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FCC Form 399: Reimbursement Request

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

(REFERENCE COPY - Not for submission) FCC Form 399: Reimbursement Request

Facility ID:
59139
Service:
DTV
Call Sign:
KTVN
Channel:
11 (High VHF)
File Number:
0000025334
FRN:
0002900330
Date Submitted:
04/23/2018

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

SARKES TARZIAN, INC.

Doing Business As: SARKES TARZIAN, INC.

Station KTVN

205 NORTH COLLEGE AVENUE

SUITE 800

BLOOMINGTON, IN 47402

United States

+1 (812) 332-7251 lfox@ktvn.com Corporation

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

Nancy Ory

Attorney

Lerman Senter PLLC

Nancy Ory

Lerman Senter PLLC

2001 L Street, NW, Suite 400

Washington, DC 20036

United States

+1 (202) 416-6791 nory@lermansenter.com

Broadcaster Information and Transition Plan

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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 Retune existing primary transmitter to the new channel. Replace non retunable auxiliary transmitter on the new channel. Replace mask filter, low pass filter and combiner. Modify existing exhaust and electrical system for install. Proof

Transmitters

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Section Question Response
Transmitter Related Expenses Do you have transmitter related expenses? Yes

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Retune Existing
Use Primary (Main)
Ownership Owned
Owner N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer Gates Air
Model VAX 3D
Year 2016
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 4.5 kW

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New IOT Tubes Number of Tubes (including accessories) needed N/A
New Mask Filter
Power 10 kW
Other Power N/A
New Exciter Is a new exciter needed? No

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service No
Description N/A
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

combiner

new combiner tuned to the new channel designation

Combiner installation

Modify transmission line from existing 2 port combiner to new 4 port combiner

Auxiliary Transmitter

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Add Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Auxiliary (Backup)
Description of Use Auxiliary
Ownership Owned
Owner N/A
Site N/A
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model Platinum
Year 2003
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 20 kW

Auxiliary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Auxiliary (Backup)
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model VAX TE8
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 6.4 kW
Justification for New Transmitter Existing Auxiliary transmitter is not re-tunable to the new designated channel.

Auxiliary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Power N/A
Rigid Conduit and Wiring No
Size N/A
Length N/A
Other Electrical Service Yes
Description Reconnection using existing wiring from currently installed Auxiliary to new Auxiliary
HVAC Service Does the replacement transmitter require HVAC Service? No
Type N/A
Size N/A
Other Size N/A
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size N/A
Channel 14 Costs Is an RF Consulting Engineer needed? N/A
Is a channel 14 Mask Filer needed? N/A
Is additional field engineering time needed? N/A
Number of Days N/A

Auxiliary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Air Exhaust

modify existing exhaust ductwork from current Auxiliary's Harris Platinum configuration to new Auxiliary's Gates Air Vax TE 8 configuration

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? No

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? No

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? No

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 100
Explanation The station's attorney will manage the reimbursement filings, review engineering applications, and engage in any additional coordination that is needed for KTVN to accomplish its repack transition over the three year period.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development 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
Quantity N/A
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
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
Quantity N/A
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification No
FAA Consultation (including preparation of FAA Form 7460) No
Negotiation of Lease and other Matter for Shared Locations No
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers No
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements Yes
Additional Field Engineering Service No
Number of Days N/A
Justification N/A

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning No
Non-zoning permits No
BLM or NFS Coordination Yes
FCC Construction Permit Minor Change Yes
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)? No
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? No
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Information not provided.

