Form 462 RHCP Description of Request for Funding

Rural Health Care
Healthcare Connect Fund Program
Description of Request for Funding FCC Form 462
(Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual
representation of what each applicant will see, the order in which they will see information, or the exact wording or directions used to collect
the information. Where possible, information already provided by applicants from previous filing years or that was pre-filed in the system portal
will be carried forward and auto-populated into the form.)
Item #
1

Field Description
Funding Request Number (FRN)

Category
System Generated

2

Funding Year

Funding Details

3

Site Number

System Generated

4

Site Name

System Generated

5

Consortium Number

System Generated

6

Consortium Name

System Generated

7

Site Contact Information

System Generated

Purpose/Instructions
Auto-generated by the system: The system creates a unique identifier
for this request.
This is the selection of the funding year the applicant is submitting the
request for. A funding year runs from July 1 through June 30 of the
following year.
Auto-generated by the system: This is the unique identifier assigned by
the Universal Service Administrative Company (USAC) to the site listed
in Site Name. The Site Number was issued by USAC when the FCC Form
460 was completed.
Auto-generated by the system: This is the name the site submitted on
the FCC Form 460.
Auto-generated by the system: This is the unique identifier assigned by
USAC to the consortium listed in Consortium Name. The Consortium
Number was issued by USAC when the FCC Form 460 was completed.
Auto-generated by the system: This is the name the consortium
submitted on the FCC Form 460.
Auto-generated by the system: This is the site’s physical address,
county, city, state, zip code, telephone, website, contact name, contact
employer and geolocation the user provided on the FCC Form 460.
Geolocation only applies to a site that does not have a street address.

1

Item #
8

Field Description
Consortium Contact Information

Category
System Generated

FCC Form 461 Application
Number
Allowable Contract Selection
Date (ACSD)

System Generated

11

Number of Vendor Bids

Contract Selection

12

498 ID of Selected Vendor

Contract Selection

13

Selected Vendor Name

Contract Selection

14
15

Contract Selection
Contract Selection

16

Service Provider Selection Date
Continuation with Current
Service Provider
Pricing Confidentiality

17

Evergreen Review

Contract Selection
Details

18

Competitive Bidding Exemption

Bidding Details

9
10

System Generated

Contract Selection

Purpose/Instructions
Auto-generated by the system: This is the consortium’s address,
county, city, state, zip code, telephone, website, contact name, contact
employer and geolocation the user provided on the FCC Form 460.
Geolocation only applies to a site that does not have a street address.
Auto-generated by the system: This is a USAC-assigned unique
identifier for the FCC Form 461 associated with this FCC Form 462.
Auto-generated by the system: This is the first day in which an
applicant may agree to or sign a contract with a vendor. This is
calculated based on the number of days the 461 was posted. The ACSD
is no less than 29 calendar days after the date on which the FCC Form
461 was posted on USAC’s website.
The number of vendors who bid on the request for services in response
to the FCC Form 461.
The selected vendor’s 498 ID (formerly Service Provider Identification
Number (SPIN) ID).
Auto-generated by the system: Based on the 498 ID entered by the
user.
The date that the vendor was selected for the line item.
The user selects if the selected vendor is their current service provider.
The user indicates if there is a restriction that prevents the pricing
information provided by the vendor from becoming public. If so, the
applicant must describe the specific restriction and its source.
The user states that the contract submitted with the funding request
shall be reviewed for an evergreen endorsement (thereby allowing a
competitive bidding exemption for the life of the contract).
Only completed if the user is claiming a competitive bidding exemption.
If the applicant is claiming the “E-rate Approved Contract” bidding
exemption, then the applicant must provide: the E-rate Contract ID
(and friendly name), as requested on this FCC Form 462; the E-rate FCC
Form 470 number that initiated bidding for that contract; the E-rate
contact person for that contract (for quick access); and the contract
expiration date.
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Item #
19
20

Field Description
Single, Multiple or Consortium
Expense(s)
Site Number

Category
Expense Request
Details
Line Item Details

21

Site Name

Line Item Details

22

Contract ID

Line Item Details

23

Contract Friendly Name

Line Item Details

24
25
26

Expense Category
Expense Type
Circuit ID

Line Item Details
Line Item Details
Line Item Details

27

Circuit Start Location

Line Item Details

28

Circuit End Location

Line Item Details

29
30

Bandwidth
Symmetrical Service

Line Item Details
Line Item Details

31
32

Upload Speed
Download Speed

Line Item Details
Line Item Details

33
34
35
36
37
38

Percentage of Expense Eligible
Percentage of Usage Eligible
Billing Account Number (BAN)
Contract Signed Date
Initial Contract Length
Number of Contract Extensions

