Form FCC Form 2100, Sch FCC Form 2100, Sch TV Broadcaster Relocation Fund Reimbursement Form

OMB Control Number: 3060-1178

Not Yet Approved by OMB

Estimated Time Per Response: 1 – 4 hours

TV Broadcaster Relocation Fund Reimbursement Form

FCC Form 2100, Schedule 399

Automatically generates from LMS (based on Facility ID)/COALS (based on COALS ID):

Legal name of Entity

DBA (doing business as) name, if applicable

Address (Street, City, State, Zip)

Phone Number

(if incorrect, correct in LMS/COALS)

Section I – Application Type

1. Type of Entity (automatically determined based on point of entry to system)

• MVPD

  • Type of MVPD (Cable Operator / DBS/Other)

• Broadcaster

  

  • Facility ID Number {numeric entry}

2. Type of Submission (automatically determine based on questions answered)

• Eligibility Certification for LPTV/TV Translator and FM Stations
  
  

• Estimated Costs
  
  

• Submission of Actual Costs with Documentation
  
  

• Final Reimbursement Submission

Section II – Contact Information

1. Is the prefilled information correct? {yes / no->direct to correct in LMS/COALS}

2. Identify the CORES address to be used for reimbursement payments (select from CORES addresses) (all CORES addresses with valid banking information will appear)

3. Reimbursement Contact Information (all fields required)

Same as CORES address

New Contact

Contact Name {text}

Contact Title {text}

Street Address {text}

City, State Zip Code {text}

Contact Telephone Number {text}

Contact E-mail address {text}

4. FCC Registration Number (FRN) (filled from login)

5. Form Preparer Contact Information {complete all fields}

Same as CORES contact

Same as Reimbursement contact

New contact

Contact Name {text}

Contact Title {text}

Contact Company{text}

Street Address {text}

City, State Zip Code {text}

Contact Telephone Number {text}

Contact E-mail address {text}

(LPTV/TV Translators and FM Broadcasters¹ Proceed to Section III, Full Power/Class A DTV Broadcasters² Proceed to Section IV, MVPDs Proceed to Section V)

Section III – Certification of Eligibility for LPTV/TV Translator and FM Stations

This section to be completed by Licensees of LPTV/TV Translator and FM Stations potentially eligible for reimbursement under provisions of the 2018 Reimbursement Expansion Act

1. LPTV/TV Translator Eligibility
   
   

   1. Enter LMS File Number of Granted Displacement Construction Permit: {text field, dropdown selection of appropriate file numbers}

      1. If no LMS File Number is provided, has Licensee completed the Station’s Construction Permit and filed the License to Cover {text field, dropdown selection}
         
         

   2. Licensee certifies the following:

1. The Station was licensed or had an application for license (FCC Form 2100 Schedule D) pending on April 13, 2017. [Yes checkbox]

2. The Station was licensed and transmitting for not less than 2 hours in each day of the week and not less than a total of 28 hours per calendar week for 9 of the 12 months prior to April 13, 2017. [Yes checkbox]

1. Licensee has attached true copies of documents or other evidence that demonstrate the Station’s operation as described in Section III.1.b.ii. [Yes checkbox] and [Place to attach files]

3. Licensee is not requesting reimbursement from the Fund for payments previously received or expected to be received from the Fund or for reimbursement of expenses paid or expected to be paid by any other source. [Yes checkbox]

2. FM Eligibility (Complete if Service Code is one of those listed above)
   
   

   1. Indicate Facility ID number of repacked full power or Class A television station(s) causing FM Facility to incur costs as a result of the reorganization of broadcast television spectrum: {list of facility identification numbers}
      
      

   2. Licensee certifies the following:

1. Licensee was licensed or had an application for license (FCC Form 302, 319, 350) pending on April 13, 2017. {Yes checkbox}

