Go to the Federal Communications Commission homepage at www.fcc.gov

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:
23277
Service:
DTV
Call Sign:
KXVO
Channel:
29 (UHF)
File Number:
0000028648
FRN:
0019424746
Date Submitted:
08/01/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

MITTS TELECASTING COMPANY, LLC

Doing Business As: MITTS TELECASTING COMPANY, LLC

Thomas Mitts, MD

205 SOUTH WEST ST.

SUITE A

VISALIA, CA 93291

United States

+1 (559) 625-4234 tmitts@forticelle.com Limited Liability Company

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

Paul A. Cicelski , Esq .

Lerman Senter PLLC

Paul Cicelski

2001 L Street NW

Suite 400

Washington, DC 20036

United States

+1 (202) 416-6756 pcicelski@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 See Exhibit A.

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 Purchase New
Use Primary (Main)
Description of Use N/A
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 Quantum QDC2 ESC
Year 2005
Type Inductive Output Tube
IOT Power Type Two
Power Capacity 50 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model THU9evo-30
Transmitter Type Solid State
Solid State Cooling Liquid Cooled
Solid State Power capacity 46 kW
Justification for New Transmitter Per the manufacturer, the current transmitter cannot be retuned. See Exhibit B.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) Yes
Transformer (480V) Yes
Power 300 kVA
Rigid Conduit and Wiring Yes
Size 2 inches
Length 800.0 feet
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

Installation Cost

Installation Cost

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Retune Existing
Antenna Use Primary (Main)
Description of Use N/A
Ownership Leased
Owner Sinclair Television of Omaha, LLC
Site N/A
Is the existing antenna shared with another station or stations? Yes
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Top Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 2
Number of Panels 40
Design power capacity in use 24.0 %
Lower Limit 476.00 MHz
Upper Limit 698.00 MHz
Other Antenna Type N/A
ERP: 490.0 kW
Manufacturer Electronics Research, Inc.
Model ETU-P4H16-(15-51)
Year 2005

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

Facility ID Call Sign
51491 KPTM

Primary Antenna

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Adjustment to Existing Antenna

Section Question Response
Sweep Test of Existing Antenna Do you need a sweep test of existing antenna? Yes

Primary Antenna

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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
Frequency N/A

Enter a list of RF channel numbers.

RF Channel Number
29
26

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? Yes

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Utilize Existing
Use Primary (Main)
Description of Use N/A
Ownership Leased
Owner Sinclair Television of Omaha, LLC
Site N/A
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 ERI
Type Rigid
Diameter 8 3/16 inches
Other Diameter N/A
Segment Length Broadband
Other Segment Length N/A
Number of parallel runs 2
Length 1645 feet per run

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

Facility ID Call Sign
51491 KPTM

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Information not provided.

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 400
Explanation Outside consulting engineering, legal work, and accounting services, as well as project management for regional and comprehensive repack execution.
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 Yes
Quantity 2
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 Yes
Quantity 2
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification Yes
FAA Consultation (including preparation of FAA Form 7460) Yes
Negotiation of Lease and other Matter for Shared Locations Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements No
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

Name Description

Station Project Manager Internal Costs

Project manager internal employee time costs

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 No
FCC Construction Permit Minor Change No
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
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 $1,702,277.49 $1,349,348.70 N/A $1,053,747.52 N/A
Total for all systems $2,210,230.04 $1,835,696.25 N/A $1,083,169.23 N/A
Primary Transmitter THU9evo-30 $1,702,277.49 $1,349,348.70 $1,053,747.52
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW $1,473,000.00 $1,080,000.00 See Response to September 6 Inquiry. $800,173.82 N/A
Transformer 3 phase/480v - 300 KVA $36,800.00 $35,000.00 N/A $19,225.00 N/A
Switchgear - industrial 800 amp $38,200.00 $57,845.21 See Rinzler invoice $57,845.21 N/A
Service entrance 3 phase/800 amp/208 volt $14,400.00 $13,895.00 N/A $13,895.00 N/A
Installation Cost $119,077.49 $119,077.49 See Rinzler Quote. $119,077.49 N/A
2" Rigid Conduit and Wiring (Cost per foot) $20,800.00 $43,531.00 Updated estimates per FCC requirement. $43,531.00 N/A

Components

Actual Information Description File Name
UHF - Liquid Cooled Solid State Transmitter 35 - 50 kW

Component Description:
Transmitter cost balance plus tax. #9500080848
Amount:
$565,341.96