Line Item Details
Line Item Details
Line Item Details
Line Item Details
Line Item Details
Line Item Details

Purpose/Instructions
Allows the user to submit single and/or multiple eligible expense items,
or Consortium expense items within the request.
For multiple expense item requests or Consortium requests, the user
can assign site numbers to line items.
For multiple expense item requests or Consortium requests, the user
can assign site names to line items.
This is the unique identifier assigned by USAC to a contract or service
agreement. This identifier helps the user identify the contract in the
future.
This is a unique identifier/nickname created by the user for this request
(e.g., Smith Telecommunications Funding Year 2016).
The user selects the expense category of a line item.
The user selects the expense type of a line item.
The user enters a vendor-specific identifier assigned to the connection
between two locations for the line item. The Circuit ID is located on the
vendor invoice.
The physical location and/or Site Number where the circuit originates
for the line item.
The physical location and/or Site Number where the circuit terminates
for the line item.
The user enters the bandwidth for the service.
The user indicates if upload and download speeds are equal for the
service.
The user enters upload speed for the service.
If service is not symmetrical (different upload and download speeds,)
then the user enters the download speed for the service.
The percentage of the line item expense that is eligible for support.
The percentage of the line item expense that is used by an eligible site.
The line item BAN listed on the vendor’s bill.
The date the line item contract with the vendor was signed.
The length of the initial contract excluding voluntary options.
If the contract includes voluntary options to extend the term of the
contract, then the user enters the number of such voluntary options.
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Item #
39

Field Description
Duration of each contract
extension
Combined Optional Extension(s)
Length

Category
Line Item Details

Purpose/Instructions
The duration of each contract extension (if applicable)

Line Item Details

41
42

Expected Service Start Date
Service Level Agreement (SLA)

Line Item Details
Line Item Details

43
44
45
46
47

Latency
Jitter
Packet Loss
Reliability
Total Number of Fiber Strands

Line Item Details
Line Item Details
Line Item Details
Line Item Details
Line Item Details

48

Number of Fiber Strands Eligible

Line Item Details

49
50

Line Item Details
Line Item Details

51

Quantity of Items
Processing: Type Funding
Request
Expense Frequency

52

Quantity of Expense Periods

Line Item Details

53

Undiscounted Cost Per Expense
Period

Line Item Details

If the contract includes one or more voluntary options to extend the
term of the contract, then the user enters the combined length of all
the voluntary options.
The date service is expected to start.
The user indicates whether the applicant’s contract with the vendor
includes an SLA.
The latency requirement per the contract SLA.
The jitter requirement per the contract SLA.
The packet loss rate requirement per the contract SLA.
The reliability requirements per the contract SLA.
The total number of fiber strands that are part of the fiber lease or
similar agreement for this line item.
The number of fiber strands that are eligible for support for this line
item.
The number of items the applicant is seeking under this line item.
The user indicates the type of funding an applicant is requesting (e.g.
multi-year, month-to-month, etc.)
The user indicates the frequency of the expense for which support is
sought.
The user indicates the number of expense periods that are included
within this request.
The total undiscounted cost per expense period (excluding taxes and
fees).

54
55
56
57

New Circuit Installation
One-Time Installation Charges
Taxes & Fees Per Expense Period
Source of Healthcare Provider
Contribution

Line Item Details
Line Item Details
Line Item Details
Line Item Details

40

Line Item Details

The user indicates if the circuit is newly installed.
The user indicates any one-time installation charges.
The taxes and fees for the line item.
The sources from which the Site or Consortium will fund its 35 percent
contribution for this line item.

4

Item #
58

60

Field Description
Total Undiscounted Cost For
Eligible (Recurring) Expenses
Total Undiscounted Cost For
Eligible (Non-Recurring) Expenses
Confidentiality

Category
Expense Request
Details
Expense Request
Details

61

Supporting Documentation

Documentation

62

I certify under penalty of perjury
that I am authorized to submit
this request on behalf of the
health care provider or
consortium.

Certifications

63

I declare under penalty of perjury
that I have examined this request
and attachments and to the best
of my knowledge, information,
and belief, all information
contained in this request and in
any attachments is true and
correct.