2. Licensee was transmitting on April 13, 2017. {Yes checkbox}

3. As a result of the reorganization of broadcast television spectrum, Licensee certifies that as a result of the repack of the full power or Class A television station(s) identified above, the Station is required to (check all that apply)

   1. permanently relocate its main transmission site [Yes checkbox]

   2. temporarily dismantle all or some of the facilities at its main transmission site [Yes checkbox]

   3. construct or modify interim auxiliary facilities to avoid unreasonable disruption of broadcast service because without construction or modification of such interim facility

1. the Station’s primary or existing auxiliary facilities would lose more than 20 percent of the Station’s normal covered population or more than 20 percent of its normal coverage area, and

2. service would be lost for more than 24 hours and service loss would not be limited to the hours 12 AM to 5 AM local time. [Yes checkbox]

3. If the Station checks “Yes,” for Section III.2.b.iii.3, Station must:

A. attach contour maps showing 60 and 70 dBu contours from main transmission site for both full-power and reduced-power transmissions, including total area covered for all contours and total population covered for all contours, based on Census Bureau population centroids [Yes checkbox] and [File Attachment Link]

B. attach contour maps showing the 60 and 70 dBu contours from the interim auxiliary facilities transmission site, and state the area and population covered under both contours. [Yes checkbox] and [File Attachment Link]

C. provide all date(s) and time(s) that broadcast transmissions at the main transmission site are or were required to cease or to operate at reduced power from the Station’s primary facility.

D. provide all date(s) and time(s) that broadcast transmissions are or will be made from the interim auxiliary facilities constructed using funds from the TV Broadcaster Relocation Fund

3. Licensee is not requesting reimbursement from the Fund for payments previously received or expected to be received from the Fund or for reimbursement of expenses paid by or expected to be paid by any other source. {Yes checkbox}

(Proceed to Section IV)

Section IV.A – Broadcaster Information and Transition Plan

Automatically generates from LMS/Kidvid:

Call Sign

Type (Class A, Full Power)

Service Code

Licensee Name

Status {Noncommercial Educational, Commercial}

Distributed Transmission System {Yes, No}

Community of License

City, State, County, Zip Code

Pre-auction RF Channel

Post-auction RF Channel

Neilsen DMA

Network Affiliation

(if incorrect, correct in appropriate DB)

Facility ID Number from above generates

1. Channel sharing {/es -> al) channel sharing:
   to transition schedule to Form 301Yes -> Sharee station Facility ID number }
   
   

2. Briefly describe transition plan {text}

Section IV.B – Broadcaster Estimated or Actual Transition Expenses

Section IV.B.1. Transmitters

1. 1. Type of Change(s) (select all that apply)

Option List:

• Retune Primary Transmitter

• Purchase New Primary Transmitter

• Lease Primary Transmitter

• Retune Auxiliary Transmitter

• Purchase New Auxiliary Transmitter

• Lease Auxiliary Transmitter

• Purchase Interim Transmitter

• Lease Interim Transmitter
  
  

• No Transmitter Related Expenses (Proceed to Section II.B.2)

2. Is this a request for upgraded equipment?

• Select if Yes

2. For each current transmitter serving a licensed facility, answer:

Existing Transmitter(s) Description [Complete All]

1. Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

2. Ownership {Owned, Leased->Owner{Text}}

3. Shared {No; Yes->Sharing Station Facility ID’s}

4. Manufacturer {text}

5. Model {text}

6. Year {text}

7. Type {Inductive Output Tube (IOT), Solid State, Other}

   1. Inductive Output Tube

      1. IOT Power Type: {Single; Two; Three Other {text}]

      2. Power capacity{kW}

   2. Solid State

      1. Solid State Cooling {Air; Liquid}

      2. Solid State Power Capacity {Number in kW}

      3. Model Type: [Analog; Hybrid] (FM Participants Only)

   3. Other Type {Text}

8. Is transmitter in operating condition? {yes, no}

3. Transmitter Costs from Catalog of Costs

1. Retuning Costs (complete for each reuse or modification of existing transmitter)

1. New IOT Tubes [Complete all and Pre-fill row in table based on data entry]

1. Number of Tubes (including accessories) needed [select: 0-9 (default: 0)]

For each Solid State transmitter, prefill retune cost with updated costs from catalog of eligible expenses

