FCC Form 498 Service Provider Identification Number (SPIN)

Save time, avoid problems. File electronically at http://www.usac.org/fund-administration/forms/
FCC Form 498

Pending Approval by OMB 3060-0824

Service Provider Identification Number and General Contact Information Form
Estimated Average Burden Hours Per Response: 1.5 hours
FCC Form 498 is used to collect contact and remittance information for service providers that receive support from the Federal universal service support mechanisms. For greater
flexibility, this form allows service providers to use the same general contact information for all their contacts and the same remittance data collected for each of the four support
mechanisms or multiple contact and remittance information, Please report any changes to this information on a revised FCC Form 498 to prevent any delays in notification and the
timeliness of disbursements. Persons willfully making false statements on this form can be punished by fine or forfeiture, under the Communications Act, 47 U.S.C. Secs. 502,
503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.
Please read instructions, located at: http://www.universalservice.org/forms , before beginning this application.

Please check one box below

See Instruction Section III.A

Original Application for SPIN

Revision to existing FCC Form 498 on file with USAC

Request for SPIN Merger/Consolidation

Request for SPIN Deactivation

See Instruction Section III.A
Service Provider Identification Number (SPIN)
(To be inserted by USAC for first time applicants. Required for subsequent revisions.)
499 Filer ID
(Required if your company is required to file the FCC form 499)

Block 1: General Company Information [All Fields REQUIRED]
See Instruction Section III.B
1
Company Name
2
Name Company is Doing Business As (DBA) or Formerly Known As (FKA)
3
Street Address
4
Address Line 2
5

6
City

7
State

Zip Code + 4

Block 2: General Contact Information [All Fields REQUIRED]
See Instruction Section III.C
8 First:
Middle Initial:
General Contact (Company Preparer Name)
10 (
)
Phone Number

Ext.

Last:

9
Title

11 (
)
Fax Number

12
Street Address
13
Address Line 2
14

15
City

16
State

Zip Code + 4

17
E-mail Address

Block 3: Federal EIN and DUNS [All Fields REQUIRED]
18

19
Enter Federal Employer Identification Number
(Federal EIN or Tax ID Number)

See Instruction Section III.D
Corporation
Partnership
(Check applicable corporate structure.)

Other

20
Enter Dunn and Bradstreet Number (DUNS)

Page 1 of 8

FCC Form 498-Sept. 2009 Edition

This page is for High-Cost Support Mechanism participants only.
For more information about the High-Cost Support Mechanism, please refer to: http://www.usac.org/hc/

Block 4: High-Cost Support Mechanism Financial Institution and Remittance
Information [ALL Fields REQUIRED]
See Instruction Section III.E

Financial institution information is required. Electronic payment of universal service support payments
is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.
Check this box if this information is the same as the General Contact information (Block 2) and continue on to lines 31 to 34.
21
Remittance Company Name, if different from Company Name
22 First:
Middle Initial:
Last:
Remittance Contact Name - Statements will be sent to Remittance Contact's attention

23
Title

24
Remittance Contact Address
25
Address Line 2
26

27
City

29 (
)
Phone Number

28
State

Ext

Zip Code + 4

30 (
)
Fax Number

Check this box if you are requesting mailed paper copy statements instead of electronic remittance statements
(If you do not check this box, your remittance statements will be sent to your e-mail address)
31
Remittance Financial Institution for ACH or locked box transfer of funds (required)
32

33
Financial Institution Account Number for ACH (required)

ACH Financial Institution Transit Number - must be nine digits (required)

34
E-mail Address of Remittance Contact (Required if participating in the High-Cost Support Mechanism)

Block 5: Company Contact for High-Cost Support Mechanism
See Instruction Section III.F

Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 6.
35 First:
Middle Initial:
Contact Name for High-Cost Support Mechanism

Last:

36
Title

(Must be a company employee or designated representative)

37
Contact Address for High-Cost Support Mechanism
38
Address Line 2
39

40
City

42 (
)
Phone Number

41
State

Ext

Zip Code + 4

43 (
)
Fax Number

44
E-mail Address of High-Cost Support Mechanism Contact

Page 2 of 8

FCC Form 498-Sept. 2009 Edition

This page is for Low-Income Support Mechanism participants only.
For more information about the Low-Income Support Mechanism, please refer to: http://www.usac.org/li/

Block 6: Low-Income Support Mechanism Financial Institution and Remittance
Information [All Fields REQUIRED]
See Instruction Section III.G
Financial institution information is required. Electronic payment of universal service support payments
is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.

