna Cost Not Listed

Name	Description
Antenna Installation	Antenna Installation

Transmission Line

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

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	Modify Existing
	Tower Use	Primary (Main)
	Description of Use	N/A
	Ownership	Leased
	Is this tower consider Complex?
	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?	No
	Is tower compliant with Rev G?	Unknown
Existing Tower Structure Registration	Do you have a tower registration number?	No
Existing Tower Structure Registration	ASR Number
Coordinates (NAD83)	Latitude (NAD83)	40° 39' 36.7" N-
	Longitude (NAD83)	112° 12' 07.7" W-
	Overall Structure Height	152.90 feet
	Support Structure Height	152.90 feet
	Ground Elevation Above Mean Sea Level (AMSL)	9019.00 feet
	Structure Type	LTOWER - Lattice Tower
	Tower Owner	KSL
	Date Constructed	06/01/1999

Primary Tower

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:	No reinforcements needed

Primary Tower

Tower Rigging Costs

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

Primary Tower

Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	Yes
	Number of Hours	13
	Explanation	Establishment of project plan and timeline, and coordination with vendors to perform work.
Outside RF consulting Engineering Services	Perform engineering study for new channel assignment and antenna development	No
	Prepare engineering section of Form FCC Construction Permit Application	No
	For Auxiliary Facility	N/A
	For Main Facility	N/A
	Prepare engineering section of Form FCC License to Cover Application	No
	For Auxiliary Facility	N/A
	For Main Facility	N/A
	Prepare request for Special Temporary Authority	No
	Quantity	N/A
	Do you have Distributed Transmission System engineering services?	N/A
	Critical Facility	N/A
	Terrain-Shielded Facility	N/A
Attorney and Other Outside Consulting Services	Prepare and file Form FCC Construction Permit Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare and file Form FCC License to Cover Application	Yes
	For Auxiliary Facility	No
	For Main Facility	Yes
	Prepare request for Special Temporary Authority	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	No
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

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	No
	BLM or NFS Coordination	No
	FCC Construction Permit Minor Change	No
	FCC License to Cover Application	No
	FCC Special Temporary Authority Application	No
Other Miscellaneous Expenses	Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)?	Yes
	Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs?	Yes
	Does this relocation require Equipment Storage?	No
	Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change?	Yes
	Does this relocation require MVPD Notification of a Channel Change?	Yes

Other Expenses

Other Expenses Not Listed

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	$124,480.00	$21,120.59	N/A	$18,320.59	N/A
Total for all systems	$865,860.77	$360,148.61	N/A	$184,046.52	N/A
Primary Transmitter UAXT-1AT	$124,480.00	$21,120.59		$18,320.59
1.5 kW mask filter	$3,030.00	$4,870.59	Cost for Mask Filter	$2,070.59	N/A
UHF and VHF - minor banding issues	$105,200.00	$0.00	N/A	$0.00	N/A
Retune and test transmitter	$16,250.00	$16,250.00	See attached quote "KEJT Electron Dynamics Proposal". Includes changing transmitter to new channel, retune existing filter if possible or install new filter if not, full test and proof of performance of transmitter on new channel.	$16,250.00	N/A

Components

Actual Information Description	File Name
1.5 kW mask filter	Component Description: Filter Tuned pack Amount: $2,070.59 Component Description: 6PPXX110E FILTER TUNED PACK 7 -16S DIN FEMALE CONNECTOR Amount: $2,070.59
UHF and VHF - minor banding issues	Information not provided.
Retune and test transmitter	Component Description: KEJT Repack Transmitter/Filter Retuning, New Antenna Testing and FCC Proof Amount: $16,250.00

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	$141,734.00	$161,212.25	N/A	$109,418.25	N/A
Total for all systems	$865,860.77	$360,148.61	N/A	$184,046.52	N/A
Primary Antenna TLP-16P (SP)-R	$141,734.00	$161,212.25		$109,418.25
Antenna Installation	$115,434.00	$115,434.00	N/A	$63,640.00	N/A
UHF - Lower Power Side Mount, Class A One Station antenna -- basic	$26,300.00	$45,778.25	Includes antenna and custom side mount brackets. See attached quote	$45,778.25	N/A

