FCC Form 498 Service Provider and Bill Entity Identification Number a

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File electronically at http://usac.org/about/tools/e-file.aspx/
FCC Form 498

OMB 3060-0824

Service Provider And Billed Entity Identification Number and General Contact Information
Form
Estimated Average Burden Hours Per Response: .75 hour
FCC Form 498 is used to collect contact and remittance information for service providers and billed entities 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.

Provider Type
Please check one box below

See Instruction Section III.A

Service Provider

School/Library or other Billed Entity

Submission Type
Please check one box below

See Instruction Section III.B

Original Application for FCC Form 498 ID

Revision to existing FCC Form 498 on file with USAC

Request for FCC Form 498 ID Merger/Consolidation

Request for FCC Form 498 ID Deactivation
See Instruction Section III.C

Service Provider and Billed Entity Identification Number (FCC Form 498 ID)
(To be inserted by USAC for first time applications. Required for subsequent revisions.)
499 Filer ID
(Required if your company is required to file the FCC Form 499)

Block 1: Organization Information [All Fields REQUIRED]
See Instruction Section III.D
1
Company or Billed Entity Name
2
Name Entity or Company is Doing Business As (DBA) or Formerly Known As (FKA)
3

4
Holding Company Name (For Service Providers )

5

Federal EIN, or TAX ID Number of Holding Company

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

6
Street Address
7
Address Line 2
8

9
City

10
State

Zip Code + 4

Block 2: General Contact Information [All Fields REQUIRED]
See Instruction Section III.E
11 First:
Middle Initial:
General Contact (Company Preparer Name)
13 (
)
Phone Number

Last:

12
Title

Ext.

14
Street Address
15
Address Line 2
16

17
City

18
State

Zip Code + 4

19
E-mail Address

Block 3: Federal EIN, DUNS and FCC Registration Number [All Fields REQUIRED]
See Instruction Section III.F
20

21
Enter Federal Employer Identification Number
(Federal EIN or Tax ID Number)

22

Corporation
Partnership
(Check applicable corporate structure.)

Other

23
Enter Dun and Bradstreet Number (DUNS)

Page 1 of 11

FCC Registration Number (CORES ID)

FCC Form 498-November 2015

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This is a Supplemental Page for Companies with Affiliate Relationships
Block 4: Affiliate Company Information
See Instruction Section III.G
Please list all companies with which this FCC Form 498 ID 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 FCC Form 498 ID Number

Affiliate Company Name

(Attach additional copies of this page if necessary)

Page 2 of 11

FCC Form 498-November 2015

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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.H

Check this box to discontinue use of this FCC Form 498 ID 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 29-31.
24
Remittance Company Name, if different from Company Name
25 First:
Middle Initial:
Last:
Remittance Contact Name - Statements will be sent to Remittance Contact's attention
27 (
)
Phone Number

26
Title

28
Ext

E-mail Address for receipt of remittance advice

29
Remittance Financial Institution for ACH or locked box transfer of funds (required)
30

31
ACH Financial Institution Transit Number - must be nine digits (required)

Financial Institution Account Number for ACH (required)

Block 6: Organization Contact for High Cost 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 7.
32 First:
Middle Initial:
Contact Name for High Cost Program

Last:

33
Title

(Must be a company employee or designated representative)

34
Contact Address or PO Box for High Cost Program
35
Address Line 2
36

37
City

39 (
)
Phone Number

Page 3 of 11

38
State

Zip Code + 4

40
Ext

E-mail Address of High Cost Program Contact

FCC Form 498-November 2015

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

Block 7: Lifeline Support Financial Institution and Remittance
Information [All Fields REQUIRED]
See Instruction Section III.J
Check this box to discontinue use of this FCC Form 498 ID for Lifeline 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 46-48.
41
Remittance Company Name, if different from Company Name
42 First:
Middle Initial:
Last:
Remittance Contact Name - Statements will be sent to Remittance Contact's attention
44 (
)
Phone Number

43
Title

45
E-mail Address for receipt of remittance advice

Ext

46
Remittance Financial Institution for ACH or locked box transfer of funds (required)
47

48
ACH Financial Institution transit Number - must be nine digits (required)

Financial Institution Account Number for ACH (required)

Block 8: Organization Contact for Lifeline Support
See Instruction Section III.K
Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 9.
49 First:
Middle Initial:
Contact address for Lifeline Program

Last:

50
Title

(Must be a organization employee or designated representative)

51
Contact Address for Lifeline Program
52
Address Line 2
53

54
City

56 (

)

Phone Number

Page 4 of 11

55
State

Zip Code + 4

57
Ext

E-mail Address of Lifeline Program Contact

FCC Form 498-November 2015

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This is a Supplemental Page for Participants in the High Cost and Lifeline Programs.
Block 9: High Cost and Lifeline Study Area/FCC Form 498 ID Association
See Instruction Section III.L
This information will be used to associate the Study Area Codes (SAC) to this FCC Form 498 ID for the purposes of
High Cost and Lifeline 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 11

FCC Form 498-November 2015

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This page is for Rural Health Care Program 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]

Check this box to discontinue use of this FCC Form 498 ID 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.

