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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:
67008
Service:
LPD
Call Sign:
K21MP-D
Channel:
21 (UHF)
File Number:
0000084352
FRN:
0003716198
Eligibility Status:
Eligible
Date Submitted:
07/08/2022

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

THREE ANGELS BROADCASTING NETWORK, INC.

Doing Business As: THREE ANGELS BROADCASTING NETWORK, INC.

MOSES PRIMO

PO BOX 220

WEST FRANKFORT, IL 62896

United States

 +1 (618) 627-4651 TECH@3ABN.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

Samuel Hariton

Widelity

Samuel Hariton

PO Box 220

Ste 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. No
Briefly describe transition plan Replace antenna and transmitter.

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 Purchase New
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
Model Innovator LX
Year 2003
Type Solid State
Solid State Cooling Air Cooled
Solid State Power Capacity 1 kW

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model TRN-5X U-36D-C
Transmitter Type Solid State
Solid State Cooling Air Cooled
Solid State Power capacity 1.6 kW
Justification for New Transmitter Previous transmitter no longer supported.

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 Purchase New
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 Slotted Coaxial
ERP: 7.31 kW
Manufacturer
Model JL16
Year 2011

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? No
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Types
Mounting Side Mount
Antenna position in stack Not in Stack
Polarization Elliptical
Type Slotted Coaxial
ERP: 15.0 kW
Manufacturer
Model SWEDL16OI
Year 2019
Justification for New Antenna Channel Change

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
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? 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

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? Unknown
Is tower compliant with Rev G? Unknown
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1011804
Coordinates (NAD83) Latitude (NAD83) 34° 36' 27.0" N-
Longitude (NAD83) 098° 16' 27.0" W-
Overall Structure Height 498.68 feet
Support Structure Height 479.00 feet
Ground Elevation Above Mean Sea Level (AMSL) 1230.30 feet
Structure Type TOWER - Free Standing or Guyed Structure
Tower Owner PATRICK, ARTHUR DBA = LAWTON COMMUNICATIONS
Date Constructed 07/01/1983


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

Information not provided.

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 194
Explanation K21MP-D does not have sufficient resource capacity and expertise in house to handle all activities necessary for completion of the station's build by the construction deadline. K21MP-D will hire an outside firm to facilitate a timely transition.
Outside RF consulting Engineering Services Perform engineering study for displacement application No
Prepare engineering section of Form FCC Construction Permit Application No
Prepare engineering section of Form FCC License to Cover Application No
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 No
Form 399 assistance or other program management costs No
RF Field Engineering Services Comprehensive coverage verification via field study Yes
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

399 Preparation

399 Preparation

Displacement Application

Displacement Application Preparation

Purchase Coordination

Purchase Coordination

Internal Labor

Internal Labor

Travel to site

Travel to site

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 $84,000.00 $60,000.00 N/A $0.00 N/A
Total for all systems $242,392.51 $127,219.81 N/A $37,219.81 N/A
Primary Transmitter TRN-5X U-36D-C $84,000.00 $60,000.00 $0.00
UHF - Air Cooled Solid State Transmitter 1 - 2.5 kW $84,000.00 $60,000.00 N/A N/A N/A

Components

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 $20,000.00 $20,000.00 N/A $0.00 N/A
Total for all systems $242,392.51 $127,219.81 N/A $37,219.81 N/A
Primary Antenna SWEDL16OI $20,000.00 $20,000.00 $0.00
UHF-Low Power, Side Mount, Slotted Coaxial, 15.0kW input, Elliptical $20,000.00 $20,000.00 N/A N/A N/A

Components

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

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 $56,190.00 $5,000.00 N/A $0.00 N/A
Total for all systems $242,392.51 $127,219.81 N/A $37,219.81 N/A
Primary Tower TOWER $56,190.00 $5,000.00 $0.00
Tower Rigging Short Tower (less than 500') $56,190.00 $5,000.00 N/A N/A N/A

Components

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 $73,067.00 $33,084.30 N/A $33,084.30 N/A
Total for all systems $242,392.51 $127,219.81 N/A $37,219.81 N/A
Outside Professional Services $73,067.00 $33,084.30 $33,084.30
Project management of the transition $20,467.00 $7,959.30 The estimated cost has been adjusted to include all invoices submitted for reimbursement at this time. $7,959.30 N/A
Comprehensive coverage verification via field study, if needed $52,600.00 $25,125.00 Please see SixArms Quote #QU-171175 $25,125.00 N/A

Components

Actual Information Description File Name
Project management of the transition

Component Description:
Project Management
Amount:
$116.25

Component Description:
Project Management
Amount:
$38.75

Component Description:
Project Management
Amount:
$241.95

Component Description:
Project Management
Amount:
$77.50

Component Description:
Project Management
Amount:
$232.50

Component Description:
Project Management
Amount:
$77.50

Component Description:
Project Management
Amount:
$1,131.50

Component Description:
Project Management
Amount:
$38.75

Component Description:
Project Management
Amount:
$836.60

Component Description:
Project Management
Amount:
$705.25

Component Description:
Project Management
Amount:
$38.75

Component Description:
Project Management
Amount:
$38.75

Component Description:
Project Management
Amount:
$288.55

Component Description:
Project Management
Amount:
$1,124.80

Component Description:
Project Management
Amount:
$155.00

Component Description:
Project Management
Amount:
$38.75

Component Description:
Project Management
Amount:
$288.05

Component Description:
Project Management
Amount:
$116.25

Component Description:
Project Management
Amount:
$348.75

Component Description:
Project Management
Amount:
$935.55

Component Description:
Project management
Amount:
$1,089.55
Comprehensive coverage verification via field study, if needed

Component Description:
Antenna Verification, Elliptical Polarization, Azimuth and Elevation Patterns
Amount:
$25,125.00

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 $9,135.51 $9,135.51 N/A $4,135.51 N/A
Total for all systems $242,392.51 $127,219.81 N/A $37,219.81 N/A
Other Expenses $9,135.51 $9,135.51 $4,135.51
Travel to site $2,000.00 $2,000.00 N/A N/A N/A
Internal Labor $245.26 $245.26 Please see K21MP-D Internal Labor Budget Revision Justification Letter $245.26 N/A
Displacement Application $2,000.00 $2,000.00 N/A N/A N/A
Purchase Coordination $1,000.00 $1,000.00 N/A N/A N/A
399 Preparation $3,890.25 $3,890.25 see Estimated Cost Justification K21MP-D-610-Form 399 Preparation v1 $3,890.25 N/A

Components

Actual Information Description File Name
Travel to site Information not provided.
Internal Labor

Component Description:
Repack internal labor hours All work performed by Dan Peek unless otherwise noted
Amount:
$245.26
Displacement Application Information not provided.
Purchase Coordination Information not provided.
399 Preparation

Component Description:
Research regarding LPTV reimbursement request process and evidence to support Form 399 submission
Amount:
$3,890.25

Cost Information

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Grand Total

Predetermined
Cost Estimate 		Estimated Cost Actual Cost
Total for all systems $242,392.51 $127,219.81 $37,219.81

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. No
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 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.

Daniel Peek , Peek .

RF Engineer


07/08/2022

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.

Daniel Peek , Peek .

RF Engineer


07/08/2022

Attachments

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