2. New Mask Filter [Complete all and Pre-fill row in table based on data entry]

• Power [select: 1.5 kW; 3 kW; 7 kW; 10 kW; 30 kW; 60 kW; 90 kW; Other {text}]

• Mask Filter Type [select: Simple; Stringent; Full Service] (LPTV and Translators only)

3. New Exciter [Complete all and Pre-fill row in table based on data entry]

• Yes

  • Type [select: single frequency agile; dual exciter with changeover]

• No

2. New Transmitter Costs (complete for each new transmitter indicated above)

1. New Transmitter [Complete all and Pre-fill row in table based on data entry]

• Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

• Manufacturer {text}

• Model {text}

• Select Type (pick one)

  • UHF-inductive output tube (IOT)

    • Type [ Single ; Two; Three; Other {text}]

    • Power capacity{kW}

  • Solid State

    • Band [UHF; High VHF;

    • Cooling {Air; Liquid}

    • Model Type: [Analog; Hybrid] (FM Participants Only)

  • Other Type {Text}

• Justification for New Transmitter {Text}

3. Other Transmitter Costs (each service optional for all applicants)

1. Electrical Service [Select all that apply and pre-fill row(s) in table based on data entry]

• Service Entrance (3 phase 800A 208V)

• Switchgear (industrial 800 amp)

• Transformer (480V)

  • Power [150 kVA ; 300 kVA; 500 kVA]

• Rigid Conduit

  • Size (in inches)

  • Length (in feet)

• Electrical Service [text]

2. HVAC Service [Select 1 and pre-fill row based on data entry]

• Yes

  • Type [ Cooling Only; Heating and Cooling]

  • Size [5 tons; 10 tons; 15 tons; 25 tons; 50 tons; Other]

• No

3. Transmitter Building Addition /Modification or Leasehold Improvement [Select 1 and pre-fill row based on data entry]

• Does the transmitter building require an addition, modification, or other leasehold improvement? [yes/no]

  • If yes: Size in square feet [number]

• Does the transmitter installation require a Transmitter Building Site Survey/Installation? [yes/no] (LPTV and FM participants only)

4. Channel 14 Costs [To be completed only by stations relocating to channel 14]

• RF Consulting Engineer {Yes, No}

• Channel 14 Mask Filter {Yes, No}

• Additional Field Engineering Time {Yes, No}

  • Number of Days {Number}

5. Inside RF System [Complete and Pre-fill row in table based on data entry]

• Yes

  • Type {VHF inside RF system including switching, or UHF inside RF system including switching}

• No

6. FM Transmitter Costs [To be completed only by FM Radio stations]

• Does the transmitter installation require an Additional Exciter? [yes/no]

• Does the transmitter installation require an additional transmitter installation cost? [yes/no]

• Does the replacement transmitter require a Remote Control? [yes/no]

• Does the replacement transmitter require an RDS Encoder? [yes/no]

• Does the replacement transmitter require Audio Processing? [yes/no]

  • If yes, select: [None; Analog Basic; Analog/HD Basic; Analog/HD Upgraded]

7. Other Transmitter Cost Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

4. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section IV.B.2. Antenna Changes

1. 1. Type of Change(s) (select all that apply)

• Utilize Existing Primary Antenna

• Purchase New Primary Antenna

• Lease Primary Antenna

• Rent Temporary

• Utilize Existing Auxiliary Antenna

• Purchase New Auxiliary Antenna

• Lease Auxiliary Antenna

• Purchase Interim Antenna

• Lease Interim Antenna
  
  