See Instruction Section III.M

Check this box if this information is the same as the General Contact information (Block 2) and complete lines 63-65.
58
Remittance Company Name, if different from Company Name
59 First:
Middle Initial:
Last:
Remittance Contact Name - Statements will be sent to Remittance Contact's attention
61 (
)
Phone Number

Ext

60
Title

62
E-mail Address for receipt of remittance advice

63
Remittance Financial Institution for ACH or locked box transfer of funds (required)
64

65
Financial Institution Account Number for ACH (required)

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

Block 11: Organization Contact for Rural Health Care 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 12.
66 First:
Middle Initial:
Contact Name for Rural Health Care Program

Last:

67
Title

(Must be a company employee or designated representative)

68
Contact Address for Rural Health Care Program
69
Address Line 2
70

71
City

73 (
)
Phone Number

Page 6 of 11

72
State

Ext

Zip Code + 4

74
E-mail Address of Rural Health Care Program Contact

FCC Form 498-November 2015

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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]
Check this box discontinue use of this FCC Form 498 ID 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.

See Instruction Section III.O

Check this box if this information is the same as the General Contact information (Block 2) and complete lines 80-82.
75
Remittance Company Name, if different from Company or Billed Entity Name
76 First:
Middle Initial:
Last:
Remittance Contact Name - Statements will be sent to Remittance Contact's attention
78 (
)
Phone Number

Ext

77
Title

79
E-mail Address for receipt of remittance advice

80
Remittance Financial Institution for ACH or locked box transfer of funds (required)
82

81

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

Financial Institution Account Number for ACH (required)

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

Last:

84
Title

(Must be a company, or entity employee or designated representative)

85
Contact Address for Schools and Libraries Program
86
Address Line 2
City
90

89

88

87
(
)
Phone Number

Page 7 of 11

State
Ext

Zip Code + 4

91
E-mail Address of Schools and Libraries Program Contact

FCC Form 498-November 2015

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This is a Supplemental Page for Schools, Libraries and Other Applicant Payment Recipients
Block 14: Billed Entity Number/FCC Form 498 Association
See Instruction Section III.Q
Please list all Billed Entity Numbers with which this FCC Form 498 ID affiliated.

Billed Entity Number

Billed Entity Name

(Attach additional copies of this page if necessary)

Page 8 of 11

FCC Form 498-November 2015

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Disbursement Offsets and Healthcare Connect Certification
Block 15: Offsetting Disbursement Payments Against Federal Universal Service
Contribution Obligations For High Cost Participants
See Instruction Section III.R
The following information pertains only to telecommunications companies participating in the High Cost Program. 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 High Cost
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 FCC Form 498 ID.

92

Yes, I want my High Cost 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 16: Offsetting Disbursement Payments Against Federal Universal Service
Contribution Obligations For Lifeline Participants
See Instruction Section III.S
The following information pertains only to telecommunications companies participating in the Lifeline Program. 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 Lifeline
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 FCC Form 498 ID.

93

Yes, I want my Lifeline 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 17: 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 FCC Form 498 ID.
94

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 18: Certification to Assist Health Care Providers
See Instruction Section III.T
In accordance with FCC rule section 54.640(b), service providers participating in the Healthcare Connect Fund Program 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.

95

I certify, as a condition of receiving support under the Healthcare Connect Fund Program, 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 19: Offsetting Disbursement Payments Against Federal Universal Service
Contribution Obligations For Schools and Libraries Participants
See Instruction Section III.U
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
96

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."

Page 9 of 11

FCC Form 498-November 2015

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Service Identification
Block 20: Principal Communications Types [REQUIRED Field]
See Instruction Section III.V
Select up to 5 boxes that best describe the reporting entity. Enter numbers starting with "1" to show the order of importance -- see instructions.
Interconnected VoIP
Audio Bridging Provider
Coaxial Cable
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)
School/Library or other Billed Entity Recipient

Officer Certification
Block 21: Officer Certification [All Fields REQUIRED]
See Instruction Section III.W
I certify that I am an officer of the above-named service provider, that I am authorized to submit this FCC Form 498 data on behalf of the above named service
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.

Officer Information

Check this box if this information is the same as the General Contact information (Block 2)

Signature of the Officer
First:

Date
Middle Initial:

Last:

Title

Printed Name

E-mail Address of Company Officer

Page 10 of 11

FCC Form 498-November 2015

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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, Lifeline, 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 hour. 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, AMD-PERM,
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.

To submit this form:

Access the USAC E-File System here: http://usac.org/about/tools/e-file.aspx/

For support:

USAC Customer Operations, Forms Processing
2000 L Street, N.W., Suite 200
Washington, DC 20036
(888) 641-8722
[email protected]

Questions?
See the FCC Form 498 Instructions found at http://usac.org/sp/tools/forms.aspx
Use this form for:
New application for a FCC Form 498 ID (FKA SPIN/Service Provider Identification Number)
Revision to existing 498 data currently on file with USAC
Merger or Consolidation of FCC Form 498 ID (Additional documentation is required, please see page 2 of the instructions)
Deactivation of an FCC Form 498 ID (Please see page 2 of the instructions)

Page 11 of 11

FCC Form 498-November 2015