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:
4206
Service:
LPD
Call Sign:
KGCS-LD
Channel:
21 (UHF)
File Number:
0000089300
FRN:
0002546273
Eligibility Status:
Eligible
Date Submitted:
10/05/2020

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

BOARD OF GOVERNORS-MISSOURI SOUTHERN STATE UNIVESITY

Public Institution of Higher Education in the state of Missouri

Doing Business As: BOARD OF GOVERNORS-MISSOURI SOUTHERN STATE UNIVESITY

Judy Stiles

3950 EAST NEWMAN Road

JOPLIN, MO 64801

United States

+1 (417) 625-9777 stiles-j@mssu.edu 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 Go off air while migrating to new channel.

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? No
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 Other
Other Antenna Type Directional Custom
ERP: 15.0 kW
Manufacturer ERI
Model ALP12L5-HSWR-21
Year 2008

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?
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency

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? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Ownership Leased
Is this tower consider Complex? No
Is this tower currently shared with any other stations? No
Is tower documented for structural analysis? Yes
Is tower compliant with Rev G? Yes
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1236206
Coordinates (NAD83) Latitude (NAD83) 37° 05' 49.2" N-
Longitude (NAD83) 094° 34' 25.8" W-
Overall Structure Height 985.88 feet
Support Structure Height 982.93 feet
Ground Elevation Above Mean Sea Level (AMSL) 970.13 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner Zimmer Radio, Inc.
Date Constructed 12/06/2005


Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: No study needed
Tower Reinforcements Please select whether tower reinforcements are needed: No reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower N/A
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Name Description

Tower Climbing

Tower climbing and tune TV antennas.

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 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 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 Yes
RF exposure measurements Yes
Additional Field Engineering Service No

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Name Description

Don Ross

Invoice 681056 updated 4-30-20

Smith and Fisher

Invoice 6959 Updated 4-30-20

Smith and Fisher

Invoice 7011 Updated 4-30-20

Don Ross

Invoice 681055 updated 4-30-20

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 Yes
FCC License to Cover Application Yes
FCC Special Temporary Authority Application Yes
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

Information not provided.

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 $5,730.00 $11,519.64 N/A $6,250.00 N/A
Total for all systems $257,009.64 $38,364.28 N/A $19,754.64 N/A
Primary Antenna ALP12L5-HSWR-21 $5,730.00 $11,519.64 $6,250.00
Sweep test of transmission line and antenna $5,730.00 $11,519.64 2 payments for project (1 prior and 1 post). $6,250.00 N/A

Components

Actual Information Description File Name
Sweep test of transmission line and antenna

Component Description:
Payment 1
Amount:
$5,269.64

Component Description:
Payment 2
Amount:
$6,250.00

Cost Information

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Transmission Line

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

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 $160,750.00 $3,000.00 N/A $2,860.00 N/A
Total for all systems $257,009.64 $38,364.28 N/A $19,754.64 N/A
Primary Tower TOWER $160,750.00 $3,000.00 $2,860.00
Tower Climbing $3,000.00 $3,000.00 Estimated charge of $1000 per day, for three days of work $2,860.00 Old information is included in Sub-total that we cannot remove.
Tower Rigging Tall Tower (greater than 500') $157,750.00 $0.00 Tower not over 500'. $0.00 Tower not over 500'.

Components

Actual Information Description File Name
Tower Climbing

Component Description:
See invoice. (Transmitter)
Amount:
N/A

Component Description:
See invoice.
Amount:
N/A

Component Description:
See invoice
Amount:
N/A

Component Description:
Revised invoice as requested. (Showing call sign)
Amount:
$2,860.00

Component Description:
See Invoice.
Amount:
N/A

Component Description:
Wallace Tower invoice revised as requested
Amount:
$2,860.00

Component Description:
See invoice. (Tower Climber)
Amount:
N/A

Component Description:
See Invoice.
Amount:
N/A
Tower Rigging Tall Tower (greater than 500') 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 $77,260.00 $12,325.00 N/A $5,375.00 N/A
Total for all systems $257,009.64 $38,364.28 N/A $19,754.64 N/A
Outside Professional Services $77,260.00 $12,325.00 $5,375.00
Comprehensive coverage verification via field study, if needed $52,600.00 $0.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $6,000.00 Invoices that were received was not broken down for each study and analysis done. $0.00 Actual cost was higher than estimated cost.
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $0.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,280.00 $0.00 N/A N/A N/A
Don Ross $1,325.00 $1,325.00 Estimated consulting costs $1,325.00 N/A
RF Exposure Measurements $12,100.00 $0.00 N/A $0.00 0.00
Perform engineering study for displacement application $1,800.00 $0.00 N/A $0.00 N/A
Smith and Fisher $5,000.00 $5,000.00 Consulting outside professional work estimated costs $4,050.00 N/A

Components

Actual Information Description File Name
Comprehensive coverage verification via field study, if needed Information not provided.
Prepare engineering section of FCC Form 2100 (main), License to Cover Application

Component Description:
Outside Consulting
Amount:
$750.00

Component Description:
Analysis
Amount:
$1,350.00

Component Description:
Analysis
Amount:
$2,700.00

Component Description:
Outside Consulting
Amount:
$575.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application Information not provided.
Prepare request for Special Temporary Authorization Information not provided.
Don Ross

Component Description:
Don Ross invoice corrected as requested - two of two for Don Ross
Amount:
$575.00

Component Description:
Invoice updated as requested - one of two from Don Ross
Amount:
$750.00
RF Exposure Measurements Information not provided.
Perform engineering study for displacement application Information not provided.
Smith and Fisher

Component Description:
Corrected invoice as requested - one of two for Smith and Fisher
Amount:
$2,700.00

Component Description:
Smith and Fisher Invoice as requested - two of two submitted
Amount:
$1,350.00

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 $13,269.64 $11,519.64 N/A $5,269.64 N/A
Total for all systems $257,009.64 $38,364.28 N/A $19,754.64 N/A
Other Expenses $13,269.64 $11,519.64 $5,269.64
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $0.00 N/A $0.00 N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $0.00 N/A $0.00 N/A
FCC Filing Fees - Special Temporary Authorization request $305.00 $0.00 N/A $0.00 N/A
Other Antenna Cost $11,519.64 $11,519.64 ***System Notice: Estimate adjusted and locked because line has been superseded.*** $5,269.64 Cost includes shipping freight charges (not included in estimate).

Components

Actual Information Description File Name
FCC Filing Fees - Form 2100 minor change CP application Information not provided.
FCC Filing Fees - Form 2100 license to cover application Information not provided.
FCC Filing Fees - Special Temporary Authorization request Information not provided.
Other Antenna Cost

Component Description:
Second invoice from ERI.
Amount:
$6,250.00

Component Description:
First invoice from ERI
Amount:
$5,269.64

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $257,009.64 $38,364.28 $19,754.64

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.

Don Mihulka

Chief Information Officer


10/05/2020

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.

Don Mihulka

Chief Information Officer


10/05/2020

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.

Don Mihulka

Chief Information Officer


10/05/2020

Attachments

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