TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
theDove Media, Inc. Applicant	theDove Media, Inc. 2070 MILLIGAN WAY MEDFORD, OR 97504 United States	+1 (541) 776-5368	PATKINSON@THEDOVE.US	Other

Applicant

Address

Phone

Applicant Type

theDove Media, Inc.

Applicant

theDove Media, Inc.

2070 MILLIGAN WAY

MEDFORD, OR 97504

United States

+1 (541) 776-5368

PATKINSON@THEDOVE.US

Other

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.	Yes
Briefly describe transition plan	Filed for and construction permit granted for channel 16 as a displacement channel for channel 44. Completed November 20, 2018.

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	UAXTE-1-C
	Year	2018
	Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power Capacity	200 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	UAXTE-1P-C
	Transmitter Type	Solid State
	Solid State Cooling	Air Cooled
	Solid State Power capacity	200 W
	Justification for New Transmitter	Different power requirements from FCC construction permit.

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
Gates Air Filter System	Mask filter system- $4,317.33

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?	Yes
	Is the existing antenna directional?	No
	Is antenna in operating condition?	Yes
	Is antenna located on or in close proximity to an antenna farm?	Yes
Existing Antenna Manufacturer and Type
	Mounting	Top Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Other
	Other Antenna Type	super turnstile
	ERP:	1.45 kW
	Manufacturer
	Model	750 10272 UHF
	Year	2018

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Facility ID	Call Sign
129254	KDOV-LD

Primary Antenna

New Antenna Costs

Section	Question	Response
New Antenna Description	Use	Primary (Main)
	Change Type	Purchase New
	Ownership	Owned
	Is antenna shared?	Yes
	Is antenna directional?	No
	Will antenna be located on or in close proximity to an antenna farm?	Yes
New Antenna Manufacturer and Types
	Mounting	Top Mount
	Antenna position in stack	Not in Stack
	Polarization	Horizontal
	Type	Other
	Other Antenna Type	super turnstile
	ERP:	1.45 kW
	Manufacturer
	Model	750 10272 UHF
	Year	2018
	Justification for New Antenna	New construction

Primary Antenna

Other Antenna Costs

Section	Question	Response
Combiner for Shared Antenna	Do you need a Combiner for a Shared Antenna?	Yes
	Type	New
	Number of channels supported	2
	Frequencies of channels supported	RF channel
Elbow Complex	Do you require the separate purchase of the Elbow Complex?	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

Enter a list of RF channel numbers.

RF Channel Number
18
16

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?	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?	Yes
	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	65 feet per run

Facility ID's and Call Signs of all stations with whom the transmission line is shared.

Facility ID	Call Sign
129254	KDOV-LD

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	80 feet per run
	Justification for New Transmission Line	new construction
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
back ordered items	hangers and ground kits etc.

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)
	Ownership	Leased
	Is this tower consider Complex?	No
	Is this tower currently shared with any other stations?	No
	Is tower documented for structural analysis?	Unknown
	Is tower compliant with Rev G?	Unknown
Existing Tower Structure Registration	Do you have a tower registration number?	No
Coordinates (NAD83)	Latitude (NAD83)	42° 17' 51.4" N-
	Longitude (NAD83)	122° 45' 04.1" W-
	Overall Structure Height	42.60 feet
	Support Structure Height	42.60 feet
	Ground Elevation Above Mean Sea Level (AMSL)	3799.00 feet
	Structure Type	TOWER - Free Standing or Guyed Structure
	Tower Owner	American Tower
	Date Constructed	07/20/2014

Primary Tower

Tower Modification Costs

Section	Question	Response
Engineering Study	Please what type of engineering study is required, if any:	No study needed
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	N/A
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?	No
Outside RF consulting Engineering Services	Perform engineering study for displacement application	Yes
	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	Yes
	Quantity	2
	Prepare Form 601	No
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	2
	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	No
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

Name	Description
Cohn and Marks LLP	FCC attorney legal expenses

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
Freight	shipping for transmitter

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	$28,403.30	$21,378.30	N/A	$21,378.30	N/A
Total for all systems	$113,552.73	$46,184.39	N/A	$43,996.39	N/A
Primary Transmitter UAXTE-1P-C	$28,403.30	$21,378.30		$21,378.30
Gates Air Filter System	$4,103.30	$4,103.30	readjusted request for mask filter. explanation emailed to FCC reimbursement team.	$4,103.30	Removing request for Mask Filter System per your Ref: MSG4987182 Requesting reimbursement for cost of mask filter system only. quote attached. Original requests was $4317.33 We will not now or in the future request the balance of this charge.
UHF - Air Cooled Solid State Transmitter 160 - 300 Watts	$24,300.00	$17,275.00	N/A	$17,275.00	Transmitter

