Form DTV-5 Low-Power Television and Translator Upgrade Program Supp

Low-Power Television and Translator Upgrade Program

Supplemental Application Form

DTV-5 Form

Section A: OMB Control No. 0660-XXXX

Applicant/Licensee Information Expiration Date: XX-XX-2012

1. Applicant Name:
2._____ Check if the applicant licensee is a Non-Profit Corporation	Exhibit A: If the applicant is a Non-Profit Corporation, submit an IRS Letter or equivalent document showing the organization=s tax-exempt status. --Non-Profit Corporations receive 10 points for meeting one of the priority criteriaB
3. _____ Check if the applicant/licensee is organized under IRS 501(c)(4). By checking this item, applicant certifies that it engages in no lobbying activities.
4. Exhibit B: Sign and place the following forms in this Exhibit:
Standard Form 424B, AAssurances C Non-Construction Programs.@ This form is required from all applicants, in spite of the reference to Anon-construction@ programs, and must have an original signature on the second page.1
Department of Commerce Form CD-511, ACertification Regarding Lobbying.@ This form is required from all applicants and must have an original signature.
Standard Form LLL, ADisclosure of Lobbying Activities.@ This form is required from all applicants that employ lobbyists in an effort to obtain a grant.

Section B. Station/Site Specific Information Preliminary Site Score:__________

(Calculated after Sections A and B are completed)

1. Licensee Name_____[Pre-fill from SF 424]_____________________________________

First, complete 2(a), then enter data not automatically inserted from the FCC database	Analog Station	Digital Station
2. FCC Facility ID	(a)	(b)
3. Call Letters	(a)	(b)
4. Channel	(a)	(b)
5. ERP (effective radiated power)	(a) kW	(b) kW
6. FCC Status: (Select One)	A. Station license or STA issued and began broadcasting before February 8, 2006 B. Station CP or STA issued before February 8, 2006; began broadcasting after February 8, 2006 C. Station CP or STA issued after February 8, 2006	A. Station license or STA issued and began broadcasting before February 8, 2006 B. Station CP or STA issued before February 8, 2006; began broadcasting after February 8, 2006 C. Station CP or STA issued after February 8, 2006
7. Analog station: (select one)	A. Analog station currently broadcasting B. Analog had analog CP; built digital Flash-cut without building prior analog C. Analog station discontinued service after digital Flash-cut
8.(a) FCC Community of License________________________		(b) State_________
9. Geographic coordinates of analog transmission system [set default to N and W] (a) Latitude (b) Longitude _____ ______ ______ N/S _____ _____ _____ E/W
10. Type of Station (select one) A. Analog Translator B. Analog LPTV C. Analog Class A D. Analog Booster	11. Project Type (select one) A. Digital Flash Cut B. Digital Companion Channel
12.____ Check if any money was spent (obligated or placed down-payment) prior to February 8, 2006, to purchase grant eligible equipment to upgrade this station to digital.
Explain any changes you made to the computer generated information drawn from the FCC database.

13. Exhibit [call letters] - 1: Attach copies of the station=s most recent FCC analog and digital licenses, or STAs. Applicants that have modified an existing transmission system must submit a copy of their transmission system modification letter filed with the FCC pursuant to Sec. 74.796(b)(5) of the FCC Rules.

14. Exhibit [call letters] - 2: Attach the FCC=s analog Service Contour Map.

(The FCC Contour Map can be printed from the FCC= website: http://www.fcc.gov/mb/video/tvq.html). To print the FCC map, enter the station=s call sign; if there is more than one entry, select the entry that is licensed (LIC); then select the link-- Area: Service Contour Map and print.)

