FCC Form 498 Service Provider Identification Number (SPIN) and Genera

Save time, avoid problems. File electronically at http://www.usac.org/sp/about/498/default.aspx
FCC Form 498

DRAFT-MAY 2013

DRAFT 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 programs. 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 programs 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://usac.org/sp/tools/forms.aspx, 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

Check this Box if the Company is part of or maintains affiliate companies and complete page 2.

4
Street Address
5
Address Line 2
6

7
City

8
State

Zip Code + 4

Block 2: General Contact Information [All Fields REQUIRED]
See Instruction Section III.C
9 First:
Middle Initial:
General Contact (Company Preparer Name)
11 (
)
Phone Number

Last:

10
Title

12 (
)
Fax Number

Ext.

13
Street Address
14
Address Line 2
15

16
City

17
State

Zip Code + 4

18
E-mail Address

Block 3: Federal EIN, DUNS and FCC Registration Number [All Fields REQUIRED]
19

20
Enter Federal Employer Identification Number
(Federal EIN or Tax ID Number)

21

Corporation
Partnership
(Check applicable corporate structure.)

See Instruction Section III.D
Other

22
Enter Dunn and Bradstreet Number (DUNS)

Page 1 of 9

FCC Registration Number (CORES ID)

FCC Form 498- DRAFT

This is a Supplemental Page for Companies with Affiliate Relationships
Block 4: Affiliate Company Information
See Instruction Section III.E
Please list all companies with which this SPIN is affiliated. The term "affiliate" means a person that (directly or indirectly) owns
or controls, is owned or controlled by, or is under common ownership or control with, another person. For purposes of this paragraph,
the term "own" means to own an equity interest (or the equivalent thereof) of more than 10 percent.
Affiliate SPIN Number

Affiliate Company Name

(Attach additional copies of this page if necessary)

Page 2 of 9

FCC Form 498- DRAFT

This page is for High Cost Program participants only.
For more information about the High Cost Program, please refer to: http://www.usac.org/hc/
Block 5: High Cost Support Financial Institution and Remittance
Information [ALL Fields REQUIRED]
See Instruction Section III.F
Check this box to discontinue use of this SPIN for High Cost Support.
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 complete lines 33-35.
23
Remittance Company Name, if different from Company Name
24 First:
Middle Initial:
Last:
Remittance Contact Name - Statements will be sent to Remittance Contact's attention

25
Title

26
Remittance Contact Address
27
Address Line 2
28

29
City

31 (
)
Phone Number

30
State

Ext

Zip Code + 4

32 (
)
Fax Number

33
Remittance Financial Institution for ACH or locked box transfer of funds (required)
34

35
Financial Institution Account Number for ACH (required)

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

36
E-mail Address of Remittance Contact (Required if participating in the High Cost Program)

Block 6: Company Contact for High Cost Support
See Instruction Section III.G

Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 7.
37 First:
Middle Initial:
Contact Name for High Cost Program

Last:

38
Title

(Must be a company employee or designated representative)

39
Contact Address for High Cost Program
40
Address Line 2
41

42
City

44 (
)
Phone Number

43
State

Ext

Zip Code + 4

45 (
)
Fax Number

46
E-mail Address of High Cost Program Contact

Page 3 of 9

FCC Form 498- DRAFT

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

Block 7: Low Income Support Financial Institution and Remittance
Information [All Fields REQUIRED]
See Instruction Section III.H
Check this box to discontinue use of this SPIN for Low Income Support.
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 complete lines 57-59.
47
Remittance Company Name, if different from Company Name
48 First:
Middle Initial:
Last:
Remittance Contact Name - Statements will be sent to Remittance Contact's attention

49
Title

50
Remittance Address
51
Address Line 2
52

53
City

55 (
)
Phone Number

54
State

Zip Code + 4

56 (
)
Fax Number

Ext

57
Remittance Financial Institution for ACH or locked box transfer of funds (required)
58

59
Financial Institution Account Number for ACH (required)

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

60
E-mail Address of Remittance Contact (Required if participating in the Low Income Program)

Block 8: Company Contact for Low Income Support
See Instruction Section III.I
Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 9.
61 First:
Middle Initial:
Contact address for Low Income Program

