TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
Gray Television Licensee, LLC	4370 Peachtree Road, NE Atlanta, GA 30319 United States	+1 (404) 266-8333	allfcclms@gray.tv	Limited Liability Company

Applicant

Address

Phone

Applicant Type

Gray Television Licensee, LLC

4370 Peachtree Road, NE

Atlanta, GA 30319

United States

+1 (404) 266-8333

allfcclms@gray.tv

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
Sam Hariton Widelity	4031 University Dr Suite 100 Fairfax, VA 22030 United States	+1 (339) 222-8107	sam.hariton@widelity.com

Applicant

Address

Phone

Sam Hariton

Widelity

4031 University Dr

Suite 100

Fairfax, VA 22030

United States

+1 (339) 222-8107

sam.hariton@widelity.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	We retuned current translator, replaced mask filter, replaced main transmit antenna and feedline. Also replaced receive antenna and feedline as it was channel specfic

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
	Is this transmitter currently shared with another station?	No
	Is this transmitter currently in operating condition?	Yes
Existing Transmitter Manufacturer and Type	Manufacturer	Axcera
	Model	CU500BRD
	Year	2007
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	500 W

Primary Transmitter

Retuning Transmitter Costs

Section	Question	Response
New Mask Filter	Does the transmitter require a new mask filter?	Yes
	Mask Filter Type	Stringent
	Power	350-600W
New Exciter	Is a new exciter needed?	No

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

Name	Description
Installation and checkout	Installation and test expenses

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?	No
Existing Antenna Manufacturer and Type
	Mounting	Side Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Slotted Coaxial
	ERP:	15.0 kW
	Manufacturer
	Model	DLP-8M
	Year	2007

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	Slotted Coaxial
	ERP:	15.0 kW
	Manufacturer
	Model	DLP-8M
	Year	2019
	Justification for New Antenna	The old antenna was the wrong channel and not able to function on new assignment

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

Name	Description
Installation	Installation of antenna
New Receive antenna	New receive antenna and feedline, connectors
Shipping	Freight to deliver antenna

Transmission Line

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

Primary Transmission Line

Existing Transmission Line

Section	Question	Response
Existing Transmission Line Description	Type of change	Purchase New
	Use	Primary (Main)
	Ownership	Owned
	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	Flexible Foam
	Diameter	7/8 inches
	Number of parallel runs	1
	Length	100 feet per run

Primary Transmission Line

New Transmission Line

Section	Question	Response
New Transmission Line Costs	Use	Primary (Main)
	Change Type	Purchase New
	Is this a request for upgraded equipment?	No
	Type	Flexible Foam
	Diameter	7/8 inches
	Number of parallel runs	1
	Length	100 feet per run
	Justification for New Transmission Line	New feedline line required due to age of line.
Interior RF Systems	Does the Installation of the Transmission Line require an additional or replacement Inside RF system including switching, patch panels, and dehydrators?	No

Primary Transmission Line

Other Transmission Line Expenses Not Listed

Name	Description
Jumpers	Jumpers to transmitter
Connectors	connectors for the end of the main line

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?	Yes
	Number of Hours	100
	Explanation	W26FB-D does not have sufficient resource capacity and expertise in house to handle all activities necessary for completion of the station's build by the construction deadline. W26FB-D will hire an outside firm to facilitate a timely transition.
Outside RF consulting Engineering Services	Perform engineering study for displacement application	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	No
	Prepare Form 601	Yes
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	No
	Negotiation of Lease and other Matter for Shared Locations	No
	Prepare or Review FCC Form 399 for Reimbursement	Yes
	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	Yes
	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
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

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	$14,950.00	$4,808.33	N/A	$0.00	N/A
Total for all systems	$56,345.50	$39,563.98	N/A	$11,318.15	N/A
Primary Transmitter CU500BRD	$14,950.00	$4,808.33		$0.00
Installation and checkout	$1,000.00	$1,000.00	N/A	N/A	N/A
Retune - UHF and VHF - minor re-channel issues	$11,000.00	$858.33	N/A	N/A	N/A
350-600W w mask filter Stringent	$2,950.00	$2,950.00	N/A	N/A	N/A

Components

Information not provided.