Components

Actual Information Description	File Name
Antenna Installation	Component Description: Antenna Reconstruction - Drone Service for Installation Amount: $20,366.00 Component Description: Install KEJT new TX line & ice sheild Amount: $6,000.00 Component Description: KEJT JTD invoice for 50% of Antenna Install Amount: $28,820.00 Component Description: Drone Service for Antenna Installation Amount: $20,366.00 Component Description: Wrong category Amount: N/A Component Description: Labor for Installing KEJT new TX line & ice shield Amount: $6,000.00 Component Description: KEJT- JTD invoice for 50% of Antenna Install Amount: $28,820.00
UHF - Lower Power Side Mount, Class A One Station antenna -- basic	Component Description: KEJT - Dielectric invoice for Antenna Mount brackets Amount: $8,606.00 Component Description: Lower power Antenna cost- side mount Amount: $37,172.25 Component Description: KEJT - Dielectric invoice for Antenna Amount: $37,172.25

Actual Information Description

File Name

Antenna Installation

Component Description:: Antenna Reconstruction - Drone Service for Installation
Amount:: $20,366.00

Component Description:: Install KEJT new TX line & ice sheild
Amount:: $6,000.00

Component Description:: KEJT JTD invoice for 50% of Antenna Install
Amount:: $28,820.00

Component Description:: Drone Service for Antenna Installation
Amount:: $20,366.00

Component Description:: Wrong category
Amount:: N/A

Component Description:: Labor for Installing KEJT new TX line & ice shield
Amount:: $6,000.00

Component Description:: KEJT- JTD invoice for 50% of Antenna Install
Amount:: $28,820.00

UHF - Lower Power Side Mount, Class A One Station antenna -- basic

Component Description:: KEJT - Dielectric invoice for Antenna Mount brackets
Amount:: $8,606.00

Component Description:: Lower power Antenna cost- side mount
Amount:: $37,172.25

Component Description:: KEJT - Dielectric invoice for Antenna
Amount:: $37,172.25

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	$447,300.00	$77,640.00	N/A	$0.00	N/A
Total for all systems	$865,860.77	$360,148.61	N/A	$184,046.52	N/A
Primary Tower LTOWER	$447,300.00	$77,640.00		$0.00
Complex Tower (includes, for example, those with candelabras and/or stacked antennas)	$421,000.00	$52,640.00	See Western Infrastructure Services spreadsheet - quote for removal and installation of new antenna on short tower.	$0.00	N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study	$26,300.00	$25,000.00	See attached estimate spreadsheet from Wireless Infrastructure Services	$0.00	N/A

Components

Actual Information Description	File Name
Complex Tower (includes, for example, those with candelabras and/or stacked antennas)	Component Description: Tower equipment and rigging Amount: $26,320.00 Component Description: Tower and rigging short tower -installation work was already reimbursed (JTD Consulting in-voices 46055 and 46304) Amount: ($26,320.00)
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study	Information not provided.

Cost Information

Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$121,239.00	$78,618.00	N/A	$47,913.31	N/A
Total for all systems	$865,860.77	$360,148.61	N/A	$184,046.52	N/A
Outside Professional Services	$121,239.00	$78,618.00		$47,913.31
Comprehensive coverage verification via field study, if needed	$84,200.00	$40,732.00	Filed Survey Study	$40,732.00	N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization	$3,680.00	$3,500.00	N/A	$1,033.40	N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$2,365.00	$2,250.00	N/A	$87.30	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$5,260.00	$5,000.00	N/A	$1,070.10	N/A
Prepare and or review reimbursement form	$2,630.00	$2,500.00	N/A	$354.51	N/A
Project management of the transition	$2,054.00	$4,636.00	Planning for transition and coordinating with vendors to perform work.	$4,636.00	N/A
RF Exposure Measurements	$21,050.00	$20,000.00	N/A	$0.00	N/A