Components

Actual Information Description	File Name
Gates Air Filter System	Component Description: Mask Filter system Amount: N/A Component Description: Mask filter with explanation of requested amount vs. invoiced amount. Amount: $4,103.30 Component Description: Mask filter system cost is under RF Accessories. explanation attached with invoice and quote description. A 2nd letter of explanation is included explaining the reason for the reimbursement amounts requested. Amount: $4,103.30
UHF - Air Cooled Solid State Transmitter 160 - 300 Watts	Component Description: see letter of explanation attached to invoice. 1- Transmitter Amount: $17,275.00 Component Description: Transmitter. We will not request now or in the future the remaining $17275. We have requested $4,103. shown on this invoice in another portion of form 399. Amount: $17,275.00

Actual Information Description

File Name

Gates Air Filter System

Component Description:: Mask Filter system
Amount:: N/A

Component Description:: Mask filter with explanation of requested amount vs. invoiced amount.
Amount:: $4,103.30

Component Description:: Mask filter system cost is under RF Accessories. explanation attached with invoice and quote description. A 2nd letter of explanation is included explaining the reason for the reimbursement amounts requested.
Amount:: $4,103.30

UHF - Air Cooled Solid State Transmitter 160 - 300 Watts

Component Description:: see letter of explanation attached to invoice. 1- Transmitter
Amount:: $17,275.00

Component Description:: Transmitter. We will not request now or in the future the remaining $17275. We have requested $4,103. shown on this invoice in another portion of form 399.
Amount:: $17,275.00

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	$5,102.00	$5,102.00	N/A	$5,102.00	N/A
Total for all systems	$113,552.73	$46,184.39	N/A	$43,996.39	N/A
Primary Antenna 750 10272 UHF	$5,102.00	$5,102.00		$5,102.00
UHF-Low Power, Top Mount, Other, 1.45kW input, Horizontal	$5,102.00	$5,102.00	Broadcast antenna	$5,102.00	N/A

Components

Actual Information Description	File Name
UHF-Low Power, Top Mount, Other, 1.45kW input, Horizontal	Component Description: Scala UHF Super turnstile antenna, 470-862MHZ, 7.5 DBD Gain, Horiz.Pol 1KW Max PWR, 7-16 DIN F Input Scala Mounting Kit for super turnstile antenna Freight Amount: $5,102.00

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	$1,009.93	$789.59	N/A	$789.59	N/A
Total for all systems	$113,552.73	$46,184.39	N/A	$43,996.39	N/A
Primary Transmission Line	$1,009.93	$789.59		$789.59
Flexible Foam Transmission Line - dielectric, 7/8"	$880.00	$659.66	N/A	$659.66	N/A
back ordered items	$129.93	$129.93	N/A	$129.93	N/A

Components

Actual Information Description	File Name
Flexible Foam Transmission Line - dielectric, 7/8"	Component Description: connectors and tool Amount: $57.49 Component Description: transmission line Amount: $602.17
back ordered items	Component Description: back ordered items Amount: $129.93

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	$56,190.00	$750.00	N/A	$750.00	N/A
Total for all systems	$113,552.73	$46,184.39	N/A	$43,996.39	N/A
Primary Tower TOWER	$56,190.00	$750.00		$750.00
Tower Rigging Short Tower (less than 500')	$56,190.00	$750.00	N/A	$750.00	N/A

Components

Actual Information Description	File Name
Tower Rigging Short Tower (less than 500')	Component Description: tower rigging Amount: $750.00

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	$21,647.50	$16,964.50	N/A	$14,776.50	N/A
Total for all systems	$113,552.73	$46,184.39	N/A	$43,996.39	N/A
Outside Professional Services	$21,647.50	$16,964.50		$14,776.50
Cohn and Marks LLP	$950.00	$950.00	FCC attorney legal expenses	$475.00	N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization	$4,470.00	$1,095.50	N/A	$1,092.50	We need to remove component and charge of $2,235.50 from this line item.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	$1,577.50	$921.50	N/A	$921.50	N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	$3,025.00	$2,375.00	N/A	$2,375.00	Corrected cover letter with correct invoice amount in the letter text.
Prepare request for Special Temporary Authorization	$2,560.00	$2,422.50	N/A	$2,422.50	There are multiple costs on one invoice. there is an explanation summary attached to the pdf file for invoice # 1015856.
Perform engineering study for displacement application	$1,800.00	$1,935.00	invoices don't match components on this form we've combined all engineering study invoices	$1,935.00	N/A
Prepare/ Review 399 reimbursement form	$1,710.00	$1,710.00	N/A	N/A	N/A
Consulting Engineer	$5,555.00	$5,555.00	*System Notice: Estimate adjusted and locked because line has been superseded.*	$5,555.00	N/A

