TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
SOUTHWEST COLORADO TV TRANSLATOR ASSOCIATION Doing Business As: SOUTHWEST COLORADO TV TRANSLATOR ASSOCIATION	Wayne Johnson PO Box 1570 CORTEZ, CO 81321 United States	+1 (970) 565-2129	swcotv@frontier.net	Government Entity

Applicant

Address

Phone

Applicant Type

SOUTHWEST COLORADO TV TRANSLATOR ASSOCIATION

Doing Business As: SOUTHWEST COLORADO TV TRANSLATOR ASSOCIATION

Wayne Johnson

PO Box 1570

CORTEZ, CO 81321

United States

+1 (970) 565-2129

swcotv@frontier.net

Government Entity

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant	Address	Phone	Email
[Confidential]

Preparer Contact Information

Preparer Contact Name and Information

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

Broadcaster Information and Transition Plan

Question	Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information.	No
Briefly describe transition plan	awaiting final determination of eligibility for reimbursement to purchase equipment for the channel move. Upon approval will order equipment for channel change, then install, then submit for reimbursement.

Transmitters

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

Primary Transmitter

Existing Transmitter Information

Section	Question	Response
Existing Transmitter Description	Type of change	Purchase New
	Use	Primary (Main)
	Ownership	Owned
	Is this transmitter currently shared with another station?	No
	Is this transmitter currently in operating condition?	Yes
Existing Transmitter Manufacturer and Type	Manufacturer
	Model	mx-30
	Year	1994
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power Capacity	30 W

Primary Transmitter

New Transmitter Costs

Section	Question	Response
New Transmitter	Use	Primary (Main)
	Change Type	Purchase New
	Is this a request for upgraded equipment?	No
	Manufacturer
	Model	VAXT-200L-UC
	Transmitter Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	500 W
	Justification for New Transmitter	Larcan is no longer in business, also going from UHF to low band VHF. More power required for similar coverage.

Primary Transmitter

Other Transmitter Costs

Section	Question	Response
Other Transmitter Costs
Other Transmitter Costs	Does the transmitter installation require a Transmitter Building Site Survey/Installation?	No
Electrical Service	Service Entrance (3 phases 800A 208V)	No
	Switchgear (industrial 800 amp)	No
	Transformer (480V)	No
	Rigid Conduit and Wiring	No
	Other Electrical Service	No
HVAC Service	Does the replacement transmitter require HVAC Service?	No
Transmitter Building Addition/Modification or Leasehold Improvement	Does the Transmitter Building require an addition, modification, other leashold improvement?	No

Primary Transmitter

Other Transmitter Cost Not Listed

Information not provided.

Antennas

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

Primary Antenna

Existing Antenna Information

Section	Question	Response
Existing Antenna Description	Type of change	Purchase New
	Antenna Use	Primary (Main)
	Ownership	Owned
	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
	Mounting	Side Mount
	Antenna position in stack	Top
	Polarization	Horizontal
	Type	Other
	Other Antenna Type	paraflector
	ERP:	5.246 kW
	Manufacturer
	Model	paraflector
	Year	1992

Primary Antenna

New Antenna Costs

Section	Question	Response
New Antenna Description	Use	Primary (Main)
	Change Type	Purchase New
	Ownership	Owned
	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
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Yagi
	ERP:	500.0 W
	Manufacturer
	Model	CL-24HRM/50N
	Year	2019
	Justification for New Antenna	changing from UHF to low band VHF

Primary Antenna

Other Antenna Costs

Section	Question	Response
Elbow Complex	Do you require the separate purchase of the Elbow Complex?	No
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

Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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

Tower Equipment And Rigging Costs

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

Outside Professional Services Costs

Section	Question	Response
Outside Project Management Services	Do you require outside project management services?	No
Outside RF consulting Engineering Services	Perform engineering study for displacement application	No
	Prepare engineering section of Form FCC Construction Permit Application	No
	Prepare engineering section of Form FCC License to Cover Application	No
	Prepare request for Special Temporary Authority	No
	Prepare Form 601	No
Attorney and Other Outside Consulting Services	Prepare and file Form FCC Construction Permit Application	No
	Prepare and file Form FCC License to Cover Application	No
	Prepare request for Special Temporary Authority	No
	Negotiation of Lease and other Matter for Shared Locations	No
	Prepare or Review FCC Form 399 for Reimbursement	No
	Form 399 assistance or other program management costs	Yes
RF Field Engineering Services	Comprehensive coverage verification via field study	No
	RF exposure measurements	No
	Additional Field Engineering Service	No

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
Permit and Filing Costs	FCC Construction Permit Major Change	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)?	No
	Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs?	No
	Does this relocation require Equipment Storage?	No
Point to Point Microwave (STL/ICR)	Frequency Coordination for Unidirection System	No
	Frequency Coordination for Bi-Direction System	No
	New Point to Point Microwave System	No

