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:
43416
Service:
LPT
Call Sign:
K17NS-D
Channel:
17 (UHF)
File Number:
0000089921
FRN:
0001591460
Eligibility Status:
Eligible
Date Submitted:
01/10/2023

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

MOHAVE COUNTY BOARD OF SUPERVISORS

Applicant

Doing Business As: MOHAVE COUNTY BOARD OF SUPERVISORS

Barbara Spoonhour

PO BOX 7000

KINGMAN, AZ 86402

United States

+1 (928) 753-0729 spoonb@mohave.gov 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. No
Briefly describe transition plan Transition complete required based on T-Mobile/FCC Repackaging

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 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? No
Existing Antenna Manufacturer and Type
Mounting Top Mount
Antenna position in stack Top
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels 1
Design power capacity in use 5.0 %
Lower Limit 488.00 MHz
Upper Limit 494.00 MHz
ERP: 60.0 W
Manufacturer
Model 4DR-4S
Year 2019

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? No
New Antenna Manufacturer and Types
Mounting Top Mount
Antenna position in stack Top
Polarization Horizontal
Type Broadband Panel
Number of Stations Supported 1
Number of Panels/Bays 1
Lower Limit 488.00 MHz
Upper Limit 494.00 MHz
Design power capacity in use 5.0 %
ERP: 60.0 W
Manufacturer
Model 4DR-4S
Year 2019
Justification for New Antenna Existing antenna cannot be modified or re-tuned. Assigned frequency requires new antenna build.

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
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? No

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 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 No
Prepare Form 601 No
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 No
Negotiation of Lease and other Matter for Shared Locations No
Prepare or Review FCC Form 399 for Reimbursement No
Form 399 assistance or other program management costs No
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

Construction expense

Actual

Staff expense

8 hours and 63.90

Technical expense

2 hours at 33.95

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 $1,750.00 $1,560.67 N/A $1,551.20 N/A
Total for all systems $15,984.40 $9,412.66 N/A $9,395.05 N/A
Primary Antenna 4DR-4S $1,750.00 $1,560.67 $1,551.20
UHF Broadband panel antenna (per panel), horizontally-polarized $1,750.00 $1,560.67 Actual - includes band pass filters $1,551.20 The numbers are higher because I uploaded a corrected invoice that includes the quote, per the email on 02/17/22.

Components

Actual Information Description File Name
UHF Broadband panel antenna (per panel), horizontally-polarized

Component Description:
Corrected documentation added quote for Band Pass Filter.
Amount:
$519.65

Component Description:
Purchase of Antennas.
Amount:
$953.59

Component Description:
Sales tax was erroneously excluded from WECOM Invoice #150491
Amount:
$77.96

Component Description:
Purchase of Band Pass Filters.
Amount:
$519.65

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 $9,557.50 $3,175.09 N/A $3,175.09 N/A
Total for all systems $15,984.40 $9,412.66 N/A $9,395.05 N/A
Outside Professional Services $9,557.50 $3,175.09 $3,175.09
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $890.37 Actual $890.37 The estimated costs and the actual costs are the same.
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $0.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $2,284.72 Actual $2,284.72 Uploaded invoice. The invoice is a flat fee price.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $0.00 N/A N/A N/A
Perform engineering study for displacement application $1,800.00 $0.00 N/A N/A N/A

Components

Actual Information Description File Name
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
Legal services for repackaging.
Amount:
$8.83

Component Description:
Legal services for repackaging.
Amount:
$44.17

Component Description:
Legal services for repackaging.
Amount:
$132.50

Component Description:
Legal services for repackaging.
Amount:
$181.10

Component Description:
Legal services for repackaging.
Amount:
$28.33

Component Description:
Legal services for repackaging.
Amount:
$9.33

Component Description:
Legal services costs for this facility. Attached is a memo and spreadsheet of cost allocations.
Amount:
$8.50

Component Description:
Legal services for repackaging.
Amount:
$107.67

Component Description:
Legal services for repackaging.
Amount:
$8.83

Component Description:
Legal services for repackaging.
Amount:
$8.50

Component Description:
Legal services for repackaging.
Amount:
$138.89

Component Description:
Legal services for repackaging.
Amount:
$222.22
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Engineering portions of applications for displacement, including request for waiver for contingent filing, if needed.
Amount:
$1,000.00

Component Description:
Preparation and submission of application for license.
Amount:
$250.00

Component Description:
Preparation and submittal of license.
Amount:
$250.00

Component Description:
Study of Mohave County's overall channel plan compatibility and antenna designs required due to FCC's recent incentive auction.
Amount:
$1,000.00

Component Description:
Engineering assistance for Mohave County to respond to FCC/T-Mobile Cases.
Amount:
$34.72
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Perform engineering study for displacement application 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 $4,676.90 $4,676.90 N/A $4,668.76 N/A
Total for all systems $15,984.40 $9,412.66 N/A $9,395.05 N/A
Other Expenses $4,676.90 $4,676.90 $4,668.76
Construction expense $4,080.00 $4,080.00 Actual $4,080.00 N/A
Technical expense $67.90 $67.90 Actual $59.76 N/A
Staff expense $529.00 $529.00 Actual costs were higher than original estimates. $529.00 Uploaded corrected invoice. 03/21/22 - Uploaded incorrect memo and resubmitted corrected memo K17NS-D Invoice #1 05/05/22: Uploaded corrected memo for #1

Components

Actual Information Description File Name
Construction expense

Component Description:
Labor for installation.
Amount:
$4,080.00
Technical expense

Component Description:
Incorrect call sign allocation attached as support for invoice 30253. FID 43416 reimbursed $60.43, but should have requested $59.76.
Amount:
($0.67)

Component Description:
Assistance to Mohave County for FCC reimbursement submittals and justifications.
Amount:
$60.43
Staff expense

Component Description:
Internal staffing charges.
Amount:
$529.00

Component Description:
Internal staff charges for working on repackaging.
Amount:
$529.00

Component Description:
Updated invoice uploaded. Staffing expenses related to repackaging.
Amount:
$420.33

Component Description:
Internal staff charges for working on repackaging.
Amount:
$529.00

Component Description:
Internal staff charges for working on repackaging.
Amount:
$529.00

Component Description:
Mohave County staff time to work on repackaging.
Amount:
$529.09

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $15,984.40 $9,412.66 $9,395.05

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. 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.

Barbara Jo Spoonhour

Administrative Services Director


01/10/2023

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.

Barbara Jo Spoonhour

Administrative Services Director


01/10/2023

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.

Barbara Jo Spoonhour

Administrative Services Director


01/10/2023

Attachments

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