TV Broadcaster Relocation Fund Reimbursement Application

Applicant Information

Applicant Name, Type, and Contact Information

Applicant	Address	Phone	Email	Applicant Type
SELECTIVE TV, INC. Applicant Doing Business As: SELECTIVE TV, INC.	P. O. BOX 665 ALEXANDRIA, MN 56308 United States	+1 (320) 763-5924	borgruds@prtel.com	Other

Applicant

Address

Phone

Applicant Type

SELECTIVE TV, INC.

Applicant

Doing Business As: SELECTIVE TV, INC.

P. O. BOX 665

ALEXANDRIA, MN 56308

United States

+1 (320) 763-5924

borgruds@prtel.com

Other

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant	Address	Phone	Email
[Confidential]

Preparer Contact Information

Preparer Contact Name and Information

Applicant	Address	Phone	Email
The Preparer is same as the reimbursement contact.

Broadcaster Information and Transition Plan

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	4 stations repacked required a new combiner and retuning of mask filters, and one new Ch 33 mask filter.

Transmitters

Section	Question	Response
Transmitter Related Expenses	Do you have transmitter related expenses?	No

Antennas

Section	Question	Response
Antenna Related Expenses	Do you have antenna related expenses?	Yes

Primary Antenna

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	5
	Number of Panels	8
	Design power capacity in use	100.0 %
	Lower Limit	470.00 MHz
	Upper Limit	860.00 MHz
	ERP:	1.05 kW
	Manufacturer	MCI
	Model	955116
	Year	2012

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

Facility ID	Call Sign
198100	K17NW-D
59632	K33DB-D
59633	K22DV-D
59645	K27KN-D

Primary Antenna

Adjustment to Existing Antenna

Section	Question	Response
Sweep Test of Existing Antenna	Do you need a sweep test of existing antenna?

Primary Antenna

Other Antenna Costs

Section	Question	Response
Combiner for Shared Antenna	Do you need a Combiner for a Shared Antenna?	Yes
	Type	New
	Number of channels supported	5
	Frequencies of channels supported	RF channel
	Frequency	N/A

Enter a list of RF channel numbers.

RF Channel Number
27
17
20
22
33

Primary Antenna

Other Antenna Cost Not Listed

Information not provided.

Transmission Line

Section	Question	Response
Transmission Line Related Expenses	Do you have transmission line related expenses?	No

Tower Equipment And Rigging Costs

Section	Question	Response
Tower Equipment or Rigging Costs Changes	Do you have tower equipment or rigging costs changes?	No

Outside Professional Services Costs

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	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	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

Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

Section	Question	Response
AM Pattern Disturbance	Is an Impact Study needed?	No
AM Pattern Disturbance	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

Other Expenses Not Listed

Name	Description
mask filter combiner	remove / replace
T-Mobile IX	Filter to reject T-Mobile incoming IX at receive site.

Cost Information

Transmitters

Information not provided.

Cost Information

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	$3,766.77	$3,766.77	N/A	$3,766.77	N/A
Total for all systems	$10,747.30	$7,777.30	N/A	$7,777.30	N/A
Primary Antenna 955116	$3,766.77	$3,766.77		$3,766.77
1.05 kW UHF Combiner	$3,766.77	$3,766.77	N/A	$3,766.77	N/A

Components

Actual Information Description	File Name
1.05 kW UHF Combiner	Component Description: Rev B of Combiner Amount: $583.30 Component Description: 1/4 cost of combiner Rev A Amount: $3,183.47

Cost Information

Transmission Line

Information not provided.

Cost Information

Tower Equipment and Rigging Costs

Information not provided.

Cost Information

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	$5,865.00	$3,060.00	N/A	$3,060.00	N/A
Total for all systems	$10,747.30	$7,777.30	N/A	$7,777.30	N/A
Outside Professional Services	$5,865.00	$3,060.00		$3,060.00
Prepare/ Review 399 reimbursement form	$1,710.00	$1,710.00	N/A	$1,710.00	N/A
Form 399 assistance or other Program Management costs	$1,000.00	$1,000.00	Fee for 399 Eligibility 1876 preparation and filing See: BWS Inv 6227.pdf	$1,000.00	N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	$2,102.50	$300.00	N/A	$300.00	N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	$1,052.50	$50.00	N/A	$50.00	N/A

Components

Actual Information Description	File Name
Prepare/ Review 399 reimbursement form	Component Description: Fee for preparation and filing of 399 Reimbursement - Turnkey Project Cost Amount: $1,710.00
Form 399 assistance or other Program Management costs	Component Description: Fee for 399 Eligibility and 1876 preparation and filing Amount: $1,000.00
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application	Component Description: Cost for preparation of displacement application Amount: $300.00
Prepare engineering section of FCC Form 2100 (main), License to Cover Application	Component Description: fee for filing license to cover cp Amount: $50.00

Cost Information

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	$1,115.53	$950.53	N/A	$950.53	N/A
Total for all systems	$10,747.30	$7,777.30	N/A	$7,777.30	N/A
Other Expenses	$1,115.53	$950.53		$950.53
FCC Filing Fees - Form 2100 license to cover application	$335.00	$170.00	N/A	$170.00	N/A
mask filter combiner	$373.35	$373.35	remove filters for retuning, remount combiner & filters, retro fit plate	$373.35	N/A
T-Mobile IX	$407.18	$407.18	1/4 cost of receive filter to reject T-Mobile signal	$407.18	N/A

Components

Actual Information Description	File Name
FCC Filing Fees - Form 2100 license to cover application	Component Description: FCC fee for license to cover CP Amount: $170.00
mask filter combiner	Component Description: 1/4 cost of invoice Amount: $192.36 Component Description: 1/4 cost of invoice Amount: $68.93 Component Description: invoice divided by four Amount: $112.06
T-Mobile IX	Component Description: 1/4 cost of receive filter Amount: $407.18

Cost Information

Grand Total

	Predetermined Cost Estimate	Estimated Cost	Actual Cost
Total for all systems	$10,747.30	$7,777.30	$7,777.30

Reimbursement Status

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

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.
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. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount. 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. 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. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission. 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.	James Borgrud President 07/27/2021

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.

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.
The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.
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.
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.
The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.
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.

James Borgrud

President

07/27/2021

(REFERENCE COPY - Not for submission) FCC Form 399: Reimbursement Request

Applicant Information

Applicant Name, Type, and Contact Information

Reimbursement Contact Information

Reimbursement Contact Name and Information

Preparer Contact Information

Preparer Contact Name and Information

Broadcaster Information and Transition Plan

Transmitters

Antennas

Primary Antenna

Existing Antenna Information

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

Primary Antenna

Adjustment to Existing Antenna

Primary Antenna

Other Antenna Costs

Enter a list of RF channel numbers.

Primary Antenna

Other Antenna Cost Not Listed

Transmission Line

Tower Equipment And Rigging Costs

Outside Professional Services Costs

Outside Professional Services Costs

Other Professional Services Expenses Not Listed

Other Expenses

Other Expenses

Other Expenses Not Listed

Cost Information

Transmitters

Cost Information

Antennas

Components

Cost Information

Transmission Line

Cost Information

Tower Equipment and Rigging Costs

Cost Information

Outside Professional Services

Components

Cost Information

Other Expenses

Components

Cost Information

Grand Total

Reimbursement Status

Certification

Attachments