Check this box if this information is the same as the General Contact information (Block 2) and continue on to lines 55 to 58.
45
Remittance Company Name, if different from Company Name
46 First:
Middle Initial:
Last:
Remittance Contact Name - Statements will be sent to Remittance Contact's attention

47
Title

48
Remittance Address
49
Address Line 2
50

51
City

53 (
)
Ph
Phone
Number
N b

52
State

E t
Ext

Zip Code + 4

54 (
)
Fax
F Number
N b

Check this box if you are requesting mailed paper copy statements instead of electronic remittance statements
(If you do not check this box, your remittance statements will be sent to your e-mail address)
55
Remittance Financial Institution for ACH or locked box transfer of funds (required)
56

57
Financial Institution Account Number for ACH (required)

ACH Financial Institution transit Number - must be nine digits (required)

58
E-mail Address of Remittance Contact (Required if participating in the Low-Income Support Mechanism)

Block 7: Company Contact for Low-Income Support Mechanism
See Instruction Section III.H
Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 8.
59 First:
Middle Initial:
Contact address for Low-Income Support Mechanism

Last:

60
Title

(Must be a company employee or designated representative)

61
Contact Address for Low-Income Support Mechanism
62
Address Line 2
63

64
City

66 (
)
Phone Number

65
State

Ext

Zip Code + 4

67 (
)
Fax Number

68
E-mail Address of Low-Income Support Mechanism Contact

Page 3 of 8

FCC Form 498-Sept. 2009 Edition

This is a Supplemental Page for Participants in the High-Cost and Low-Income Programs.
Block 8: High-Cost and Low Income Study Area/SPIN Association
See Instruction Section III.I
This information will be used to associate the Study Area Codes (SAC) to this SPIN for the purposes of
High-Cost and Low-Income Support.
Check this box if there is no change to the SAC data on File

Study Area Code (SAC)

Page 4 of 8

Check this box if you are changing your Organization's
SAC data currently on file with USAC.
Study Area Type
Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

FCC Form 498-Sept. 2009 Edition

This page is for Rural Health Care Support Mechanism participants only.
For more information about the Rural Health Care Support Mechanism, please refer to: http://www.usac.org/rhc/

Block 9: Rural Health Care Support Mechanism Financial Institution and Remittance
Information [ALL Fields REQUIRED]
See Instruction Section III.J
Financial institution information is required. Electronic payment of universal service support payments
is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.
Check this box if this information is the same as the General Contact information (Block 2) and continue on to lines 79-82.
69
Remittance Company Name, if different from Company Name
70 First:
Middle Initial:
Last:
Remittance Contact Name- Statements will be sent to Remittance Contact's attention

71
Title

72
Remittance Address
73
Address Line 2
74

75
City

77 (
)
Phone Number

76
State

Ext

Zip Code + 4

78 (
)
Fax Number

Check this box if you are requesting mailed paper copy statements instead of electronic remittance statements
(If you do not check this box, your remittance statements will be sent to your e-mail address)
79
Remittance Financial Institution for ACH or locked box transfer of funds (required)
80

81
Financial Institution Account Number for ACH (required)

ACH Financial Institution transit Number - must be nine digits (required)

82
E-mail Address of Remittance Contact (Required if participating in the Rural Health Care Support Mechanism)

Block 10: Company Contact for Rural Health Care Support Mechanism
See Instruction Section III.K

Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 11.
83 First:
Middle Initial:
Contact Name for Rural Health Care Mechanism -

Last:

84
Title

(Must be a company employee or designated representative)