Last:

62
Title

(Must be a company employee or designated representative)

63
Contact Address for Low Income Program
64
Address Line 2
65

66
City

68 (
)
Phone Number

67
State

Ext

Zip Code + 4

69 (
)
Fax Number

70
E-mail Address of Low Income Program Contact

Page 4 of 9

FCC Form 498- DRAFT

This is a Supplemental Page for Participants in the High Cost and Low Income Programs.
Block 9: High Cost and Low Income Study Area/SPIN Association
See Instruction Section III.J
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)

SAC Company Name

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

(Attach additional copies of this page if necessary)

Page 5 of 9

FCC Form 498- DRAFT

This page is for Rural Health Care Support participants only.
For more information about Rural Health Care Support, please refer to: http://www.usac.org/rhc/
Block 10: Rural Health Care Support Financial Institution and Remittance
Information [ALL Fields REQUIRED]
See Instruction Section III.K
Check this box to discontinue use of this SPIN for Rural Health Care Support.
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 complete lines 81-83.
71
Remittance Company Name, if different from Company Name
72 First:
Middle Initial:
Last:
Remittance Contact Name - Statements will be sent to Remittance Contact's attention

73
Title

74
Remittance Address
75
Address Line 2
76

77
City

79 (
)
Phone Number

78
State

Ext

Zip Code + 4

80 (
)
Fax Number

81
Remittance Financial Institution for ACH or locked box transfer of funds (required)
82

83
Financial Institution Account Number for ACH (required)

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

84
E-mail Address of Remittance Contact (Required if participating in the Rural Health Care Program)

Block 11: Company Contact for Rural Health Care Support
See Instruction Section III.L
Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 12.
85 First:
Middle Initial:
Contact Name for Rural Health Care Program

Last:

86
Title

(Must be a company employee or designated representative)

87
Contact Address for Rural Health Care Program
88
Address Line 2
89

90
City

92 (
)
Phone Number

91
State

Ext

Zip Code + 4

93 (
)
Fax Number

94
E-mail Address of Rural Health Care Program Contact

Page 6 of 9

FCC Form 498- DRAFT

This page is for Schools and Libraries Program participants only.
For more information about the Schools and Libraries Program, please refer to: http://www.usac.org/sl/
Block 12: Schools and Libraries Support Financial Institution and
Remittance Information [ALL Fields REQUIRED]
See Instruction Section III.M
Check this box discontinue use of this SPIN for Schools and Libraries Support.
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 complete lines 105-107.
95
Remittance Company Name, if different from Company Name
96 First:
Middle Initial:
Last:
Remittance Contact Name - Statements will be sent to Remittance Contact's attention

97
Title

98
Remittance Address
99
Address Line 2
100

101
City

102
State

103 (
)
Phone Number

Zip Code + 4

104 (
)
Fax Number

Ext

105
Remittance Financial Institution for ACH or locked box transfer of funds (required)
107

106
Financial Institution Account Number for ACH (required)

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

Alternative Banking Information for the payment of Billed Entity Applicant Reimbursements
Check this box if you wish to use the same banking information as listed in lines 105-107.
108
Remittance Financial Institution for ACH or locked box transfer of funds (required)
110

109
Financial Institution Account Number for ACH (required)

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

111
E-mail Address of Remittance Contact (Required if participating in the Schools and Libraries Program)

Block 13: Company Contact for Schools and Libraries Support
See Instruction Section III.N
Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 14.
112 First:
Middle Initial:
Contact Name for Schools and Libraries Program

Last:

113
Title

(Must be a company employee or designated representative)

114
Contact Address for Schools and Libraries Program
115
Address Line 2
117

116
City
119

(
)
Phone Number

118
State

120
Ext

(
Fax Number

Zip Code + 4
)