• No Antenna Related Costs

2. Is this a request for upgraded equipment?

• Select if Yes

2. For each existing antenna:

Existing Antenna Description [Repeat below for each antenna]

1. Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

2. Ownership {Leased->Owner{Text},Owned by station}Shared {No, Yes->enter facility ID numbers}

3. Manufacturer {text}

4. Model {text}

5. Year {text}

6. Antenna Class: [Class A, Full Power] (DTV Participants Only)

7. Mounting {select: top-mount single, top-mount stacked, side-mount}

8. Antenna position in stack {not in stack, top, middle, bottom}

9. Polarization {Horizontal, Elliptical, Circular}

10. Type {Slotted coaxial, Broadband Panel, Broadband Slot (side mount), Yagi/Cross Dipole/Log Periodic, Other}

11. Broadband Panel{no, yes->give frequency range of antenna}

12. Is antenna in operating condition? {yes, no}

13. Will antenna be located on or in close proximity to an antenna farm?

3. Antenna Costs from Catalog of Costs

1. Retune Existing Antenna (complete for each “utilize existing” indicated above)

Field Testing and Adjustment [Complete All and Pre-fill row in table based on data entry]

• Antenna Use {Primary (Main); Auxiliary (Backup) ->Name; DTS->Site Number}

  • Sweep Test of Existing Antenna {yes,no}

2. New Antenna Costs (complete for each “purchase” indicated above)

New Antenna Description [Complete All for each new antenna and Pre-fill row in table based on data entry]

• Antenna Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

• Shared {No, Yes->facility id of sharing stations}

• Mounting [ Top-mount single, top-mount stacked, Side-mount]

• Polarization [Horizontal, Elliptical, Circular]

• Directional {yes/no}

• Type {Slotted coaxial, Broadband Panel, Broadband Slot (side mount), Yagi/Cross Dipole/Log Periodic, Other}

• If Broadband Panel:

  • Number of Panels/Bays {Number}

  • Frequency range of panel {lower in MHz, upper in MHz}

  • Percent of total power capacity planned to be used {%}

• Effective radiated Power {Number}

• Manufacturer {Text}

  • Model

  • Year

• Justification for New Antenna{Text}

3. Other Antenna Costs

1. Combiner for Shared Antenna [Select 1 and Pre-fill row in table based on data entry] (Display only if antenna is “shared” above)

• Yes

  • Combiner output splitter/switcher for dual feed lines?

  • Type [New; Additional Module]

  • Number of channels supported {number}

  • Frequencies of channels supported {list of RF channel numbers or upper and lower frequency in MHz}

• No

2. Other Antenna Expenses Not Listed [Repeat below for each Other cost]

• Elbow Complex

  • Separate purchase {No, Yes 

    • Broadband or Single Channel

      • {select: Broadband or Single Channel}

      • Default selection is blank.

    • Feed Line Size

      • {select: 7/8”, 1 5/8”, 3 1/8”, 4 1/16”, 6 1/8”, 7 3/16”,8 3/16”}

• Side Mount Brackets for high power antenna (If antenna mounting is “side mount” above)

  • Separate purchase {No (default), Yes}

• Pattern Scatter Analysis for a side mount high or medium power antenna

  • Separate purchase {No (default), Yes}

• Sweep Test of transmission line and antenna

  • Separate purchase {No (default), Yes}

• Power Dividers {yes/no} (LPTV Only, If antenna type is “broadband panel”)

  • Number of Power Dividers {integer}

• Cable Harness {yes/no} (LPTV Only, If antenna type is “broadband panel”)

  • Number of Cable Harnesses {integer}

• Other Antenna Expense

  • Name of Expense {Short Text}

  • Description of Cost {Text}

3. Other FM Antenna Expenses Not Listed [Repeat below for each FM Antenna]

• FM Band Pass Filter: {No (default), Yes}

• Notch Filter: {No (default), Yes}

• De-Icers: {No (default), Yes}

• Radomes: {No (default), Yes}

  • Number of Bays: {integer} (if Radomes is Yes)

4. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section IV.B.3. Transmission Line Changes

1. 1. Type of Change(s) (select all that apply)

• Utilize Existing Transmission Line for Primary Facility

• Purchase New Transmission Line for Primary Facility

• Lease Transmission Line for Primary Facility

• Utilize Existing Transmission Line for Auxiliary Facility

• Purchase New Transmission Line for Auxiliary Facility

• Lease Transmission Line for Auxiliary Facility

• Purchase New Transmission Line for Interim Facility

• Lease Transmission Line for Interim Facility
  
  

• No Transmission Line Changes

2. Is this a request for upgraded equipment?

• Select if Yes

2. Existing Transmission Line(s) (complete for each existing transmission line)

Existing Transmission Line Description

1. Ownership {Leased->Owner{Text},Owned by station}

2. Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

3. Shared {No, Yes->enter facility ID numbers}

4. Manufacturer {text}

5. Type {select: Flexible Foam, Flexible Air, Rigid, Waveguide}

i. For Rigid, Segment Length {19 ½’, 19 ¾’, 20’, Broadband, Other Segment length in feet}

6. Diameter (in inches) {text}

7. Number of parallel runs {number}

8. Length (in feet, per run) {number}

9. Is transmission line in operating condition {yes, no}

3. Transmission Line Costs from Catalog of Costs

1. New Transmission Line Costs (complete for each transmission line indicated above)

Transmission Line Description [Complete All and Pre-fill row in table based on data entry]

• Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

• Type {select one}

  • Flexible Foam

    • Diameter {select: 1/2", 7/8", 1 5/8", other}

  • Flexible Air

    • Diameter {select: 7/8", 1 5/8", 3", 4", 5", other}

  • Rigid

    • Diameter {select: 7/8”, 1 5/8” 3 1/8", 4 1/16", 6 1/8", 7 3/16", 8 3/16", other}

    • Segment Length {select: 20', 19 3/4', 19 1/2', broadbanded, other}

  • Waveguide

• Number of parallel runs {number}

• Length (in feet, per run) {number}

• Justification for New Transmission Line {text}

2. Other Expenses

1. Interior RF Systems [Repeat below for each Other cost] (LPTV and FM Participants Only)

• Additional or Replacement Inside RF System including switching, patch panels, and dehydrators: {yes/no} (LPTV and FM Participants Only)

• Additional or Replacement Inside RF system elbows, fittings, hangers, etc.: {yes/no} (FM Participants Only)

2. Other Transmission Line Expenses Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

4. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section IV.B.4. Tower Equipment and Rigging Costs

1. 1. Type of Change(s) (select all that apply)

• Modify Primary Tower

• Move Equipment to New Tower for Primary Facility

• Construct New Primary Tower

• Modify Auxiliary Tower

• Move Equipment to New Tower for Auxiliary Facility

• Construct New Auxiliary Tower
  
  

• No Tower Equipment or Rigging Costs

2. Is this a request for upgraded equipment?

• Select if Yes

2. Existing Tower Information

Existing Tower Description (complete for each tower currently in use)

1. Tower Registration Number {No, Yes}

2. If YES: ASR {Numeric->Is the below information correct {yes, no}}

3. If NO: enter tower coordinates and Height AGL {lat/long, number in feet or meters}

4. Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

5. Ownership {Leased->Owner{Text},Owned by station}Shared {No, Yes- Other users on tower (select all that apply or none)

• One or more FM radio broadcaster(s)

• One or more AM radio broadcaster(s)

• One or more TV broadcaster(s)

• Others Types of Users {List}

>enter facility ID numbers of other broadcast stations on tower}

6. Complex tower {select: no, Candelabra, Located on Building, Terrain Constrained }

7. Year tower built (if known) {text}

8. Is tower documented for structural analysis?{yes, no, unknown}

9. Is the tower compliant with Rev G?{yes/no/don’t know}

Automatically generates from ASR:

