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Universal Service - Rural Health Care Program

ICR 201308-3060-013 · OMB 3060-0804 · Object 41844401.

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Document Metadata

Record metadata
File Type	application/vnd.ms-excel
File Title	Universal Service - Rural Health Care Program
Author	Mark Walker
Last Modified By	Calc
File Modified	2013-06-28
File Created	2026-10-12
Conversion State	complete

Extracted Text

TELECOMMUNICATIONS PROGRAM INVOICE
FOR RHCD USE ONLY

Service Provider Name
SPIN
Service Provider Invoice Number
Invoice Date to RHCD (mm/dd/yy)
Total Invoice Amount
Funding
Year
(yyyy)

HCP #

Header
Verification
____
RHCD Processed Date
____
Number of Records
____
Number of Records Approved
____
RHCD Approved Total Amount
____

$0.00

Funding
Request #

Billing Account #

Multiple
Months
(Y or N)

Support Date
(mmyyyy)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Support Amount
to be Paid by
USAC

Code
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____

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 # :
OMB 3060-0804
Estimated time per response: 0.25 hours

RHCD SERVICE PROVIDER INVOICE
Service Provider Name
SPIN
Service Provider Invoice Number
Invoice Date to RHCD (mm/dd/yy)
Total Invoice Amount
Funding
Year
(yyyy)
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45

HCP #

0
0
0
12/30/99
$0.00

Funding
Request #

Billing Account #

Multiple
Months
(Y or N)

Support Date
(mmyyyy)

Support Amount
to be Paid by
USAC

For RHCD
Use OnlyCode
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____

OMB 3060-0804
Estimated time per response: 0.25 hours

RHCD SERVICE PROVIDER INVOICE
Service Provider Name
SPIN
Service Provider Invoice Number
Invoice Date to RHCD (mm/dd/yy)
Total Invoice Amount
Funding
Year
(yyyy)
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70

HCP #

0
0
0
12/30/99
$0.00

Funding
Request #

Billing Account #

Multiple
Months
(Y or N)

Support Date
(mmyyyy)

Support Amount
to be Paid by
USAC

For RHCD
Use OnlyCode
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____

OMB 3060-0804
Estimated time per response: 0.25 hours

RHCD SERVICE PROVIDER INVOICE
Service Provider Name
SPIN
Service Provider Invoice Number
Invoice Date to RHCD (mm/dd/yy)
Total Invoice Amount
Funding
Year
(yyyy)
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95

HCP #

0
0
0
12/30/99
$0.00

Funding
Request #

Billing Account #

Multiple
Months
(Y or N)

Support Date
(mmyyyy)

Support Amount
to be Paid by
USAC

For RHCD
Use OnlyCode
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____

OMB 3060-0804
Estimated time per response: 0.25 hours

RHCD SERVICE PROVIDER INVOICE
Service Provider Name
SPIN
Service Provider Invoice Number
Invoice Date to RHCD (mm/dd/yy)
Total Invoice Amount
Funding
Year
(yyyy)
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120

HCP #

0
0
0
12/30/99
$0.00

Funding
Request #

Billing Account #

Multiple
Months
(Y or N)

Support Date
(mmyyyy)

Support Amount
to be Paid by
USAC

For RHCD
Use OnlyCode
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____

OMB 3060-0804
Estimated time per response: 0.25 hours