85
Contact Address for Rural Health Care Support Mechanism
86
Address Line 2
87

88
City

90 (
)
Phone Number

89
State

Ext

Zip Code + 4

91 (
)
Fax Number

92
E-mail Address of Rural Health Care Support Mechanism Contact

Page 5 of 8

FCC Form 498-Sept. 2009 Edition

This page is for Schools and Libraries Support Mechanism participants only.
For more information about the Schools and Libraries Support Mechanism, please refer to:
http://www.usac.org/sl/
Block 11: Schools and Libraries Support Mechanism Financial Institution and
Remittance Information [ALL Fields REQUIRED]
See Instruction Section III.L
Financial institution information is required. Electronic payment of universal service support payments
is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.
Check this box if this information is the same as the General Contact information (Block 2) and continue on to lines 103-106.
93
Remittance Company Name, if different from Company Name
94 First:
Middle Initial:
Last:
Remittance Contact Name- Statements will be sent to Remittance Contact's attention

95
Title

96
Remittance Address
97
Address Line 2
98

99
City

100
State

101 (
)
Phone Number

Ext

Zip Code + 4

102 (
)
Fax Number

Check this box if you are requesting mailed paper copy statements instead of electronic remittance statements
(If you do not check this box, your remittance statements will be sent to your e-mail address)
103
Remittance Financial Institution for ACH or locked box transfer of funds (required)
105

104
Financial Institution Account Number for ACH (required)

ACH Financial Institution Transit Number - must be nine digits (required)

106
E-mail Address of Remittance Contact (Required if participating in the Schools and Libraries Support Mechanism)

Block 12: Company Contact for Schools and Libraries Support Mechanism
See Instruction Section III.M

Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 13.
107 First:
Middle Initial:
Contact Name for Schools and Libraries Mechanism

Last:

##
Title

(Must be a company employee or designated representative)

109
Contact Address for Schools and Libraries Support Mechanism
110
Address Line 2
112

111
City
114

(
)
Phone Number

113
State

115
Ext

Zip Code + 4

(
)
Fax Number

116
E-mail Address of Schools and Libraries Support Mechanism Contact

Page 6 of 8

FCC Form 498-Sept. 2009 Edition

Block 13: Offsetting Disbursement Payments Against Federal Universal Service
Contribution Obligations
See Instruction Section III.N
The following information pertains only to telecommunications companies participating in the Schools and Libraries and Rural Health Care Support
mechanisms. In accordance with FCC rule section 54.515 regarding Schools and Libraries Support mechanism payments, a telecommunications company
may choose to offset its Schools and Libraries Support Mechanism payment against its Federal universal service contribution. In accordance with FCC rule
section 54.611 regarding Rural Health Care Support Mechanism payments, a telecommunications company MUST offset its Rural Health Care Support
Mechanism payment against its Federal universal service contribution. A telecommunications company must have an FCC Form 499 Filer ID number in
order to offset its Schools and Libraries or Rural Health Care Support Mechanism payments against its Federal universal service contribution. In order to
obtain an FCC Form 499 Filer ID number, visit www.universalservice.org/forms and select FCC Form 499. You do not need an FCC Form 499 Filer ID in
order to be issued a SPIN.
117

Yes, I want my Schools and Libraries Support Mechanism disbursement payments to be offset againbe offset against my Federal
universal service contribution obligations. This box must be checked in order to receive offsets.
The default is "No."

Block 14: Principal Communications Types [REQUIRED Field]
See Instruction Section III.O
Select up to 5 boxes that best describe the reporting entity. Enter numbers starting with "1" to show the order of importance -- see instructions.
CAP/CLEC
Prepaid Card
Cellular/PCS/SMR

Private Service Provider

Coaxial Cable

Satellite Service Provider

Incumbent LEC

Shared-Tenant Service Provider/Building LEC

Interexchange Carrier (IXC)

SMR (Dispatch)

Interconnected VOIP Provider

Toll Reseller

Local Reseller

Wireless Data Provider

Operator Service Provider

Non Traditional Provider (NTP)

Paging and Messaging

Internet Service Provider

Payphone Service Provider

Block 15: Authorized Contact Signature [All Fields REQUIRED]
See Instruction Section III.P
I certify that I am an officer of the above-named service provider, that I am authorized to submit this FCC Form 498 on behalf of the above named
service provider, and that to the best of my knowledge, the data set forth in this form is true, accurate, and complete.

