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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:
5959
Service:
LPT
Call Sign:
K27MX-D
Channel:
27 (UHF)
File Number:
0000081124
FRN:
0001560135
Eligibility Status:
Eligible
Date Submitted:
07/20/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

BLUE MOUNTAIN TRANSLATOR DISTRICT

Doing Business As: BLUE MOUNTAIN TRANSLATOR DISTRICT

PO BOX 901

LA GRANDE, OR 97850

United States

 +1 (541) 963-0196 BMTD.ORG@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 8/17. Conference with T-Mobile. 9/17. Channel Studies. STA/Displacement filings. 10/17. K40AJ-D-D to K40AJ-D repack begins. 11/17. K40AJ-D-D to K40AJ-D repack continues. 12/17. K40AJ-D-D to K40AJ-D repack completed.

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 Retune Existing
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 Larcan
Model MXi-101U
Year 2007
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 50 W

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New Mask Filter Does the transmitter require a new mask filter? No
New Exciter Is a new exciter needed? No

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? 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 Yes
Prepare engineering section of Form FCC Construction Permit Application No
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 Yes
For Auxiliary Facility Yes
For Main Facility 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 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 Yes
Number of Days 5
Justification BMTD does not employ engineering staff. All engineering services are performed by independent contractors.

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

Aluminum Pipe

Aluminum 2-inch pipe for $30.00.

Antenna amp and pre-amp

Antenna amp and pre-amp for $60.00.

Clamps

Clamps for $100.00.

Foam

Foam for $7.00.

Ground kit

Ground kit for $20.00.

RF Adapter

RF Adapter for $5.00.

Rg11 Cable

175 feet of Rg11 cable for $90.00.

Tar and tape

Tar and tape for $15.00.

U bolts and Amp

U bolts and amp for $35.00.

Channel Delete Filter

Channel Delete Filter and shipping.

Scala Antenna Element

Element for Scala antenna.

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 $11,000.00 $800.00 N/A $779.00 N/A
Total for all systems $16,939.50 $3,507.00 N/A $2,265.72 N/A
Primary Transmitter MXi-101U $11,000.00 $800.00 $779.00
Retune - UHF and VHF - minor re-channel issues $11,000.00 $800.00 N/A $779.00 N/A

Components

Actual Information Description File Name
Retune - UHF and VHF - minor re-channel issues

Component Description:
Technician rate: $85.00/hour. 11/11/17. 15.5 hours to begin re-tune. 12/1/17. 16.5 hours to continue re-tune. 12/3/17. 15.5 hours to complete re-tune.
Amount:
$779.00

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 $4,732.50 $1,500.00 N/A $652.66 N/A
Total for all systems $16,939.50 $3,507.00 N/A $2,265.72 N/A
Outside Professional Services $4,732.50 $1,500.00 $652.66
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $225.00 N/A $76.36 N/A
Perform engineering study for displacement application $1,800.00 $225.00 N/A $143.18 N/A
Additional Field Engineering Service, 5 Days $600.00 $600.00 N/A $126.31 N/A
Prepare request for Special Temporary Authorization $1,280.00 $450.00 N/A $306.81 N/A

Components

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

Component Description:
1/11 of cost of completing 11 License to Cover applications.
Amount:
$76.36
Perform engineering study for displacement application

Component Description:
1/11 of the cost of completing 11 channel studies.
Amount:
$143.18
Additional Field Engineering Service, 5 Days

Component Description:
20% of mileage for 3 trips to Beaver Mtn. Facility for repack operations at 2017 IRS mileage reimbursement rate.
Amount:
$107.00

Component Description:
1/11 cost of STA/Displacement Application review.
Amount:
$19.31

Component Description:
No longer requesting reimbursement as per FCC notice. Component cannot be removed from application.
Amount:
N/A
Prepare request for Special Temporary Authorization

Component Description:
1/11 of the cost of completing 11 STA/Displacement applications.
Amount:
$306.81

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 $1,207.00 $1,207.00 N/A $834.06 N/A
Total for all systems $16,939.50 $3,507.00 N/A $2,265.72 N/A
Other Expenses $1,207.00 $1,207.00 $834.06
Scala Antenna Element $100.00 $100.00 N/A $20.00 N/A
Channel Delete Filter $745.00 $745.00 N/A $741.66 N/A
U bolts and Amp $35.00 $35.00 N/A $7.00 N/A
Tar and tape $15.00 $15.00 N/A $3.00 N/A
Rg11 Cable $90.00 $90.00 N/A $18.00 N/A
RF Adapter $5.00 $5.00 N/A $1.00 N/A
Foam $7.00 $7.00 N/A $1.40 N/A
Clamps $100.00 $100.00 N/A $20.00 N/A
Antenna amp and pre-amp $60.00 $60.00 N/A $12.00 N/A
Aluminum Pipe $30.00 $30.00 N/A $6.00 N/A
Ground kit $20.00 $20.00 N/A $4.00 N/A

Components

Actual Information Description File Name
Scala Antenna Element

Component Description:
20% of component cost.
Amount:
$20.00
Channel Delete Filter

Component Description:
1/3 cost of component and shipping.
Amount:
$741.66
U bolts and Amp

Component Description:
20% of component cost.
Amount:
$7.00
Tar and tape

Component Description:
20% of component cost.
Amount:
$3.00
Rg11 Cable

Component Description:
20% of component cost.
Amount:
$18.00
RF Adapter

Component Description:
20% of component cost.
Amount:
$1.00
Foam

Component Description:
20% of component cost.
Amount:
$1.40
Clamps

Component Description:
20% of component cost.
Amount:
$20.00
Antenna amp and pre-amp

Component Description:
20% of component cost.
Amount:
$12.00
Aluminum Pipe

Component Description:
20% of component cost.
Amount:
$6.00
Ground kit

Component Description:
20% of component cost.
Amount:
$4.00

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $16,939.50 $3,507.00 $2,265.72

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.

Alex McHaddad

Executive Director


07/20/2020

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.

Alex McHaddad

Executive Director


07/20/2020

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.

Alex McHaddad

Executive Director


07/20/2020

Attachments

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