Components

Actual Information Description	File Name
Comprehensive coverage verification via field study, if needed	Component Description: Field survey Study/Strength measurement- Deposit Revised Amount: $20,366.00 Component Description: Final Payment- Field survey/Measurement Amount: $20,366.00 Component Description: Field survey and measurement- Deposit Amount: $20,366.00
Attorney Fees - Prepare and File request for Special Temporary Authorization	Component Description: Attorney Fees for Station KEJT Amount: $1,033.40
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Component Description: Attorney Fees for Station KEJT- Revised Amount: $87.30
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	Component Description: Attorney Fees for Station KEJT Amount: $43.65 Component Description: Attorney Fees for Station KEJT Amount: $43.65 Component Description: Preparation of minor change application for post-repack facility. Amount: $264.60 Component Description: See lines 1, 2, and half of the cost of line 3, less 10% vendor discount. Amount: $718.20
Prepare and or review reimbursement form	Component Description: Review of Form 399 Amount: $43.65 Component Description: See half of line 3 and all of line 4, less 10% vendor discount. Amount: $310.86
Project management of the transition	Component Description: project management services Amount: $2,145.00 Component Description: project management services Amount: $348.95 Component Description: July 2018 Project Management Amount: $1,001.18 Component Description: August 2018 Project Management and Travel Amount: $1,140.87
RF Exposure Measurements	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	$31,107.77	$21,557.77	N/A	$8,394.37	N/A
Total for all systems	$865,860.77	$360,148.61	N/A	$184,046.52	N/A
Other Expenses	$31,107.77	$21,557.77		$8,394.37
MVPD Notification of Channel Change	$5,000.00	$5,000.00	Estimate until final costs are known	N/A	N/A
Develop and air announcement of upcoming channel change	$1,500.00	$1,500.00	Estimate until final costs are known	N/A	N/A
Equipment Delivery and Handling Charges	$8,557.77	$8,557.77	See spreadsheet from Wireless Infrastructure Services	$6,394.37	N/A
Disposal Costs (for equipment and other waste, net of any salvage value)	$4,500.00	$4,500.00	See spreadsheet from Western Infrastructure Services	N/A	N/A
DTV Medical Facility Notification	$11,550.00	$2,000.00	See attached quote "KEJT RF Notifications Quote"	$2,000.00	N/A

Components

Actual Information Description	File Name
MVPD Notification of Channel Change	Information not provided.
Develop and air announcement of upcoming channel change	Information not provided.
Equipment Delivery and Handling Charges	Component Description: Only Total line haul expenses are requested for the payment. Amount: $6,394.37 Component Description: Total Line Haul and fuel surcharge Amount: $8,557.77
Disposal Costs (for equipment and other waste, net of any salvage value)	Information not provided.
DTV Medical Facility Notification	Component Description: Medical Notification Mailing Amount: $2,000.00

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$865,860.77	$360,148.61	$184,046.52

Reimbursement Status

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

Certification

Section	Question	Response
Submission of Estimated Expenses Statements	WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.
The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD). The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Margaret L. Tobey Assistant Secretary 05/12/2022

Section

Question

Response

Submission of Estimated Expenses Statements

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.

The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.
The above-named entity acknowledges that all certifications and attached documentation are considered material representations.
The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.
The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).
The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.
The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.
The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.
The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Margaret L. Tobey

Assistant Secretary

05/12/2022

Certification

Section	Question	Response
Submission of Final Allocation or Accounting Information Statements	WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.
The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Margaret L. Tobey Assistant Secretary 05/12/2022

Section

Question

Response

Submission of Final Allocation or Accounting Information Statements

The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.
The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.
The above-named entity certifies that all costs identified as "actual costs" herein accurately represent the costs actually paid by the above-named entity, including any discounts, refunds, or rebates.
The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.
The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.
The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Margaret L. Tobey

Assistant Secretary

05/12/2022

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

Applicant Information

Applicant Name, Type, and Contact Information

Reimbursement Contact Information

Reimbursement Contact Name and Information

Preparer Contact Information

Preparer Contact Name and Information

Broadcaster Information and Transition Plan

Transmitters

Primary Transmitter

Existing Transmitter Information

Primary Transmitter

Retuning 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 Modification Costs

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