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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:
125747
Service:
LPD
Call Sign:
K28OH-D
Channel:
28 (UHF)
File Number:
0000089314
FRN:
0007251655
Eligibility Status:
Eligible
Date Submitted:
05/27/2021

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

Cooperative Television of Southern Minnesota, Inc.

Doing Business As: CTV

David Sunderman

20946 549TH AVENUE

MANKATO, MN 56001

United States

 +1 (507) 387-7963 daves@benco.org 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

Sam Hariton

Widelity

Sam Hariton

4031 University Dr

Suite 100

Fairfax, VA 22030

United States

 +1 (339) 222-8107 sam.hariton@widelity.com

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 K28OH-D is planning to retune its transmitter and reuse its antenna and transmission line on the existing tower.

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 Axcera
Model CU1RD-1
Year 2014
Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 0.25 kW

Primary Transmitter

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Retuning Transmitter Costs

Section Question Response
New Mask Filter Does the transmitter require a new mask filter? Yes
Mask Filter Type Stringent
Power 200-300W
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? 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? Yes
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 Broadband Panel
Number of Stations Supported 6
Number of Panels 16
Design power capacity in use 8.33 %
Lower Limit 482.00 MHz
Upper Limit 806.00 MHz
ERP: 3.0 kW
Manufacturer Kathrein
Model 771-304
Year 2014

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

Facility ID Call Sign
13840 K14KE-D
13844 K26CS-D
28003 K30FN-D
125749 K32GX-D
167237 K34JX-D

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? Yes
Type Additional Module
Number of channels supported 1
Frequencies of channels supported Upper and lower frequency
Frequency 470.0 MHz - 596.0 MHz

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? Yes
Number of Hours 254
Explanation K28OH-D does not have sufficient resource capacity and expertise in house to handle all of the reimbursement activities necessary to facility on-time completion of the station's build. K28OH-D will hire an outside firm to support K28OH-D in these tasks.
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 Yes
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 Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
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 Yes
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

Information not provided.

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 $12,925.00 $14,833.04 N/A $3,833.04 N/A
Total for all systems $66,613.61 $76,807.01 N/A $25,195.62 N/A
Primary Transmitter CU1RD-1 $12,925.00 $14,833.04 $3,833.04
200-300W w mask filter Stringent $1,925.00 $3,833.04 see Estimated Cost Justification K28OH-D-110-Primary Transmitter - 200-300 W Mask Filter, Stringent v0 $3,833.04 N/A
Retune - UHF and VHF - minor re-channel issues $11,000.00 $11,000.00 N/A N/A N/A

Components

Actual Information Description File Name
200-300W w mask filter Stringent

Component Description:
K28OH-D-110-Primary Transmitter - 200-300 W Mask Filter, Stringent
Amount:
$3,833.04
Retune - UHF and VHF - minor re-channel issues 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 $10,161.61 $10,161.61 N/A $6,328.57 N/A
Total for all systems $66,613.61 $76,807.01 N/A $25,195.62 N/A
Primary Antenna 771-304 $10,161.61 $10,161.61 $6,328.57
3.0 kW UHF Combiner $10,161.61 $10,161.61 see Estimated Cost Justification K28OH-D-210-Primary Antenna - 3.0 kW UHF Combiner v0 $6,328.57 N/A