Tower Height (AGL, HAAT, AMSL)

Tower Coordinates

Tower Owner

Date Constructed

3. Tower cost descriptions from Catalog of Costs

1. Tower Modification Costs (complete for each tower modification indicated above)

1. Engineering Study [Select 1 and Pre-fill row in table based on data entry]

• No study needed

• Study needed for undocumented/poorly documented tower (DTV only)

• Study needed for documented tower (DTV only)

• Study needed for tower with candelabra (DTV only)

• Tower mapping and report for structural engineer (LPTV and FM only)

• Study needed for guyed or free-standing tower (LPTV and FM only)

2. Tower Reinforcements [select 1 and pre-fill row in table based on data entry

• No reinforcements needed

• Minor Reinforcements needed

• Major Reinforcements needed

• Serious Reinforcements needed

2. Tower Construction Costs (complete for each tower construction indicated above)

1. New Tower [Complete and Pre-fill row in table based on data entry]

• Use {Primary (Main); Auxiliary (Backup)->Name; DTS->Site Number}

• Height (in feet)

• Justification for New Tower {text}

c. Tower Rigging Costs (complete for each tower move, modification, or construction above)

1. Tower Rigging [Select 1 and Pre-fill row in table based on data entry]

• Tall Tower {yes - greater than 500', no - less than 500'}

• Complex Tower {select reason below}:

  • Candelabra

  • Located on Building

  • Terrain constrained

  • Other

2. Helicopter Services Required [select 1 and pre-fill row in table based on data entry]

• Yes

• No

4. Other Expenses

1. Other Tower Expenses Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

4. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section IV.B.5. Outside Professional Services

1. Professional Services Costs

1. Professional Services Costs

1. Outside Project Management Services [Select 1 and Pre-fill row in table based on data entry]

• Yes [complete all below]

  • Number of hours {numeric}

  • Explanation of necessity and inability to perform internally {text box}

• No

2. Outside RF consulting Engineering Services [select all that apply]

• Perform engineering study for new channel assignment and antenna development (DTV Participants Only)

• Perform engineering study for displacement application (LPTV only)

• Prepare engineering section of Form 301or 340 FCC Construction Permit Application (Main, Auxiliary) (you may be filing both forms (main and auxiliary))

• Prepare engineering section of Form 302 FCC License to Cover Application (Main, Auxiliary) (you may be filing both forms (main and auxiliary))

• Prepare request for Special Temporary Authority (quantity)

• Prepare Form 601 (LPTV and FM Participants only)

• Distributed Transmission System engineering services (no, complete below)

  • Critical Facility (enter number of sites)

  • Terrain-Shielded Facility (enter number of sites)

3. Attorney and Other Outside Consultant Costs [select all that apply]

• Prepare and file Form 301 or 340 (Main, Auxiliary)

• Prepare and file Form 302 (Main, Auxiliary)

• Prepare and file request for Special Temporary Authority (quantity)

• NEPA Section 106 environmental review (DTV Participants Only)

• Environmental Assessment (DTV Participants Only)

• ASR Modification (DTV Participants Only)

• FAA Consultation (including preparation of FAA Form 7460) (DTV Participants Only)

• Prepare or Review FCC Form 399 for Reimbursement

• Address transition timing and coordination issues w/ other stations and wireless providers (DTV Participants Only)

• Form 399 assistance or other program management costs (LPTV and FM Participants Only)

4. RF Field Engineering Services [select all that apply and pre-fill row in table based on data entry]

• Comprehensive coverage verification via field study

• RF exposure measurements

• Additional Field Engineering Service

  • Number of Days {Number}

  • Justification {Text}

2. Other Expenses Not Listed (list)

1. Other Professional Service Expenses Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

2. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section IV.B.6. Other Expenses

1. Miscellaneous Expense Costs
   
   