Other Expenses

Other Expenses Not Listed

Name	Description
Output filter VHF	HR6P110A VHF low band 6 pole filter

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	$11,300.00	$10,735.00	N/A	$10,735.00	N/A
Total for all systems	$17,235.00	$17,795.46	N/A	$13,955.46	N/A
Primary Transmitter VAXT-200L-UC	$11,300.00	$10,735.00		$10,735.00
Low VHF - Air Cooled Solid State Transmitter 50 - 500 Watts	$11,300.00	$10,735.00	Actual cost VHF transmitter	$10,735.00	The antenna we thought we could use could not be retuned to channel 3 so we needed to purchase antenna

Components

Actual Information Description	File Name
Low VHF - Air Cooled Solid State Transmitter 50 - 500 Watts	Component Description: Transmitter Amount: $10,735.00 Component Description: CM for Transmitter Amount: ($11,705.83) Component Description: Transmitter and accessories Amount: $11,705.83 Component Description: Antenna for channel 3 thought I had one but would not retune to channel 3 Amount: N/A

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	$1,095.00	$2,220.46	N/A	$2,220.46	N/A
Total for all systems	$17,235.00	$17,795.46	N/A	$13,955.46	N/A
Primary Antenna CL-24HRM/50N	$1,095.00	$2,220.46		$2,220.46
Low-VHF, Low Power,Yagi/Cross dipole/Log Periodic Transmit antenna	$1,095.00	$2,220.46	Actual Cost.	$2,220.46	N/A

Components

Actual Information Description	File Name
Low-VHF, Low Power,Yagi/Cross dipole/Log Periodic Transmit antenna	Component Description: Combiner Amount: $698.75 Component Description: Antenna Ch 3 FI 61491 Amount: $1,521.71

Cost Information

Transmission Line

Information not provided.

Cost Information

Tower Equipment and Rigging Costs

Information not provided.

Cost Information

Outside Professional Services

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$1,000.00	$1,000.00	N/A	$1,000.00	N/A
Total for all systems	$17,235.00	$17,795.46	N/A	$13,955.46	N/A
Outside Professional Services	$1,000.00	$1,000.00		$1,000.00
Form 399 assistance or other Program Management costs	$1,000.00	$1,000.00	Assistance to correct 399 submission	$1,000.00	N/A

Components

Actual Information Description	File Name
Form 399 assistance or other Program Management costs	Component Description: 399 work Amount: $500.00 Component Description: 399 Review Amount: $500.00

Cost Information

Other Expenses

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$3,840.00	$3,840.00	N/A	$0.00	N/A
Total for all systems	$17,235.00	$17,795.46	N/A	$13,955.46	N/A
Other Expenses	$3,840.00	$3,840.00		$0.00
Output filter VHF	$3,840.00	$3,840.00	N/A	$0.00	N/A

Components

Information not provided.

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$17,235.00	$17,795.46	$13,955.46

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.	No

Certification

Section	Question	Response
Submission of Estimated Expenses Statements	WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.
The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD). The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Susan Hansen Consultant 09/04/2022

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.

Susan Hansen

Consultant

09/04/2022

Certification

Section	Question	Response
Submission of Actual Cost Documentation Statements	WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).
The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct. The above-named entity acknowledges that all certifications and attached documentation are considered material representations. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) . The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.
I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.	Susan Hansen Consultant 09/04/2022

Section

Question

Response

Submission of Actual Cost Documentation Statements

WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISIONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).

The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.
The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.
The above-named entity acknowledges that all certifications and attached documentation are considered material representations.
The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.
The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (full power and Class A stations) and/or otherwise modify a television station’s facility as a result of the spectrum repack (LPTV/TV Translator stations); or to minimize service disruption resulting from a repacked television station (FM stations); or to continue to carry the signal of a broadcaster that changes channels (MVPD) .
The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.
The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.
The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.
The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a prerequisite for obtaining the payments herein requested.

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

Susan Hansen

Consultant

09/04/2022

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.	Wayne Johnson Administrator 09/04/2022

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.

Wayne Johnson

Administrator

09/04/2022

(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

New Transmitter Costs

Primary Transmitter

Other Transmitter Costs

Primary Transmitter

Other Transmitter Cost Not Listed

Antennas

Primary Antenna

Existing Antenna Information

Primary Antenna

New Antenna Costs

Primary Antenna

Other Antenna Costs

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Tower Equipment And Rigging Costs

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

Cost Information

Outside Professional Services

Components

Cost Information

Other Expenses

Components

Cost Information

Grand Total

Reimbursement Status

Certification

Certification

Certification

Attachments