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	$14,838.00	$14,838.00	N/A	$7,408.00	N/A
Total for all systems	$56,345.50	$39,563.98	N/A	$11,318.15	N/A
Primary Antenna DLP-8M	$14,838.00	$14,838.00		$7,408.00
Shipping	$1,930.00	$1,930.00	N/A	$0.00	N/A
Installation	$3,000.00	$3,000.00	N/A	N/A	N/A
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal	$7,408.00	$7,408.00	N/A	$7,408.00	estimated cost
New Receive antenna	$2,500.00	$2,500.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Shipping	Component Description: resubmitted invoice Amount: N/A
Installation	Information not provided.
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Horizontal	Component Description: antenna and shipping Amount: $7,408.00
New Receive antenna	Information not provided.

Cost Information

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	$1,450.00	$1,450.00	N/A	$0.00	N/A
Total for all systems	$56,345.50	$39,563.98	N/A	$11,318.15	N/A
Primary Transmission Line	$1,450.00	$1,450.00		$0.00
Flexible Foam Transmission Line - dielectric, 7/8"	$1,100.00	$1,100.00	N/A	N/A	N/A
Jumpers	$100.00	$100.00	N/A	N/A	N/A
Connectors	$250.00	$250.00	N/A	N/A	N/A

Components

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	$23,572.50	$16,932.65	N/A	$3,910.15	N/A
Total for all systems	$56,345.50	$39,563.98	N/A	$11,318.15	N/A
Outside Professional Services	$23,572.50	$16,932.65		$3,910.15
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$1,577.50	$1,577.50	N/A	N/A	N/A
Prepare Form 601	$755.00	$755.00	N/A	N/A	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$3,025.00	$3,025.00	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,052.50	$1,052.50	N/A	N/A	N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$2,102.50	$2,102.50	N/A	N/A	N/A
Perform engineering study for displacement application	$1,800.00	$1,800.00	N/A	N/A	N/A
Form 399 assistance or other Program Management costs	$1,000.00	$1,000.00	N/A	N/A	N/A
Project management of the transition	$10,550.00	$3,910.15	Please see W26FB-D Project Management Budget Revision Justification Letter. The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time.	$3,910.15	N/A
Prepare/ Review 399 reimbursement form	$1,710.00	$1,710.00	N/A	N/A	N/A

Components

Actual Information Description	File Name
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Information not provided.
Prepare Form 601	Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	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 displacement application	Information not provided.
Form 399 assistance or other Program Management costs	Information not provided.
Project management of the transition	Component Description: Project Management Amount: $742.50 Component Description: Project Management Amount: $232.50 Component Description: Project Management Amount: $387.50 Component Description: Project Management Amount: $271.25 Component Description: Project Management Amount: $620.00 Component Description: Project Management Amount: $80.60 Component Description: Project Management Amount: $852.50 Component Description: Project Management Amount: $723.30
Prepare/ Review 399 reimbursement form	Information not provided.

Cost Information

Other Expenses

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

Description	Predetermined Cost Estimate	Estimated Cost	Estimated Cost Justification	Actual Cost	Actual Cost Justification
Sub-total	$1,535.00	$1,535.00	N/A	$0.00	N/A
Total for all systems	$56,345.50	$39,563.98	N/A	$11,318.15	N/A
Other Expenses	$1,535.00	$1,535.00		$0.00
FCC Filing Fees - Form 2100 license to cover application	$335.00	$335.00	N/A	N/A	N/A
Disposal Costs (for equipment and other waste, net of any salvage value)	$200.00	$200.00	N/A	N/A	N/A
Equipment Delivery and Handling Charges	$1,000.00	$1,000.00	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	$56,345.50	$39,563.98	$11,318.15

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.	Robert Folliard , III . Assistant Secretary 08/19/2022

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.

Robert Folliard , III .

Assistant Secretary

08/19/2022

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.	Robert Folliard , III . Assistant Secretary 08/19/2022

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.

Robert Folliard , III .

Assistant Secretary

08/19/2022

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.	Robert Folliard , III . Assistant Secretary 08/19/2022

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.

Robert Folliard , III .

Assistant Secretary

08/19/2022

(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

Primary Transmission Line

Existing Transmission Line

Primary Transmission Line

New Transmission Line

Primary Transmission Line

Other Transmission Line Expenses Not Listed

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

Components

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