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:
28594
Service:
LPT
Call Sign:
K25PL-D
Channel:
25 (UHF)
File Number:
0000083654
FRN:
0010379311
Eligibility Status:
Eligible
Date Submitted:
04/13/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

INDIAN WELLS VALLEY TV BOOSTER, INC.

Doing Business As: INDIAN WELLS VALLEY TV BOOSTER, INC.

P. O. BOX 562

RIDGECREST, CA 93556

United States

+1 (760) 608-7783 edwort@earthlink.net Not-for-Profit

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 stations displaced during the "Special Displacement Window." K18MP-D FI 28590 is PBS Eligible and not seeking reimbursement thru this program.

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)
Ownership Owned
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model 820A
Year 2011
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity .1 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? No
Manufacturer
Model TRN-5X022-U-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 60 W
Justification for New Transmitter ITS no longer supported.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Other Transmitter Costs
Does the transmitter installation require a Transmitter Building Site Survey/Installation? No
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

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Other Transmitter Cost Not Listed

Information not provided.

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 Purchase New
Antenna Use Primary (Main)
Ownership Owned
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? Yes
Existing Antenna Manufacturer and Type
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Other
Other Antenna Type Zig Zag Cut to Ch45
ERP: 0.1 kW
Manufacturer
Model Zig Zag
Year 1979

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Change Type Purchase New
Ownership Owned
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? Yes
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 2
Lower Limit 470.00 MHz
Upper Limit 698.00 MHz
Design power capacity in use 30.0 %
ERP: 0.65 kW
Manufacturer
Model 2x1 750 10325
Year 2019
Justification for New Antenna Old antenna cut to Ch 45.

Primary Antenna

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Other Antenna Costs

Section Question Response
Elbow Complex Do you require the separate purchase of the Elbow Complex? No
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? No
Power Dividers Does the panel antenna require power dividers? No
Cable Harness Does the panel antenna require cable harness? Yes
Number of Cable Harnesses 2

Primary Antenna

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Other Antenna Cost Not Listed

Name Description

LCF78-78NM-50

Jumper Cables

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 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 No
RF exposure measurements No
Additional Field Engineering Service No

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Almendarez Technical Services

Remove and install antennas

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

CA USE TAX

California Use Tax

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 $13,750.00 $12,828.42 N/A $12,828.42 N/A
Total for all systems $25,740.46 $22,653.88 N/A $22,653.87 N/A
Primary Transmitter TRN-5X022-U-C $13,750.00 $12,828.42 $12,828.42
UHF - Air Cooled Solid State Transmitter 50.001 - 150 Watts $13,750.00 $12,828.42 N/A $12,828.42 N/A

Components

Actual Information Description File Name
UHF - Air Cooled Solid State Transmitter 50.001 - 150 Watts

Component Description:
1/6 of Invoice total
Amount:
$12,828.42

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 $7,155.29 $5,155.29 N/A $5,155.29 N/A
Total for all systems $25,740.46 $22,653.88 N/A $22,653.87 N/A
Primary Antenna 2x1 750 10325 $7,155.29 $5,155.29 $5,155.29
UHF-Low Power, Side Mount, Broadband Panel, 2 bay, 0.65kW input, Elliptical $4,504.23 $4,504.23 750 10325 adjusted for horizontal cost on only. Includes Harness. $4,504.23 N/A
LCF78-78NM-50 $651.06 $651.06 LCF78-78NM-50 7/8" Foam Cable and Connectors, 50 ft $651.06 N/A
Cable harness (each, for panel antenna system, if not included in antenna cost) $2,000.00 $0.00 Included with antenna cost. N/A N/A

Components

Actual Information Description File Name
UHF-Low Power, Side Mount, Broadband Panel, 2 bay, 0.65kW input, Elliptical

Component Description:
Rev B
Amount:
$1,699.03

Component Description:
Antenna Array 2 panel adjusted cost to horizontal pol.
Amount:
$2,805.20
LCF78-78NM-50

Component Description:
1/6 of cost
Amount:
$651.06

Component Description:
1/6 of Invoice for cable
Amount:
$651.06
Cable harness (each, for panel antenna system, if not included in antenna cost) 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 $3,210.00 $3,210.00 N/A $3,210.00 N/A
Total for all systems $25,740.46 $22,653.88 N/A $22,653.87 N/A
Outside Professional Services $3,210.00 $3,210.00 $3,210.00
Almendarez Technical Services $500.00 $500.00 Removed-Installed antennas $500.00 N/A
Form 399 assistance or other Program Management costs $1,000.00 $1,000.00 BWS consulting for 399 Eligibility Filing $1,000.00 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
Almendarez Technical Services

Component Description:
1/6th cost of Invoice
Amount:
$500.00
Form 399 assistance or other Program Management costs

Component Description:
BWS Invoice for Services Rendered for 399 Eligibility Filing
Amount:
$1,000.00
Prepare/ Review 399 reimbursement form

Component Description:
BWS Invoice for services rendered for 399 Reimbursement Filing
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 $1,625.17 $1,460.17 N/A $1,460.16 N/A
Total for all systems $25,740.46 $22,653.88 N/A $22,653.87 N/A
Other Expenses $1,625.17 $1,460.17 $1,460.16
CA USE TAX $1,290.17 $1,290.17 CA Use Tax $1,290.16 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $170.00 N/A $170.00 N/A

Components

Actual Information Description File Name
CA USE TAX

Component Description:
1/6th Use tax for antenna and transmitter
Amount:
$1,248.16

Component Description:
1/6 of total coax use tax
Amount:
$42.00
FCC Filing Fees - Form 2100 license to cover application

Component Description:
Agency Tracking ID PGC3230002
Amount:
$170.00

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $25,740.46 $22,653.88 $22,653.87

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. Yes

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


04/13/2021

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.

Edward Middlemiss

Chairman


04/13/2021

Attachments

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