Universal Service - Rural Health Care Program

TELECOMMUNICATIONS PROGRAM INVOICE
					FOR RHCD USE ONLY
					Header Verification
Service Provider Name					____	RHCD Processed Date
SPIN					____	Number of Records
Service Provider Invoice Number					____	Number of Records Approved
Invoice Date to RHCD (mm/dd/yy)					____	RHCD Approved Total Amount
Total Invoice Amount			$0.00		____
	Funding Year (yyyy)	HCP #	Funding Request #	Billing Account #	Multiple Months (Y or N)	Support Date (mmyyyy)	Support Amount to be Paid by USAC		Code
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I certify that the information contained in this invoice is correct and that the health care providers and Billing Account Numbers listed above have been credited with the amount shown under "Support Amount to be Paid by USAC".
Signature:						Date:
Print Name:						Telephone # :
RHCD SERVICE PROVIDER INVOICE
Service Provider Name			0
SPIN			0
Service Provider Invoice Number			0
Invoice Date to RHCD (mm/dd/yy)			12/30/99
Total Invoice Amount			$0.00
	Funding Year (yyyy)	HCP #	Funding Request #	Billing Account #	Multiple Months (Y or N)	Support Date (mmyyyy)	Support Amount to be Paid by USAC		For RHCD Use Only- Code
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RHCD SERVICE PROVIDER INVOICE
Service Provider Name			0
SPIN			0
Service Provider Invoice Number			0
Invoice Date to RHCD (mm/dd/yy)			12/30/99
Total Invoice Amount			$0.00
	Funding Year (yyyy)	HCP #	Funding Request #	Billing Account #	Multiple Months (Y or N)	Support Date (mmyyyy)	Support Amount to be Paid by USAC		For RHCD Use Only- Code
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70									____
RHCD SERVICE PROVIDER INVOICE
Service Provider Name			0
SPIN			0
Service Provider Invoice Number			0
Invoice Date to RHCD (mm/dd/yy)			12/30/99
Total Invoice Amount			$0.00
	Funding Year (yyyy)	HCP #	Funding Request #	Billing Account #	Multiple Months (Y or N)	Support Date (mmyyyy)	Support Amount to be Paid by USAC		For RHCD Use Only- Code
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RHCD SERVICE PROVIDER INVOICE
Service Provider Name			0
SPIN			0
Service Provider Invoice Number			0
Invoice Date to RHCD (mm/dd/yy)			12/30/99
Total Invoice Amount			$0.00
	Funding Year (yyyy)	HCP #	Funding Request #	Billing Account #	Multiple Months (Y or N)	Support Date (mmyyyy)	Support Amount to be Paid by USAC		For RHCD Use Only- Code
96									____
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