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:
69924
Service:
LPT
Call Sign:
K49HP
Channel:
32 (UHF)
File Number:
0000089840
FRN:
0005009618
Eligibility Status:
Eligible
Date Submitted:
06/02/2021

Applicant Information

Back to Top

Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

THE CAMP VERDE TV CLUB, INC.

Doing Business As: THE CAMP VERDE TV CLUB

Roger Doering

420 W Angus Drive

CAMP VERDE, AZ 86322

United States

+1 (928) 399-9402 RPDELECTRONICS@HOTMAIL.COM Not-for-Profit

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

Back to Top

Preparer Contact Name and Information

Applicant Address Phone Email

Tony zumMallen

Anywave Communications Technologies

Tony zumMallen

300 Knightsbridge Parkway, Suite 150

Lincolnshire, IL 60069

United States

+1 (816) 882-5600 tony.zummallen@anywave.com

Broadcaster Information and Transition Plan

Back to Top
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 The Camp Verde TV club proposes to install digital transmitter and combiner feeding common antenna for K30OI-D and K32ME-D.

Transmitters

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

Primary Transmitter

Back to Top

Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Ownership Owned
Is this transmitter currently shared with another station? Yes
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model MX-20U
Year 2004
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity .02 kW

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

Facility ID Call Sign
69922 K47IK

Primary Transmitter

Back to Top

New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? No
Manufacturer
Model TRN-U-200-D-FB
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 200 W
Justification for New Transmitter This is the lowest power transmitter that Anywave manufactures

Primary Transmitter

Back to Top

Other Transmitter Costs

Section Question Response
Other Transmitter Costs
Does the transmitter installation require a Transmitter Building Site Survey/Installation? Yes
Electrical Service Service Entrance (3 phases 800A 208V) No
Switchgear (industrial 800 amp) No
Transformer (480V) No
Rigid Conduit and Wiring No
Other Electrical Service No
HVAC Service Does the replacement transmitter require HVAC Service? No
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No

Primary Transmitter

Back to Top

Other Transmitter Cost Not Listed

Name Description

Combiner

channel FID 69922 and FID 69924 Replacement combiner

Antennas

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

Transmission Line

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

Tower Equipment And Rigging Costs

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

Outside Professional Services Costs

Back to Top
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 No
Prepare engineering section of Form FCC License to Cover Application No
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 Yes
RF exposure measurements No
Additional Field Engineering Service No

Outside Professional Services Costs

Back to Top

Other Professional Services Expenses Not Listed

Name Description

Engineering-General

Engineering Consultation

Other Expenses

Back to Top
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

Back to Top

Other Expenses Not Listed

Information not provided.

Cost Information

Back to Top

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 $35,700.00 $34,460.00 N/A $0.00 N/A
Total for all systems $94,699.00 $84,381.00 N/A $4,689.00 N/A
Primary Transmitter TRN-U-200-D-FB $35,700.00 $34,460.00 $0.00
Transmitter Building Site Survey/Installation $10,000.00 $10,000.00 N/A N/A N/A
Combiner $1,400.00 $1,400.00 N/A N/A N/A
UHF - Air Cooled Solid State Transmitter 160 - 300 Watts $24,300.00 $23,060.00 Per attached quote PR1910-0527 N/A N/A

Components

Information not provided.

Cost Information

Back to Top

Antennas

Information not provided.

Cost Information

Back to Top

Transmission Line

Information not provided.

Cost Information

Back to Top

Tower Equipment and Rigging Costs

Information not provided.

Cost Information

Back to Top

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 $58,999.00 $49,921.00 N/A $4,689.00 N/A
Total for all systems $94,699.00 $84,381.00 N/A $4,689.00 N/A
Outside Professional Services $58,999.00 $49,921.00 $4,689.00
Form 399 assistance or other Program Management costs $4,389.00 $4,389.00 Cost determined by invoices $4,389.00 N/A
Engineering-General $300.00 $300.00 Cost determined by invoices $300.00 N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $43,732.00 Per-attached quote number 745-R for Coverage Verification N/A N/A
Prepare/ Review 399 reimbursement form $1,710.00 $1,500.00 N/A N/A N/A

Components

Actual Information Description File Name
Form 399 assistance or other Program Management costs

Component Description:
PM Paperwork
Amount:
$1,185.80

Component Description:
PM Paperwork
Amount:
$431.20

Component Description:
PM Paperwork
Amount:
$415.80

Component Description:
PM Paperwork
Amount:
$431.20

Component Description:
Paperwork PM
Amount:
$415.80

Component Description:
Paperwork PM
Amount:
$385.00

Component Description:
Paperwork PM
Amount:
$200.20

Component Description:
Paperwork PM
Amount:
$924.00
Engineering-General

Component Description:
Consultation Services.
Amount:
$300.00
Comprehensive coverage verification via field study, if needed Information not provided.
Prepare/ Review 399 reimbursement form Information not provided.

Cost Information

Back to Top

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 $0.00 $0.00 N/A $0.00 N/A
Total for all systems $94,699.00 $84,381.00 N/A $4,689.00 N/A
Other Expenses $0.00 $0.00 $0.00

Components

Information not provided.

Cost Information

Back to Top

Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $94,699.00 $84,381.00 $4,689.00

Reimbursement Status

Back to Top
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

Back to Top
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.

Roger Doering

Vice President and Engineer


06/02/2021

Certification

Back to Top
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.

Roger Doering

Vice President and Engineer


06/02/2021

Attachments

Back to Top