Certifications

59

Purpose/Instructions
The system will calculate and display the total undiscounted cost for
recurring eligible expenses.
The system will calculate and display the total undiscounted cost for
non-recurring eligible expenses.
Optional. The user may request nondisclosure for certain commercial
and financial information. See 47 C.F.R. § 0.459(a)(4).
There is additional documentation required to be submitted (where
applicable) with the FCC Form 462 to support the request for funding.
Specifically, consortium and individual health care provider (HCP)
applicants must submit: contracts, terms of service agreements (if
applicable), competitive bidding documents, and written descriptions
of cost allocation (if applicable). Consortium applicants must also
submit: revisions to financial agreements (if submitted with the FCC
Form 460), revisions to the Network Plan (submitted with the FCC Form
461), a network cost worksheet listing all participating HCPs, evidence
of a viable source for the 35 percent contribution, sustainability plans
(if applicable), revisions to sustainability plans (if previously submitted)
and letters of agency (if not previously submitted).
Applicants are required to provide this certification in order to receive
Healthcare Connect Fund support. For individual Healthcare Provider
applicants, certifications must be signed by an officer or director of the
Healthcare Provider or other authorized employee of the Healthcare
Provider. For consortia applicants, an officer, director, or other
authorized employee of the Consortium Leader must sign the required
certification.
See Item #62 Purpose/Instructions above.

5

Item #
64

65

66

Field Description
I certify under penalty of perjury
that the health care provider or
consortium has considered all
bids received and selected the
most cost-effective method of
providing the requested services.
The “most cost-effective service”
is defined as the “method that
costs the least after
consideration of the features,
quality of transmission,
reliability, and other factors that
the health care provider deems
relevant to choosing a method of
providing the required health
care services.” 47 C.F.R. §
54.642(c).
I certify under penalty of perjury
that all Healthcare Connect Fund
support will be used only for the
eligible program purposes for
which support is intended.
I certify that the health care
provider or consortium is not
requesting support for the same
service from both the
Telecommunications Program
and the Healthcare Connect
Fund.

Category
Certifications

Purpose/Instructions
See Item #62, Purpose/Instructions above.

Certifications

See Item #62, Purpose/Instructions above.

Certifications

See Item #62, Purpose/Instructions above.

6

Item #
67

68

69

70
71

Field Description
I certify that the health care
provider or consortium satisfies
all of the requirements under
Section 254 of the
Telecommunications Act of 1996,
as amended, and applicable
Commission rules, and
understand that any letter from
the Administrator that
erroneously commits funds for
the benefit of the applicant may
be subject to rescission.
I certify that I have reviewed all
applicable rules and
requirements for the program
and will comply with those rules
and requirements.
I understand that all
documentation associated with
this application, including all bids,
contracts, scoring matrices, and
other information associated
with the competitive bidding
process, and all billing records for
services received, must be
retained for a period of at least
five years pursuant to 47 C.F.R. §
54.648, or as otherwise
prescribed by the Commission’s
rules.
Signature
Date Submitted

Category
Certifications

Purpose/Instructions
See Item #62, Purpose/Instructions above.

Certifications

See Item #62, Purpose/Instructions above.

Certifications

See Item #62, Purpose/Instructions above.

Signature
System Generated

The FCC Form 462 must be certified electronically.
Auto generated by system. This date is assigned based on the date the
user submits the FCC Form 462.
7

Item #
72

Field Description
Date Signed

Category
System Generated

73
74

Authorized Person Name
Authorized Person’s Employer

Signature
Signature

75

Authorized Person’s Employer
FCC Registration Number
Authorized Person’s
Title/Position
Authorized Person’s Mailing
Address
Authorized Person Telephone
Number
Authorized Person Email Address

Signature

76
77
78
79

Signature
Signature
Signature
Signature

Purpose/Instructions
Auto generated by system. This date is assigned based on the date the
user signs the FCC Form 462.
This is the name of the Authorized Person signing the FCC Form 462.
This is the name of the employer of the Authorized Person signing the
FCC Form 462.
This is the FCC registration number of the Authorized Person signing
the FCC Form 462.
This is the title of the Authorized Person signing the FCC Form 462.
This is the address (can be physical address or mailing address) of the
Authorized Person signing the FCC Form 462.
This is the telephone number of the Authorized Person signing the FCC
Form 462.
This is the email address of the Authorized Person signing the FCC Form
462.

8