Population Information

15. Complete ONE of the following:	NTIA provided population figure: #________
____(a) Check here if the population in the station=s Coverage Contour area as provided by NTIA is fewer than 20,000. (If NTIA=s population data shows N/A- Not Available, use option 15(b).) BStations which cover fewer than 20,000 people receive 10 points based on eligibility.-- BStations which cover fewer than 10,000 people receive 10 additional points for meeting one of the priority criteria. Note: If the station=s coverage contour is predominantly in a large urban area (shown in yellow on the FCC=s coverage map), it may not qualify as Arural@ even if serves fewer than 20,000 people.
____(b) Check here if the population in the station=s Coverage Contour area as provided by NTIA is greater -than 20,000, but none of the counties shown on the FCC contour map contain an urban area greater than 20,000. Go to the website http://www.ers.usda.gov/Data/RuralUrbanContinuumCodes/2003/. If all the counties covered have a code of 6, 7, 8, or 9, enter the name of the county(ies) covered and the codes below: BStations which cover no urban areas greater than 20,000 people receive 10 eligibility points.--
	County Name	County Code
_____(c) Check here if the population in the station=s Coverage Contour area as provided by NTIA is greater than 20,000 and the counties shown on the FCC contour map contain an urban area greater than 20,000. Urban areas are shown in yellow on the FCC contour maps (http://www.fcc.gov/mb/video/tvq.html). Population data of urban areas can be found on the American Factfinder Web site http://factfinder.census.gov/home/saff/main.html?_lang=en). --Stations may receive between 6 and 9 points to reflect the degree of Rurality of the coverage areaB The Rurality Supplemental Form will calculate a Rurality Score for the station. Exhibit [call letters] - 3: Complete and Attach the Rurality Supplemental Form.
	Rurality Score forwarded from the accompanying Rurality Supplemental Form __________
_____(d) Check here if you wish to use another method to determine the population covered by the station. Explain how coverage was estimated. This estimated coverage contour population is subject to acceptance by NTIA. Exhibit [call letters] - 3: Attach your supporting documentation.

Section C: Equipment Request

16. Identify the ANALOG transmitter/translator
a) Manufacturer_________	(b) Model #_________	(c)________approximate year of purchase
d) Type (select one) ____1. Tube-type analog transmission system: Eligible for Replacement grant with $20,000 cap ____2. Solid State analog transmission system: Purchased after February 2006B Eligible for Modification grant with $6,000 cap ____3. Solid State analog transmission system: Purchased before February 2006 ____(i) Request Modification grant: ($6,000 cap) We were able to modify the analog transmission system to digital. ____(ii) Request Replacement grant: ($20,000 cap) We were not able to modify the analog transmission system to digital.
If you checked 3(i) or 3(ii): Describe your analog transmission system and discuss your ability or inability to modify the unit to digital in compliance with Section 74.796 of the FCC Rules. Applicants that have modified an existing transmission system must submit a copy of their transmission system modification letter filed with the FCC pursuant to Sec. 74.796(b)(5) of the FCC Rules.
17. Digital Equipment Reimbursement Request:
	Item	Cost

Exhibit 3 - Rurality Supplemental Form

Licensee_ [System Pre-fill]_____________________	Station Call Letters _[System Pre-fill]___	Community of License____[System Pre-fill]___________
	NTIA provided population figure:	#__System Pre-fill____ (A)
Enter the populations of urban areas greater than 20,000 (Areas shown in yellow on the FCC contour map)
Urban area	Pop. >20,000
(The application form will automatically calculate the Rurality score from this point)
Total population greater than 20,000	________ (B)
Rural Population (A minus B)	_________ (C)
Rural Percentage (C divided by A)	_________ (D)
Rurality Score (to be forwarded to question 15(C)	___________

For your information: The Rurality Score is based on the percentage of the population in the protected coverage area that is rural (i.e., not living within urban areas greater than 20,000). A station that covers an area 64% rural would receive a Rurality Score of 6. A station that covers an area 65% rural would receive a Rurality Score of 7. A station that covers an area 66% rural would also receive a Rurality Score of 7.

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.

1 Another Federal Standard Form, 424D AAssurances for Construction Programs,@ is used for projects to construct highways, airports, etc. and is not used by the Upgrade Program.

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