   1. Miscellaneous costs from Catalog of Costs

1. AM Pattern Disturbance

• Impact Study (yes, no)

[Pre-fill Predetermined Cost Estimate from Appendix]

• Remediation (yes, no)

[Pre-fill Predetermined Cost Estimate from Appendix]

2. Facility Expenses (DTV Participants Only)

• Other Interim Facility Expenses {Name, Amount}

• Other Distributed Transmission System Expenses {Name, Amount}

• DTV Medical Facility Notification {Yes, No}

3. Permit and Filing Costs (Complete all that apply)

• Local Zoning (DTV Participants Only)

• Non-zoning permits (DTV Participants Only)

• BLM or NFS Coordination (DTV Participants Only)

• FCC Construction Permit Major Change (LPTV and FM Participants Only)

• FCC Construction Permit Minor Change

• FCC License to Cover Minor Change

• FCC Special Temporary Authority Application

4. Other Miscellaneous Expenses [Complete all that apply]

• Disposal Costs (for equipment and other waste, net of any salvage value) {Yes, No}

• Equipment Delivery and Handling Charges {Yes, No}

• Equipment Storage {Yes, No}

• Develop and air announcement of upcoming channel change {Yes, No} (DTV Participants Only)

• MVPD Notification of Channel Change {Yes, No} (DTV Participants Only)

• Point to Point Microwave (STL/ICR) (LPTV and FM Participants Only)

  • Select applicable Costs: [Frequency Coordination for Unidirectional System; Frequency Coordination for Bi-Directional System; New Point to Point Microwave System)

    • If New Point to Point Microwave System, Select Type: [6/11 GHz Licensed Part 101; 7/13 GHz Licensed Part 74 (LPTV Only); 950 MHz Licensed Part 74 (FM Only)]

  • 1 Pair IP-Only Codecs for Fiber, Internet, or IP Microwave System (FM Participants Only)

2. Other expenses not listed

1. Other Miscellaneous Expenses Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

2. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide an explanation for the higher amount {text box}

Section V.A – MVPD Information and Transition Plan

1. Type of MVPD {prefill cable operator, DBS/Other MVPD}

2. Broadcast Station List (for each station requiring modification complete chart)

Facility ID

Call sign

Nature of Change (channel reassigned, new station resulting from sharing)

PSID(s) or Receive Site at which channel is received

Example Broadcast Station List Chart

Facility ID	Call Sign	Nature of Change	PSID(s)/Receive Site
000001	WAAA	Reassigned	PSID1, PSID2, PSID3, …
000002	WBBB	Reassigned	PSID1, PSID2, …
000003	WCCC	Sharing	PSID2, PSID3, …
…	…	…	…

Section V.B – MVPD Estimated or Actual Transition Expenses

1. For each channel on each PSID or Receive Site, complete as applicable:
   
   

1. PSID or Receive Site (identifier)
   
   

1. Channel Specific Costs

• Channel(s) Affected

• Coaxial Cable [{length in feet or meters}

• Antenna {Make, Model, Frequency Range, Gain}

• Structural or Capacity Augments for Tower

• Tower Rigging Expenses

• RF Processing Equipment {Pre-amp, Receiver, Decoder, Other-> Describe}

  • Identification {Make, Model}

• Other channel-specific costs {Describe}

2. Outside Professional Services

• Structural Study of Tower Capacity

• Engineering Study

• Other Professional Service Costs Not Listed {Describe}

Example PSID/Receive Site Chart

PSID	Channels	Costs	Appendix A Cost Chart
PSID1
	WAAA	Antenna	[continue to chart]
	WBBB	Pre-Amp	[continue to chart]
	…	…	[continue to chart]
PSID2
	WBBB, WCCC	…	[continue to chart]
…	…	…

2. Other Expenses Not Listed (list)

1. Other Miscellaneous Expenses Not Listed [Repeat below for each Other cost]

• Name of Cost {Short Text}

• Description of Cost {Text}

2. For each element above, enter estimated or actual cost, as applicable

[See chart attached as Appendix A]

1. For each entry where estimated cost is greater than the predetermined cost specified in the Catalog of Costs, provide justification {text box}

2. For each entry where actual cost is greater than estimated cost, provide justification {text box}

Section VI: Certifications

Certify to the following sections as appropriate (as determined automatically based on user input):

Section VI.A: WITH SUBMISSION OF ESTIMATED EXPENSES:

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).