Components

Actual Information Description	File Name
Cohn and Marks LLP	Component Description: correspondence re auction closing and channel reassignment PN. We will not be requesting the remaining balance of this invoice now or in the future. Amount: $118.75 Component Description: correspondence regarding deadline on post-auction progress reports. Amount: $237.50 Component Description: correspondence re displacement and post auction applications. Reduced requested reimbursement amount. removed request for item on 5/18/17. Letter of explanation included with invoice Amount: $475.00 Component Description: correspondence re PN freezing filing minor change applications Amount: $118.75
Attorney Fees - Prepare and File request for Special Temporary Authorization	Component Description: STA Prep with letter of explanation for multiple charges on invoice. Amount: $2,235.50 Component Description: sta prep. This invoices has charges that do not relate to KDSO-LD. We will not be requesting the remaining balance of the invoice. Amount: $1,092.50
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application	Component Description: Displacement application prep with letter of explanation for multiple charges on invoice. Amount: $522.50 Component Description: displacement application prep and correspondence with engineers Amount: $522.50 Component Description: license application prep Amount: $399.00
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application	Component Description: FCC Attorney prep for displacement CP. moved this item from the incorrect line item. Amount: $2,232.50 Component Description: construction permit prep with letter of explanation for multiple charges on invoice. Amount: $142.50 Component Description: construction permit prep with letter of explanation for multiple charges on invoice. Amount: $142.50 Component Description: form 2100 prep Amount: N/A Component Description: FCC Attorney prep for displacement CP. moved this item from the incorrect line item. Amount: $2,232.50
Prepare request for Special Temporary Authorization	Component Description: Email re: FCC PN Lifting freeze on minor modifications to LPTV CP Amount: $142.50 Component Description: sta prep Amount: N/A Component Description: Review Ch. 16 displacement CP new letter of explanation of charges included with invoice. Amount: $2,232.50 Component Description: Ch. 16 displacement application filing Amount: $522.50 Component Description: Ch. 16 displacement application filing Amount: $522.50 Component Description: STA prep with letter of explanation for multiple charges on invoice. Amount: $2,422.50 Component Description: STA prep with letter of explanation for multiple charges on invoice. Amount: $2,422.50
Perform engineering study for displacement application	Component Description: Displacement study, app & STA request Amount: $1,575.00 Component Description: ch 16 license app. The attached invoice shows license application charges for two stations. We are only requesting reimbursement for one station so we will not be requesting the remaining balance of invoice 46256 for $180. Amount: $180.00 Component Description: ch 16 app for conflicts Amount: $120.00 Component Description: amendment with letter of explanation and consultation fee. We will not be requesting the balance for the remaining charge of $60 as it is not for KDSO-LD. Amount: $60.00
Prepare/ Review 399 reimbursement form	Information not provided.
Consulting Engineer	Component Description: transmitter consultant and expenses with correct expense invoice not quote. Rick Carrara is a sole practitioner. Amount: $1,682.73 Component Description: Transmitter consultant and expenses Amount: $1,593.71 Component Description: Transmitter consultant-Rick Carrara is a contract engineer. He is a sole practitioner. Amount: $500.00 Component Description: Transmitter consultant and expenses-revised invoice fixing clerical error and Valmont invoice is attached for freight only expense. The pipe mount was expensed on Sept. 2018 invoice. Additional letters of explanation are attached with the invoice. Amount: $1,778.56

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	$1,200.00	$1,200.00	N/A	$1,200.00	N/A
Total for all systems	$113,552.73	$46,184.39	N/A	$43,996.39	N/A
Other Expenses	$1,200.00	$1,200.00		$1,200.00
Freight	$1,200.00	$1,200.00	N/A	$1,200.00	N/A

Components

Actual Information Description	File Name
Freight	Component Description: Freight for transmitter for KDSO-LD, please note order number referenced is order # from transmitter invoice. Amount: $1,200.00 Component Description: freight for transmitter Amount: $1,200.00

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$113,552.73	$46,184.39	$43,996.39

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.	Perry Atkinson President/CEO 10/14/2022

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.

Perry Atkinson

President/CEO

10/14/2022

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.	Perry Atkinson President/CEO 10/14/2022

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.

Perry Atkinson

President/CEO

10/14/2022

(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

Facility ID's and Call Signs of all stations with whom the antenna is shared.

Primary Antenna

New Antenna Costs

Primary Antenna

Other Antenna Costs

Enter a list of RF channel numbers.

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Primary Transmission Line

Existing Transmission Line

Facility ID's and Call Signs of all stations with whom the transmission line is shared.

Primary Transmission Line

New Transmission Line

Primary Transmission Line

Other Transmission Line Expenses Not Listed

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

Components

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