121
E-mail Address of Schools and Libraries Program Contact

Page 7 of 9

FCC Form 498- DRAFT

Disbursement Offsets and Healthcare Connect Certification
Block 14: Offsetting Disbursement Payments Against Federal Universal Service
Contribution Obligations For Rural Healthcare Participants
See Instruction Section III.O
The following information pertains only to telecommunications companies participating in the Rural Health Care Program. In accordance with FCC rule section 54.679
regarding Rural Health Care payments, a telecommunications company may choose to offset its payment against its Federal universal service contribution. A
telecommunications company must have an FCC Form 499 Filer ID number in order to offset its Rural Health Care Program payments against its Federal universal
service contribution. In order to obtain an FCC Form 499 Filer ID number, visit http://www.usac.org/cont/tools/forms/default.aspx and select FCC Form 499. You do not
need an FCC Form 499 Filer ID in order to be issued a SPIN.

122

Yes, I want my Rural Health Care Program disbursement payments to be offset against my Federal
universal service contribution obligations. This box must be checked in order to receive offsets. The Default is "No."

Block 15: Certification to Assist Health Care Providers
See Instruction Section III.P
In accordance with FCC rule section 54.640(b), service providers participating in the Healthcare Connect Fund must certify, as a condition of receiving support, that they
will provide to health care providers, on a timely basis, all information and documents regarding supported equipment, facilities, or services that are necessary for the
health care provider to submit required forms or respond to FCC or USAC inquiries. USAC may withhold disbursements to the service provider if the service provider,
after written notice from USAC, fails to comply with this requirement.

123

I certify, as a condition of receiving support under the Healthcare Connect Fund, that the above-named service provider will provide to
health care providers, on a timely basis, all information and documents regarding the supported equipment, facility(ies), or service(s)
that are necessary for the health care provider to submit required forms or respond to FCC or USAC inquiries.

Block 16: Offsetting Disbursement Payments Against Federal Universal Service
Contribution Obligations For Schools and Libraries Participants
See Instruction Section III.Q
The following information pertains only to telecommunications companies participating in the Schools and Libraries Program. In accordance with FCC rule section 54.515
regarding Schools and Libraries Program payments, a telecommunications company may choose to offset its Schools and Libraries Program 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 payments against
its Federal universal service contribution. In order to obtain an FCC Form 499 Filer ID number, visit http://www.usac.org/cont/tools/forms/default.aspx and select FCC
Form 499. You do not need an FCC Form 499 Filer ID in order to be issued a SPIN.

124

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

Service Identification
Block 17: Principal Communications Types [REQUIRED Field]
See Instruction Section III.R
Select up to 5 boxes that best describe the reporting entity. Enter numbers starting with "1" to show the order of importance -- see instructions.
Audio Bridging Provider
Interconnected VoIP
Coaxial Cable

Page 8 of 9

Paging and Messaging

Non-Interconnected VoIP

SMR (Dispatch)

Private Service Provider

Shared-Tenant Service Provider

Toll Reseller

Cellular/PCS/SMR

Incumbent LEC

Interexchange Carrier

Operator Service Provider

Payphone Service Provider

Satellite Service Provider

Local Reseller

Wireless Data

Internet Service Provider

CAP/CLEC

Non-Traditional Provider (NTP)

FCC Form 498- DRAFT

Officer Certification
Block 18: Authorized Contact Signature [All Fields REQUIRED]
See Instruction Section III.S
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. 220(e), 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

Date
Middle Initial:

Last:

Title

E-mail address

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 programs. 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
Programs, 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, regulation, or order. In certain cases, the
information in your application may be disclosed to the Department of Justice, a 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, AMDPERM, 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, Forms Processing
2000 L Street, N.W., Suite 200
Attn: FCC Form 498
Washington, DC 20036
Questions?
See the FCC Form 498 Instructions found at http://usac.org/sp/tools/forms.aspx
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 9 of 9

FCC Form 498- DRAFT