FCC Form 467 Connection Certification

FCC Form

467

Health Care Providers Universal Service

Connection Certification

Approval by OMB

3060-0804

_{Estimated time per response: .5 hour}

Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.

The Connection Certification (Form 467) is the means by which an HCP informs RHCD that the service provider(s) has turned on the service(s) for which the HCP is seeking reduced rates under the universal service support mechanism. Form 467 must also be used to notify RHCD that a supported service was disconnected or that the service was not or will not be turned on during the funding year.

applicant must submit one Form 467 for each Form 466 or Form 466-A that it previously submitted to RHCD.

5 By filing this form, the HCP or its authorized representative is (check one):

c=J

c=Jconfirming the connection of a telecommunications or Internet service for which the HCP has requested a discount and is confirming the accuracy of all information previously filed with RHCD regarding this service; or

Notifying RHCD of the disconnection of a discounted service. Date of Disconnection (mm/dd/yyyy) _

c=Jinforming RHCD that service was not (or will not be) turned on during the funding year

Block 4: Connection Information

6 Funding Request Number

7 Service Provider Name

8 Service Provider Identification Number (SPIN)

9 Billing Account Number

10 Type of Telecommunications Service & Circuit Bandwidth or "Internet" for Internet service.

11 Actual Service Start Date (date service began)

12 End of Service Date (date service was or will be turned off)

Block 5: Certification

13 c=JI certify that the service identified above has been or is being provided to the above-named health care provider. I certify that the

universal service credit will be applied to the telecommunications service or Internet billing account of the HCP or the billed entity

as directed by the HCP. I certify that I am authorized to submit this request on behalf of the above-named HCP, and that I have examined this request and that to the best of my knowledge, information and belief, all statements of fact contained herein are true.

14 c=]Pursuant to 47 C.F.R. Sees. 54.601 and 54.603, I certify that the HCP or consortium that I am representing satisfies all of the requirements herein and will abide by all of the relevant requirements, including all applicable FCC rules, with respect to universal service benefits provided under 47 U.S.C. Sec. 254. I understand that any letter from RHCD that erroneously states that funds will be made available for the benefit of the applicant may be subject to rescission.

15 Signature 16 Date

17 Printed name of authorized person 18 Title or position of authorized person

19 Employer of authorized person 20 Employer's FCC RN

FCC Form 467

November 2012

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Please remember:

• This form must be submitted to RHCD in order for the HCP to receive support and may be submitted at the same time or after the billed entity has submitted the Form 466 or Form 466-A.

• You may submit this form along with the Form 466 or Form 466-A only if the service has started.

Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act, 47 U.S.C. Sees. 502,

503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 3 of the Commission's Rules authorize the FCC to request the information on this form. The data reported will be used to verify that the

health care provider participating in the universal service support mechanism has begun to receive, or has stopped receiving, the services for which universal service support has been allocated. The information will be used by the Universal Service Administrative Company and/or the staff of the Federal Communications Commission, to evaluate this form, to provide information for enforcement and rulemaking proceedings and to maintain a current inventory of applicants, health care providers, billed entities, and service providers. No authorization can be granted unless all information requested is provided. Failure to provide all requested information will delay the processing of the application or result in the application being returned without action. Information requested by this form will be available for public inspection. Your response is required to obtain the

requested authorization.

The public reporting for this collection of information is estimated to average .5 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you have any comments on this burden estimate, or how we can improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, AMD-PERM, Paperwork Reduction Act Project (3060-0804), Washington, DC 20554. We will also accept your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to [email protected]. PLEASE

DO NOT SEND YOUR RESPONSE TO THIS ADDRESS.

Remember- 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 OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-0804.

THE FOREGOING NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974,5 U.S.C. 552a(e)(3) AND THE PAPEWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995,44 U.S.C. SECTION 3507.

This form should be submitted to: Rural Health Care Division

30 Lanidex Plaza West, P.O.Box 685

Parsippany NJ 07054-0685

FCC Form 467

November 2012