FCC Form 466-A Internet Service Funding Request and Certification Form

FCC Form

Health Care Providers Universal Service

Approval by OMB

466 - A

3060—0804
Internet Service Funding Request and Certification Form
(And Advanced Services Funding Request and Certification for Entirely Rural States)
The Deadline to submit this Form is the June 30th End of the Funding Year.
Estimated time per response: 1.5 hours
Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.

Block 1: HCP Information
1 HCP Name
2 HCP Number
3 Form 465 Application #
4 Consortium Name (If any)
Block 2: Bill Payer Information
5 Billed Entity Name
6 Billed Entity's FCC RN
7 Contact Name
8 Address Line 1
9 Address Line 2
10 City
11 State
12 Zip
13 Contact Phone #
14 Fax #
15 E-Mail
Block 3: Funding Year Information
16 Funding Year - Check only one box
Year 2013 (7/1/2013-6/30/2014)
Year 2014 (7/1/2014-6/30/2015)
Year 2015 (7/1/2015-6/30/2016)
Block 4: Service Information
17 Give a brief description of the service for which support is requested:

18 Percentage of HCP's service used for the provision of health care. (If less than 100%, please explain.)

19
20
21
23
25

Location where service is provided:
Service Provider Name
Service Provider Identification Number (SPIN)
Contract Number (NA if no contract)
Contract Expiration Date (NA if no contract)

22 Billing Account Number
24 Date contract signed or service selected
26 Expected Service Start Date

27 Were bids received in response to Form 465?
Yes
No If yes, submit copies.
Block 5: Cost of Service
28 Installation Charge (If applicable)
29 Monthly rate charge (Enclose documentation)
Block 6: Certification
30
I certify that the above named entity has considered all bids received and selected the most cost-effective method of providing the
requested service or services. The "most cost-effective service" is defined in the Universal Service Order as the service available at the
lowest cost after consideration of the features, quality of transmission, reliability, and other factors that the health care provider deems
necessary for the service to adequately transmit the health care services required by the health care provider.
31
Pursuant to 47 C.F.R. Secs. 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.
32
I hereby certify that the billed entity requesting reduced rates will maintain complete records for the service for five years.
33

I certify that I am authorized to submit this request on behalf of the above-named Billed Entity and HCP, and that I have examined this
form and attachments and that to the best of my knowledge, information, and belief, all statements of fact contained herein are true.
34 Signature
35 Date
36 Printed name of authorized person

37 Title or position of authorized person

38 Employer of authorized person

39 Employer's FCC RN

FCC Form 466 - A
November 2012

Please remember:
w An applicant may not file a Form 466-A until after signing the contract or otherwise selecting a service provider
w The HCP or its authorized representative must wait at least 28 days from the Form 465 posting date before signing the contract
or otherwise selecting a service provider.
w You must be authorized to provide the information required by Form 466-A on behalf of the HCP, and you must sign and date the form.
w Provide data for all items that apply. Attach additional sheets if necessary. Any attachments to Form 466-A must be clearly labeled.
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.
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 ensure that health
care providers have selected the most cost-effective method of providing the requested services as set forth in 47 C.F.R. § 54.603(b)(4). 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 1 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

Approval by OMB 3060-0804
Estimated time per response: 1.5 hours

FCC Form 466 - A
November 2012