Components

Actual Information Description File Name
3.0 kW UHF Combiner

Component Description:
Non-inventory part
Amount:
$2,960.00

Component Description:
Custom Equipment
Amount:
$3,368.57

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 $42,082.00 $50,367.36 N/A $14,864.01 N/A
Total for all systems $66,613.61 $76,807.01 N/A $25,195.62 N/A
Outside Professional Services $42,082.00 $50,367.36 $14,864.01
Project management of the transition $26,797.00 $41,910.00 Please see K28OH-D-LPTV strategic support quote $12,283.32 N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $3,262.50 $814.61 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $814.61 N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $1,577.50 $1,577.50 N/A $38.50 N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $3,025.00 $716.00 Please see Justification Cooperative Television Legal Fees $288.33 N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,052.50 $1,052.50 N/A N/A N/A
Perform engineering study for displacement application $1,800.00 $990.00 Please see Estimated Cost Justification K19LI-D-530-RF Eng - Engineering Study for Displacement Application v0 $990.00 N/A
Prepare/ Review 399 reimbursement form $1,710.00 $449.25 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $449.25 N/A
Prepare Form 601 $755.00 $755.00 N/A $0.00 N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $2,102.50 $2,102.50 N/A N/A N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$1,057.05

Component Description:
Invoice K28OH-D-510-Project Management Widelity, Inc. CTA-K28OH-D-032
Amount:
$1,426.05

Component Description:
Project Management
Amount:
$996.85

Component Description:
Project management
Amount:
$367.15

Component Description:
Project Management
Amount:
$468.95

Component Description:
Project Management
Amount:
$1,203.90

Component Description:
Project Management
Amount:
$291.00

Component Description:
Project Management
Amount:
$397.00

Component Description:
Project Management
Amount:
$14.95

Component Description:
Invoice K28OH-D-510-Project Management Widelity, Inc. CTA-K28OH-D-031
Amount:
$1,526.80

Component Description:
Project Management
Amount:
$516.40

Component Description:
Project Management
Amount:
$799.80

Component Description:
Project Management
Amount:
$749.10

Component Description:
Project Management
Amount:
$862.60

Component Description:
Project Management
Amount:
$1,137.95

Component Description:
Consulting
Amount:
$23.57

Component Description:
Project Management
Amount:
$338.80

Component Description:
Project Management
Amount:
$105.40
Attorney Fees - Negotiation of lease and other matters for shared locations

Component Description:
Email to D. Sunderman
Amount:
$277.49

Component Description:
TV Translator System (Labor)
Amount:
$215.41

Component Description:
Review and respond to T-Mobile
Amount:
$64.02

Component Description:
Review FCC emails
Amount:
$141.03

Component Description:
Prepare emails to FCC
Amount:
$116.66
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application

Component Description:
K28OH-D-550-Attorney - License to Cover Application (Main)
Amount:
$38.50
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application

Component Description:
K28OH-D-550-Attorney - Construction Permit Application (Main)
Amount:
$8.33

Component Description:
K28OH-D-550-Attorney - Construction Permit Application (Main)
Amount:
$280.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application Information not provided.
Perform engineering study for displacement application

Component Description:
In-core channel check for current channel 14 to 36 LPTV stations (13 total)
Amount:
$990.00
Prepare/ Review 399 reimbursement form

Component Description:
K28OH-D-510-Prepare/Review 399 Reimbursement Form
Amount:
$48.75

Component Description:
K28OH-D-510-Prepare/Review 399 Reimbursement Form
Amount:
$338.84

Component Description:
K28OH-D-510-Prepare/Review 399 Reimbursement Form
Amount:
$61.66
Prepare Form 601 Information not provided.
Prepare engineering section of FCC Form 2100 (main), Construction Permit 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 $1,445.00 $1,445.00 N/A $170.00 N/A
Total for all systems $66,613.61 $76,807.01 N/A $25,195.62 N/A
Other Expenses $1,445.00 $1,445.00 $170.00
FCC Filing Fees - Form 2100 minor change CP application $1,110.00 $1,110.00 N/A N/A N/A
FCC Filing Fees - Form 2100 license to cover application $335.00 $335.00 N/A $170.00 N/A

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

Component Description:
K28OH-D-610-FCC Filing Fee - License to Cover Application
Amount:
$170.00

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $66,613.61 $76,807.01 $25,195.62

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. No

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.

David Sunderman

Manager


05/27/2021

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.

David Sunderman

Manager


05/27/2021

Attachments

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