1. 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.

2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

4. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

5. 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).

6. 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.

7. 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.

8. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

9. 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.

Print Name of Authorized Person	Print Title of Authorized Person
Signature	Date

Section VI.B: WITH SUBMISSION OF ACTUAL COST DOCUMENTATION:

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).

1. 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.

2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

4. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

5. 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).

6. 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.

7. The above-named entity certifies that the cost information/documents submitted reflect costs actually incurred.

8. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

9. 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.

Print Name of Authorized Person	Print Title of Authorized Person
Signature	Date

Section VI.C: WITH SUBMISSION OF FINAL REIMBURSEMENT SUBMISSION:

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).

1. 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.

2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

4. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

5. 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.

6. 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.

7. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

8. 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.

Print Name of Authorized Person	Print Title of Authorized Person
Signature	Date

Section VI.D: WITH SUBMISSION OF LPTV/TV TRANSLATOR/FM ELIGIBILITY CERTIFICATION:

WILLFUL FALSE, FRAUDULENT, OR FICTITIOUS STATEMENTS IN 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 AND/OR FRAUDULENT STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT (U.S. CODE, TITLE 31, SECTIONS 3729-3733).

1. The Authorized Person signing below certifies and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Eligibility Certification Form on behalf of the above-named entity.

2. The above-named entity certifies that the statements in this form and attached documentation are true, complete, and correct.

3. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

4. 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.

Print Name of Authorized Person	Print Title of Authorized Person
Signature	Date

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT

We have estimated that each response to this collection of information will take 1 – 4

hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Paperwork Reduction Project (3060-1178), Washington, DC 20554. We will also accept your comments via the Internet if you send them to [email protected]. Please DO NOT SEND COMPLETED APPLICATIONS TO THIS ADDRESS. Remember - you are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-1178.

THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. 3507

(A) Description

(B) Predetermined Cost Estimate (if available)

(C) Estimated Cost

Actual Cost Information

(D) Component Description

(E) Component Amount

Documentation

(F) Vendor Name/EIN/TIN (if available)

(G) Invoice Number

(H) Invoice Date/ Due Date

(I) Total Invoice Amount

(J) File Upload

(K) Invoice Type

(L) Payment Date

(M) Partial Payment Request

[Pre-fill from above]

[Pre-fill from Catalog of Potential Expenses and Estimated Costs]

[Provide amount]

[Describe]

[Provide Amount]

[Name of vendor]

[Date]

[total]

[select]

[Date]

…

…

…

{yes, no}

Subtotal

[Calculated Sum]

{yes, no}

…

…

…

…

…

…

{yes, no}

[Calculated Sum]

[Calculated Sum]

Total

[Calculated Sum]

[total]

{yes, no}

APPENDIX A – COST CHART

1 This category of broadcaster includes: a) Low power television (LPTV) and television translator stations, as defined by 47 CFR § 74.701, that may be eligible for reimbursement of their reasonable costs to construct facilities authorized by grant of the station’s Special Displacement Window application; and b) full power and low power FM stations, and FM translators, as defined by 47 CFR §§ 73.310, 74.1201, that were licensed and transmitting on April 13, 2017, using facilities affected by a repacked television station.

2 This category of broadcaster includes full-power television stations, or low-power television stations that were accorded primary status as a Class A television licensee under 47 CFR 73.6001(a), that, as of February 22, 2012, were licensed or had filed an application for a license to cover.

22 Edition date: 2019