Persons willfully making false statements on this form can be punished by fine or forfeiture, under the Communications Act, as amended, 47 U.S.C.
Secs.502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.

Company Officer Information

Check this box if this information is the same as the General Contact information (Block 2)

Signature of the Company Officer
First:
Printed Name

Title

Page 7 of 8

Date
Middle Initial:

Last:

E-mail address

FCC Form 498-Sept. 2009 Edition

You do not need to submit this page.
Notice: The Federal Communications Commission (the Commission) has designated the Universal Service Administrative Company (USAC) as administrator of Federal universal
service. One of the functions of USAC is to provide a mechanism for the billing, collection, and disbursement of funds for the various Federal universal service support
mechanisms. In an effort to implement these requirements and obligations, the Commission has adopted this collection of information. Pursuant to the Commission rules, 47 C.F.R.
§§ 54.301, 54.303, 54.307, 54.309, 54.311, 54.407, 54.413, 54.515, 54.611, 54.702, 54.802, and 54.902, USAC must obtain information relating to service provider name and
address, telephone number, Federal employee identification number, contact names and telephone numbers, and billing and collection information. Each service provider receiving
Federal universal service support from the High Cost, Low Income, Rural Health Care, or Schools and Libraries Support Mechanisms, should complete the FCC Form 498. USAC
will use this information in administering the billing, collections, and disbursement operations of the Federal universal service programs.

Reminder: You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection,
unless it displays a currently valid Office of Management and Budget (OMB) control number. This collection has been assigned an OMB control number of 3060-0824.

The Commission is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. We will use the information you provide for
the Federal universal service billing, collections, and disbursement purposes. If we believe there may be a violation or a potential violation of a state or Federal statute, or of a
Commission regulation, rule, or order, your form may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the
statute rule,
statute,
rule regulation,
regulation or order.
order In certain cases
cases, the information in your application may be disclosed to the Department of Justice
Justice, a court
court, or adjudicative body when (a) the
Commission; or (b) any employee of the Commission; or (c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding. In
addition, consistent with the Communications Act of 1934, FCC regulations and orders, the Freedom of Information Act, 5 U.S.C. § 552, or other applicable law, information
provided in or submitted with this form or in response to subsequent inquiries may be disclosed to the public.
If you owe a past due debt to the Federal government, the information you provide may also be disclosed to the Department of the Treasury Financial Management Service, other
Federal agencies, and/or your employer to offset your salary, IRS tax refund, or other payments to collect that debt. The Commission may also provide the information to these
agencies through the matching of computer records where authorized.
If you do not provide the information we request on the form, the Commission may delay processing of your application, or may return your application without action.

This Notice is required by the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. 3501 et seq. We have estimated that each response to this collection of information
will take, on average, 1.5 hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete
and review the form for response. If you have any comments on this estimate, or how we can improve the collections and reduce the burden it causes you, please write to the
Federal Communications Commission, AMD-PERM, Washington D.C. 20554, Paperwork Reduction Project (3060-0824). We will also accept your comments via Internet if you
send them to [email protected]. Please DO NOT SEND COMPLETED DATA COLLECTION FORMS TO THIS ADDRESS.
Mail this signed form to:
USAC Customer Operations, Billing and Disbursements
2000 L Street, N.W., Suite 200
Attn: FCC Form 498
Washington, DC 20036
Questions?
See the Form 498 Instructions found at www.usac.org/forms
Use this form for:
New application for a Service Provider Identification Number
Revision to existing Service Provider data currently on file with USAC
Merger or Consolidation of Existing Service Provider Identification Number (Additional documentation is required, please see page 2 of
the instructions)
Deactivation of a Service Provider Identification Number (Please see page 2 of the instructions

Page 8 of 8

FCC Form 498-Sept. 2009 Edition