Cost Information

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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 $418,510.00 $305,000.00 N/A $195,618.04 N/A
Total for all systems $577,405.00 $364,750.00 N/A $213,983.04 N/A
Primary Transmitter VAX 3D $243,510.00 $130,000.00 $96,053.50
combiner $120,000.00 $120,000.00 N/A $96,053.50 Dielectric Invoice MAN002243. The previous submission for the combiner was corrected by the new submission. The former request should be deleted from the cost spreadsheet. Total requested amount should be $48,026.75.
UHF and VHF - minor banding issues $105,200.00 $0.00 N/A N/A N/A
10 kW mask filter $8,310.00 $0.00 Mask filter built into combiner. No need for an external filter. N/A N/A
Combiner installation $10,000.00 $10,000.00 N/A N/A N/A
Auxiliary Transmitter VAX TE8 $175,000.00 $175,000.00 $99,564.54
High VHF - Air Cooled Solid State Transmitter 6.4 kW $165,000.00 $165,000.00 estimate from Gates Air $99,564.54 Gates Air VAXTE-6R44. The previous submission for the transmitter was corrected by the new submission. The former request should be deleted from the cost spreadsheet. Total requested amount should be $49,782.27.
Air Exhaust $5,000.00 $5,000.00 N/A N/A N/A
Other Electrical Service: Reconnection using existing wiring from currently installed Auxiliary to new Auxiliary $5,000.00 $5,000.00 N/A N/A N/A

Components

Actual Information Description File Name
combiner

Component Description:
Invoice with purchase order and quote backup provided
Amount:
$48,026.75

Component Description:
45% of Dielectric Invoice for combiner
Amount:
$48,026.75
UHF and VHF - minor banding issues Information not provided.
10 kW mask filter Information not provided.
Combiner installation Information not provided.
High VHF - Air Cooled Solid State Transmitter 6.4 kW

Component Description:
1/3 down payment for transmitter
Amount:
$49,782.27

Component Description:
transmitter
Amount:
$49,782.27
Air Exhaust Information not provided.
Other Electrical Service: Reconnection using existing wiring from currently installed Auxiliary to new Auxiliary Information not provided.

Cost Information

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Antennas

Information not provided.

Cost Information

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Transmission Line

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Information not provided.

Cost Information

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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 $143,400.00 $53,250.00 N/A $18,365.00 N/A
Total for all systems $577,405.00 $364,750.00 N/A $213,983.04 N/A
Outside Professional Services $143,400.00 $53,250.00 $18,365.00
Project management of the transition $15,800.00 $15,000.00 N/A $11,386.25 N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $2,891.25 Actual cost exceeded Widelity Report estimate.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $2,000.00 N/A $1,837.50 Subtotal invoice includes other line items.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,260.00 $5,000.00 N/A N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,365.00 $2,250.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $15,000.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $3,000.00 N/A $2,250.00 N/A
RF Exposure Measurements $21,050.00 $8,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project management involving FRN association and banking information.
Amount:
$1,050.00

Component Description:
Project management - advice and counsel regarding repack and reimbursement process
Amount:
$4,036.25

Component Description:
Work includes FCC Forms 1876, 2100 and 399.
Amount:
$6,300.00
Prepare and or review reimbursement form

Component Description:
Work was primarily FCC Forms 2100 and 399.
Amount:
$2,891.25
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Remainder of invoice ($625) is separate line item for review of repacked channel assignment.
Amount:
$1,837.50
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Comprehensive coverage verification via field study, if needed Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
Engineering study for new channel assignment
Amount:
$1,625.00

Component Description:
$625.00 of invoice for engineering study for new channel assignment. $1,837.50 of invoice for CP application - separate line item.
Amount:
$625.00
RF Exposure Measurements Information not provided.

Cost Information

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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 $15,495.00 $6,500.00 N/A $0.00 N/A
Total for all systems $577,405.00 $364,750.00 N/A $213,983.04 N/A
Other Expenses $15,495.00 $6,500.00 $0.00
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $0.00 N/A N/A N/A
MVPD Notification of Channel Change $0.00 $0.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $0.00 $0.00 N/A N/A N/A
Equipment Delivery and Handling Charges $1,500.00 $1,500.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $0.00 N/A N/A N/A
BLM or NFS Coordination $1,000.00 $1,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,550.00 $4,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $577,405.00 $364,750.00 $213,983.04

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. No
Construction of final facilities or all necessary modifications are complete. No
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

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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.

  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 acknowledges that all certifications and attached documentation are considered material representations.

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

  4. 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).

  5. 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.

  6. 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.

  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 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.

Lawson Fox

Vice President


04/23/2018

Certification

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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).

  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.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Lawson Fox

Vice President


04/23/2018

Attachments

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