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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:
125109
Service:
LPT
Call Sign:
K21MR-D
Channel:
21 (UHF)
File Number:
0000083928
FRN:
0008277105
Eligibility Status:
Not Determined
Date Submitted:
10/03/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

CARIBOU COUNTY TV ASSOCIATION

Doing Business As: CARIBOU COUNTY TV ASSOCIATION

C/O CORD MCCURDY

8571 Winning Way

Pocatello, ID 83204

United States

+1 (208) 317-0008 cordly1@gmail.com Government Entity

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

The Preparer is same as the reimbursement contact.

 

 

 

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 Applicant had 6 translators displace during the 2018 "Special Displacement Window". They are colocated and share the same antenna. Only expense involved was a two new combiners to feed the turnstile antenna.

Question Response
Sharee Station Facility ID 8805
Call Sign K29LG-D
Type
Licensee Name CARIBOU COUNTY TV ASSOCIATION
Status LICENSED
DTS No
Community of License SODA SPRINGS, ID
Pre-auction RF Channel 29
Post-auction RF Channel
Neilsen DMA
Network Affiliation
Question Response
Sharee Station Facility ID 8806
Call Sign K25OI-D
Type
Licensee Name CARIBOU COUNTY TV ASSOCIATION
Status LICENSED
DTS No
Community of License SODA SPRINGS, ID
Pre-auction RF Channel 25
Post-auction RF Channel
Neilsen DMA
Network Affiliation
Question Response
Sharee Station Facility ID 8812
Call Sign K27MW-D
Type
Licensee Name CARIBOU COUNTY TV ASSOCIATION
Status LICENSED
DTS No
Community of License SODA SPRINGS, ID
Pre-auction RF Channel 27
Post-auction RF Channel
Neilsen DMA
Network Affiliation

Transmitters

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Section Question Response
Transmitter Related Expenses Do you have transmitter related expenses? No

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? No
Outside RF consulting Engineering Services Perform engineering study for displacement application No
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 1
Prepare Form 601 No
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application No
Prepare and file Form FCC License to Cover Application No
Prepare request for Special Temporary Authority No
Negotiation of Lease and other Matter for Shared Locations No
Prepare or Review FCC Form 399 for Reimbursement Yes
Form 399 assistance or other program management costs Yes
RF Field Engineering Services Comprehensive coverage verification via field study No
RF exposure measurements No
Additional Field Engineering Service No

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
Permit and Filing Costs FCC Construction Permit Major Change No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
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? No
Does this relocation require Equipment Storage? No
Point to Point Microwave (STL/ICR) Frequency Coordination for Unidirection System No
Frequency Coordination for Bi-Direction System No
New Point to Point Microwave System No

Other Expenses

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Other Expenses Not Listed

Name Description

Combiner

Microwave Filter Combiner Ch 21, 25, 27, 29, 31, 33, 35

Cost Information

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Transmitters

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 $7,145.00 $3,060.00 N/A $3,060.00 N/A
Total for all systems $10,546.25 $6,461.25 N/A $6,461.25 N/A
Outside Professional Services $7,145.00 $3,060.00 $3,060.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $50.00 BWS Invoice 5827 License to Cover K21MR $50.00 N/A
Form 399 assistance or other Program Management costs $1,000.00 $1,000.00 BWS Consulting 399 Eligibility / 1876 Form Turnkey Project see Caribou 399E BWS Invoice 6180.pdf $1,000.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $250.00 N/A $250.00 N/A
Prepare request for Special Temporary Authorization $1,280.00 $50.00 N/A $50.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A $1,710.00 N/A

Components

Actual Information Description File Name
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
K21MR License to Cover BWS Invoice 5827
Amount:
$50.00
Form 399 assistance or other Program Management costs

Component Description:
399 Eligibility / Form 1876 Turnkey Management
Amount:
$1,000.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
BWS Invoice 5646 K21MR Displacement
Amount:
$250.00
Prepare request for Special Temporary Authorization

Component Description:
STA Filing K21MR
Amount:
$50.00
Prepare/ Review 399 reimbursement form

Component Description:
K21MR 399 Reimbursement Project Management BWS Invoice 6181
Amount:
$1,710.00

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 $3,401.25 $3,401.25 N/A $3,401.25 N/A
Total for all systems $10,546.25 $6,461.25 N/A $6,461.25 N/A
Other Expenses $3,401.25 $3,401.25 $3,401.25
Combiner $3,401.25 $3,401.25 Microwave Filter Company UHF Combiner Invoice157700 $13605 divided by 4 channels repacked = $3401.25 ea $3,401.25 N/A

Components

Actual Information Description File Name
Combiner

Component Description:
1/4 of total invoice #13605 divided by four is $3401.25 ea
Amount:
$3,401.25

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $10,546.25 $6,461.25 $6,461.25

Reimbursement Status

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Question Response
The facility has ceased operating on its pre-auction channel. Yes
Construction of final facilities or all necessary modifications are complete. Yes
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.

Susan Hansen

Consultant


10/03/2019

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.

Cord McCurdy

Board Member


10/03/2019

Certification

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Section Question Response
Submission of Final Allocation or Accounting Information 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 and represents that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

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

  3. 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.

  4. 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.

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

  6. 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.

Cord McCurdy

Board Member


10/03/2019

Attachments

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