Form DTV-4 Low-Power Television and Translator Digital-to-Analog Co

NTIA Form # DTV-4 OMB Control No. 0660-XXXX

Expiration Date: XX-XX-XXXX

NTIA APPLICATION FORM

Low-Power Television and Translator

Digital-to-Analog Conversion Program

DRAFT 7/9/07

1. Applicant/Licensee__________________________________________________________________

Address______________________________________

Address______________________________________

City ______________ State _______ Zip________ County_______________

DUNS #______________________ EIN #______________________

Congressional District of Licensee____________ (this can only be one number)

Is applicant delinquent on Federal debt? __ yes ___ no

If yes, explain _________________________________________________

Is applicant is a non-profit corporation organized under IRS 501(c) [excluding (c)(4)]

__ yes ___ no

Type of Applicant [Enter One] ______

A. State B. County C. Municipal D. Township E. Interstate F. Intermunicipal G. Special District H. Independent School District

I. State Controlled Institution of Higher Learning J. Private University K. Indian Tribe L. Individual M. Profit Organization N. Non-Profit O. Other

Contact Name_________________________ Title________________________________

Email __________________________ Phone #__________________________

Applicants applying for the Digital-to-Analog Conversion Program, must complete sections 2 and 3, and are requested to complete optional section 4.

(If you are not applying for the Digital-to-Analog Conversion Program, but wish to provide information to assist NTIA in planning for the Digital Upgrade Program, please also complete sections 2 and 4).

2. Identify the Low-Power Television Station that is the subject of this application.

(Low power television stations, translators, Class A facilities and boosters)

a. Call letters___________ City of license__________ State_______ FCC facility number_______

b. Applicant Station receives corresponding full-power digital TV station (call letters)_____________

______ directly off-air, (conversion device will be co-located with Station transmission site)

______ pick-up at head end (conversion device will be located at head end)

________signal delivered to Station transmission site via Microwave (FCC #)___________

______ Full-power station signal delivered to Facilities Transmission site via analog translator in "Daisy Chain"

______ Full-power station signal delivered to Facilities Transmission site via Satellite

______ Full-power station signal delivered to Facilities Transmission site via other means

Explanation__________________________________________

c. The facility is licensed by the FCC. ______ yes ______ no

d. The facility filed an application for a license to cover on_______________[date].

e. The facility is broadcasting exclusively in analog, (has not activated a digital Companion Channel or digital Flash Cut). _______ yes ______no

f. The facility has not purchased a digital-to-analog conversion device prior to 2/08/2006.___yes ___no

g. The low-power station serves a rural area of less than 10,000 viewers (within the station’s

FCC 50/50 contour). Yes____________ No___________

3. Certification: The applicant certifies that the above information is true and that it will comply with the Department of Commerce Standard Terms and Conditions for grants, as applicable for this award, and the provisions set forth in the [insert date of] Federal Register Notice and Federal Funding Opportunity Notice regarding this program. Additionally, for each station for which funds are requested, the applicant certifies that the low-power station:

a. is licensed by the FCC, or has filed an application for license on as described above, and

b. is broadcasting exclusively in analog, [has not activated a Companion Channel or digital Flash Cut), and

c. did not purchase a digital-to-analog conversion device prior to February 8, 2006.

Signed_________________________________ Date_______________

4. Optional Information for future Digital Upgrade Program (upgrade transmission to digital)

a. Translator: model #________ power level of transmitter________

Age of transmitter___________ Tube_______ Solid State______

Is the translator capable of digital conversion? ______yes _____ no ___ do not know

What filters would be required? __________________ ____none ___ do not know

b. Transmit Antenna: model#________ # bays____________

Channel #___________ Planning to change to channel _________ N/A___

c. Site:

Any accessibility issues?_________________________________________________________

Any electrical limitations at site?___________________________________________________

Can the facility house a digital transmitter?___________________________________________

Has a study been done to determine what interference might be a concern for the site or the daisy chain, if applicable?_________ yes _____no _____do not think this is an issue

d. Located in a community of less than 20,000 inhabitants____ yes ____no

e. Serves a rural area of less than 10,000 viewers (within the station’s FCC 50/50 contour)___yes ___no.

f. Interested in applying for the §3009 program in the future. ___yes ____no ___do not know

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for

failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act (PRA), unless that

collection displays a currently valid Office of Management and Budget (OMB) Control Number.