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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:
59632
Service:
LPD
Call Sign:
K33DB-D
Channel:
33 (UHF)
File Number:
0000088777
FRN:
0002633089
Eligibility Status:
Not Determined
Date Submitted:
11/11/2019

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

SELECTIVE TV, INC.

Applicant

Doing Business As: SELECTIVE TV, INC.

P. O. BOX 665

ALEXANDRIA, MN 56308

United States

+1 (320) 763-5924 borgruds@prtel.com Other

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 4 stations repacked required a new combiner and retuning of mask filters, and one new Ch 33 mask filter.

Question Response
Sharee Station Facility ID 59645
Call Sign K27KN-D
Type
Licensee Name SELECTIVE TV, INC.
Status LICENSED
DTS No
Community of License ALEXANDRIA, MN
Pre-auction RF Channel 27
Post-auction RF Channel
Neilsen DMA
Network Affiliation
Question Response
Sharee Station Facility ID 198100
Call Sign K17NW-D
Type
Licensee Name SELECTIVE TV,INC.
Status LICENSED
DTS No
Community of License ALEXANDRIA, MN
Pre-auction RF Channel 17
Post-auction RF Channel
Neilsen DMA
Network Affiliation
Question Response
Sharee Station Facility ID 59643
Call Sign K20AC-D
Type
Licensee Name SELECTIVE TV, INC.
Status LICENSED
DTS No
Community of License ALEXANDRIA, MN
Pre-auction RF Channel 20
Post-auction RF Channel
Neilsen DMA
Network Affiliation
Question Response
Sharee Station Facility ID 59633
Call Sign K22DV-D
Type
Licensee Name SELECTIVE TV, INC.
Status LICENSED
DTS No
Community of License ALEXANDRIA, MN
Pre-auction RF Channel 22
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? 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)
Ownership Owned
Is the existing antenna shared with another station or stations? Yes
Is the existing antenna directional? No
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 5
Number of Panels 8
Design power capacity in use 100.0 %
Lower Limit 470.00 MHz
Upper Limit 860.00 MHz
ERP: 1.05 kW
Manufacturer MCI
Model 955116
Year 2012

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

Facility ID Call Sign
59643 K20AC-D
198100 K17NW-D
59633 K22DV-D

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?

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 5
Frequencies of channels supported RF channel
Frequency N/A

Enter a list of RF channel numbers.

RF Channel Number
33
17
20
22
27

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? 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 No
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 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? 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

T-Mobile IX

Filter to reject T-Mobile incoming IX at receive site.

mask filter

mask filter

mask filter combiner

remove / replace

Cost Information

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Transmitters

Information not provided.

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 $3,766.76 $3,766.76 N/A $3,766.76 N/A
Total for all systems $12,013.78 $9,043.78 N/A $9,043.78 N/A
Primary Antenna 955116 $3,766.76 $3,766.76 $3,766.76
1.05 kW UHF Combiner $3,766.76 $3,766.76 new combiner $3,766.76 N/A

Components

Actual Information Description File Name
1.05 kW UHF Combiner

Component Description:
1/4 cost of combiner
Amount:
$3,766.76

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 $5,865.00 $3,060.00 N/A $3,060.00 N/A
Total for all systems $12,013.78 $9,043.78 N/A $9,043.78 N/A
Outside Professional Services $5,865.00 $3,060.00 $3,060.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $50.00 N/A $50.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $300.00 Displacement Application preparation $300.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,710.00 N/A $1,710.00 N/A
Form 399 assistance or other Program Management costs $1,000.00 $1,000.00 Fee for 399 Eligibility 1876 preparation and filing See: BWS Inv 6227.pdf $1,000.00 N/A

Components

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

Component Description:
fee for filing license to cover cp
Amount:
$50.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application

Component Description:
Cost for preparation of displacement application
Amount:
$300.00
Prepare/ Review 399 reimbursement form

Component Description:
Fee for preparation and filing of 399 Reimbursement - Turnkey Project Cost
Amount:
$1,710.00
Form 399 assistance or other Program Management costs

Component Description:
Fee for 399 Eligibility and 1876 preparation and filing
Amount:
$1,000.00

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 $2,382.02 $2,217.02 N/A $2,217.02 N/A
Total for all systems $12,013.78 $9,043.78 N/A $9,043.78 N/A
Other Expenses $2,382.02 $2,217.02 $2,217.02
mask filter combiner $373.36 $373.36 remove filters for retuning, remount combiner & filters, retro fit plate $373.36 N/A
T-Mobile IX $407.19 $407.19 1/4 cost of receive filter to reject T-Mobile signal $407.19 N/A
mask filter $1,266.47 $1,266.47 Ch 33 mask filter $1,266.47 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $170.00 fee for license to cover CP $170.00 N/A

Components

Actual Information Description File Name
mask filter combiner

Component Description:
1/4 cost of invoice
Amount:
$68.93

Component Description:
1/4 cost of invoice
Amount:
$192.37

Component Description:
1/4 cost of invoice
Amount:
$112.06
T-Mobile IX

Component Description:
1/4 cost of receive filter
Amount:
$407.19
mask filter

Component Description:
Ch 33 mask filter
Amount:
$1,266.47
FCC Filing Fees - Form 2100 license to cover application

Component Description:
FCC fee for license to cover CP
Amount:
$170.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $12,013.78 $9,043.78 $9,043.78

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


11/11/2019

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.

James Borgrud

President


11/11/2019

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.

James Borgrud

President


11/11/2019

Attachments

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