Component Description:
Transmitter related cost. #158366265-001
Amount:
$586.27

Component Description:
Transmitter downpayment. #9500074908
Amount:
$186,804.37

Component Description:
Transmitter related cost. #INV267952
Amount:
$7,799.37

Component Description:
Transmitter related cost. #INV275711
Amount:
$35,521.85

Component Description:
Transmitter related cost. #WO5887RC
Amount:
$4,120.00
Transformer 3 phase/480v - 300 KVA

Component Description:
Transformer cost. #1925.2
Amount:
$19,225.00
Switchgear - industrial 800 amp

Component Description:
Switchgear cost. #2INV00673
Amount:
$57,845.21
Service entrance 3 phase/800 amp/208 volt

Component Description:
Transmitter related cost. #2INV00673
Amount:
$13,895.00
Installation Cost

Component Description:
Installation costs. #423
Amount:
$357.49

Component Description:
Installation cost. #2INV00673
Amount:
$118,720.00
2" Rigid Conduit and Wiring (Cost per foot)

Component Description:
Transmitter related cost. #1925
Amount:
$20,000.00

Component Description:
Transmitter related cost. #1925.1
Amount:
$20,000.00

Component Description:
Transmitter related cost. #1892
Amount:
$585.00

Component Description:
Transmitter Related Cost. #1883
Amount:
$2,946.00

Cost Information

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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 $216,930.00 $206,400.00 N/A $0.00 N/A
Total for all systems $2,210,230.04 $1,835,696.25 N/A $1,083,169.23 N/A
Primary Antenna ETU-P4H16-(15-51) $216,930.00 $206,400.00 $0.00
Combiner output splitting/switching for dual feed lines, if applicable $126,000.00 $120,000.00 N/A N/A N/A
New combiner, cost per channel (without antenna) $84,200.00 $80,000.00 N/A N/A N/A
Sweep test of existing antenna $6,730.00 $6,400.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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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 $0.00 $0.00 N/A $0.00 N/A
Total for all systems $2,210,230.04 $1,835,696.25 N/A $1,083,169.23 N/A
Primary Transmission Line $0.00 $0.00 $0.00

Components

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 $192,326.55 $181,816.55 N/A $26,146.71 N/A
Total for all systems $2,210,230.04 $1,835,696.25 N/A $1,083,169.23 N/A
Outside Professional Services $192,326.55 $181,816.55 $26,146.71
Project management of the transition $63,200.00 $60,000.00 N/A $21,035.45 N/A
Station Project Manager Internal Costs $66.55 $66.55 N/A $66.55 N/A
Comprehensive coverage verification via field study, if needed $84,200.00 $80,000.00 N/A N/A N/A
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase $2,105.00 $2,000.00 N/A N/A N/A
ASR modification (prepare FCC Form 854) $2,105.00 $2,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $7,360.00 $7,000.00 N/A N/A N/A
Prepare and or review reimbursement form $2,630.00 $2,500.00 N/A $2,332.79 N/A
Address transition timing and coordination issues w/ other stations and wireless $2,630.00 $2,500.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,360.00 $7,000.00 N/A $870.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,155.00 $3,000.00 N/A $1,620.00 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,580.00 $1,500.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $4,100.00 $3,000.00 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 $221.92 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
Attorney Fees - Negotiation of lease and other matters for shared locations $4,210.00 $4,000.00 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #463026
Amount:
$801.57

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1063
Amount:
$262.29

Component Description:
$207.48 credit to be split across 52 Sinclair stations reimbursed $269.71 for invoice 1093 (correct reimbursement amount is $265.72). #1093
Amount:
($3.99)

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #466690
Amount:
$446.87

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #467378
Amount:
$576.96

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations.
Amount:
$30.47

Component Description:
Legal services cost. #460926
Amount:
$605.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #463567
Amount:
$566.48

Component Description:
Legal services cost. #457839
Amount:
$1,027.20

Component Description:
Legal services cost. #465199
Amount:
$240.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #464321
Amount:
$683.07

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1058
Amount:
$187.24

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1098
Amount:
$238.07

Component Description:
Legal Service Cost. #473534
Amount:
$51.25

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #470923
Amount:
$406.65

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1105
Amount:
$216.88

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #470237
Amount:
$436.37

Component Description:
Legal Service Cost. #471545
Amount:
$163.75

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1111
Amount:
$159.58

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1099
Amount:
$266.93

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1133
Amount:
$307.72

Component Description:
Legal Service Cost. #470295
Amount:
$711.25

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1130
Amount:
$281.49

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1123
Amount:
$342.14

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1114
Amount:
$242.25

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1117
Amount:
$282.68

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #461759
Amount:
$29.98

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #471524
Amount:
$341.18

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #473506
Amount:
$421.40

Component Description:
Legal services cost. #466714
Amount:
$360.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations. #461289
Amount:
$91.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1079
Amount:
$177.14

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1078
Amount:
$215.68

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$32.35

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$716.28

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$943.95

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 99 stations. #1086
Amount:
$275.35

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$91.76

Component Description:
Legal Service Cost. #467402
Amount:
$62.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$20.65

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations.
Amount:
$105.97

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1072
Amount:
$237.64

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$999.04

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #465001
Amount:
$596.30

Component Description:
Legal services cost. #464713
Amount:
$292.50

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #463026
Amount:
$815.02

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 99 stations. #469573
Amount:
$377.14

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #467861
Amount:
$470.30

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$818.59

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1093
Amount:
$269.71

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #465173
Amount:
$654.26

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations.
Amount:
$185.10

Component Description:
Legal services cost. #463007
Amount:
$315.30

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$20.91

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 99 stations. #468718
Amount:
$349.51

Component Description:
Legal Service Cost. #467899
Amount:
$491.25

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 100 stations. #1090
Amount:
$176.70

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$43.72

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$86.88

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1055
Amount:
$243.38

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$836.44

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #1069
Amount:
$246.68
Station Project Manager Internal Costs

Component Description:
Portion of general repack matter internal time card attributable to this station - divided by 100.
Amount:
$66.55

Component Description:
Internal time expense for April - D.S.
Amount:
$41.43

Component Description:
Internal time expense for April - H.A.
Amount:
$85.05

Component Description:
Internal time expense for April - D.S.
Amount:
$41.43

Component Description:
Internal time expense for April - H.A.
Amount:
$85.05
Comprehensive coverage verification via field study, if needed Information not provided.
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase Information not provided.
ASR modification (prepare FCC Form 854) Information not provided.
Attorney Fees - Prepare and File request for Special Temporary Authorization Information not provided.
Prepare and or review reimbursement form

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations. #461289
Amount:
$1,311.48

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #461759
Amount:
$869.30

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$152.01

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$1,315.27
Address transition timing and coordination issues w/ other stations and wireless Information not provided.
Perform engineering study for new channel assignment and antenna development

Component Description:
Consulting engineering cost.
Amount:
$870.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Consulting engineering cost.
Amount:
$1,620.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations. #461289
Amount:
$122.00

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 93 stations.
Amount:
$122.35

Component Description:
Portion of general repack matter invoice attributable to this station - divided by 98 stations. #461759
Amount:
$99.92
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application Information not provided.
Attorney Fees - Negotiation of lease and other matters for shared locations 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 $98,696.00 $98,131.00 N/A $3,275.00 N/A
Total for all systems $2,210,230.04 $1,835,696.25 N/A $1,083,169.23 N/A
Other Expenses $98,696.00 $98,131.00 $3,275.00
DTV Medical Facility Notification $11,550.00 $11,000.00 N/A $3,275.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $325.00 N/A N/A N/A
FCC Filing Fees - Special Temporary Authorization request $195.00 $190.00 N/A N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $28,566.00 $28,566.00 See Response to September 6 Inquiry. N/A N/A
Equipment Delivery and Handling Charges $10,000.00 $10,000.00 See Exhibit J. N/A N/A
Equipment Storage $15,000.00 $15,000.00 See Exhibit J. N/A N/A
Develop and air announcement of upcoming channel change $28,050.00 $28,050.00 See Response to September 6 Inquiry. N/A N/A
MVPD Notification of Channel Change $5,000.00 $5,000.00 See Exhibit J. N/A N/A

Components

Actual Information Description File Name
DTV Medical Facility Notification

Component Description:
Medical notification costs. #1108
Amount:
$3,275.00
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
Disposal Costs (for equipment and other waste, net of any salvage value) Information not provided.
Equipment Delivery and Handling Charges Information not provided.
Equipment Storage Information not provided.
Develop and air announcement of upcoming channel change Information not provided.
MVPD Notification of Channel Change Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $2,210,230.04 $1,835,696.25 $1,083,169.23

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 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.

Thomas Mitts , MD .

President


08/01/2019

Attachments

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