Form 463 RHCP Description of Request for Funding Disbursement

Rural Health Care
Healthcare Connect Fund Program
Description of Request for Funding Disbursement FCC Form 463
(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-generated into the form.)
Item # Field Description
1
Rural Health Care Invoice Number

Category
Request Information

2

Funding Request Number (FRN)

Request Information

3

Funding Year: Funding Start Date

Request Information

4

Funding Year: Funding End Date

Request Information

5

Site Number

Request Information

6

Site Name

Request Information

7

Consortium Number

Request Information

8

Consortium Name

Request Information

Purpose/Instructions
Auto-generated by the system: This is the unique identifier for the
FCC Form 463.
Auto-generated by the system: This is a unique identifier autogenerated by the system on the FCC Form 462 and provided in the
funding commitment letter to the applicant.
Auto-generated by the system: This displays the date funding began
for this Funding Request Number (FRN). Taken from information
provided on the FCC Form 462. Funding years start on July 1 of each
year and end on June 30 of the following year.
Auto-generated by the system: This displays the date funding will
end/ended for this FRN. Taken from information provided on the FCC
Form 462.
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 Site 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.
1

Item # Field Description
9
Site Contact Information

Category
Request Information

10

Consortium Contact Information

Request Information

11

498 ID of Service Provider

Request Information

12

Service Provider Name

Request Information

13

Service Provider/Applicant Invoice
Number
Funding Request Number
Identification Number (FRN ID)
Site Number: Line Item Details
Site Name: Line Item Details
Expense Category
Expense Type
Bandwidth
Service Start Date
Quantity of Items
Billing Account Number (BAN)
Billing Period Start Date
Billing Period End Date
Billing Period Eligible Amount

Request Information

14
15
16
17
18
19
20
21
22
23
24
25

Purpose/Instructions
Auto-generated by the system: This is the site’s physical address,
county, city, state, zip code, telephone, website, 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 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: The selected service provider’s 498 ID
(formerly Service Provider Identification Number (SPIN) ID). The 498
ID is pulled from the FCC Form 462 for an FRN.
Auto-generated by the system: Based on the 498 ID entered by the
user and pulled from the FCC Form 462 for the FRN.
Optional. Allows the vendor and/or applicant to track their FCC Form
462 within their billing system.
Auto-generated by the system: Building upon the FRN, the system
auto-generates an FRN ID to correspond to an individual line item.
Auto-generated by the system: Based on the line item’s FRN ID.
Auto-generated by the system: Based on the line item’s FRN ID.
Auto-generated by the system: Based on the line item’s FRN ID.
Auto-generated by the system: Based on the line item’s FRN ID.
Auto-generated by the system: Based on the line item’s FRN ID.
The date service is expected to start for the line item.
The number of items the applicant is seeking under the line item.
The line item BAN is listed on the service provider’s bill.
The first date of the billing period for the invoice.
The last date of the billing period for the invoice.
Auto-generated by the system: The amount an applicant is eligible to
receive for the billing period. This is derived from information
supplied on the FCC Form 462.

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

2

Item # Field Description
26
Total Actual Undiscounted Cost

Category
Line Item Details

27

Percentage of Expense Eligible

Line Item Details

28

Percentage of Usage Eligible

Line Item Details

29

Total Eligible Actual Cost

Line Item Details

30

USF Support To Be Paid

Line Item Details

31

Supporting Documentation

Documentation

32

I certify under penalty of perjury
that I am authorized to submit this
request on behalf of the service
provider.
I understand that the service
provider must apply the amount
submitted, approved, and paid by
USAC to the billing account of the
health care provider(s) and
FRN/FRN ID listed on this invoice.

Service provider
Certifications

33

Purpose/Instructions
The actual total undiscounted cost (including taxes and fees) for the
billing period.
Auto-generated by the system: The percentage of the line item
expense that is eligible for support. Taken from information provided
on the FCC Form 462.
Auto-generated by the system: The percentage of the line item
expense that is used by an eligible site. Taken from information
provided on the FCC Form 462.
Auto-generated by the system: The system will calculate and display
the total amount of the line item expense that is eligible for universal
service fund (USF) support. Taken from information provided on the
FCC Form 462.
The system will calculate and display the total amount of the line
item expense that USAC will pay the service provider for the line
item.
Optional. Provides the option for the user to upload and submit
documents to support their request.
The service provider’s representative must make this certification.

See Item # 32, Purpose/Instructions.

Service provider
Certifications

3

Item # Field Description
34
I declare under penalty of perjury
that I have examined this form and
attachments to the best of my
knowledge, information, and
belief, the date, quantities, and
costs provided are true and
correct.
35
Signature

Category
Service provider
Certifications

Purpose/Instructions
See Item # 32, Purpose/Instructions.

Service provider Signature

The FCC Form 463 must be certified electronically by the service
provider.
Auto generated by system.
Auto generated by system.
This is the name of the Authorized Person signing the FCC Form 463
on behalf of the service provider.
This is the name of the employer of the Authorized Person signing the
FCC Form 463 on behalf of the service provider.
This is the FCC RN of the Authorized Person signing the FCC Form 463
on behalf of the service provider.
This is the title of the Authorized Person signing the FCC Form 463 on
behalf of the service provider.
This is the address (can be physical address or mailing address) of the
Authorized Person signing the FCC Form 463 on behalf of the service
provider.
This is the telephone number of the Authorized Person signing the
FCC Form 463 on behalf of the service provider.
This is the email address of the Authorized Person signing the FCC
Form 463 on behalf of the service provider.
The authorized representative of the Consortium Leader (or,
Healthcare Provider, if participating individually) must make this
certification.

36
37
38

Date Submitted
Date Signed
Authorized Person Name

System Generated
System Generated
Service provider Signature

39

Authorized Person’s Employer

Service provider Signature

40

Authorized Person’s Employer FCC
RN
Authorized Person’s Title/Position

Service provider Signature

42

Authorized Person’s Mailing
Address

Service provider Signature

43

Authorized Person Telephone
Number
Authorized Person Email Address

Service provider Signature

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

Applicant Certifications

41

44
45

Service provider Signature

Service provider Signature

4

Item # Field Description
46
I declare under penalty of perjury
that I have examined this form and
attachments to the best of my
knowledge, information, and
belief, the date, quantities, and
costs provided are true and
correct.
47
I declare under penalty of perjury
that the HCP or consortium
members have received the
related services, network
equipment, and/or facilities
itemized on this Form 463.
48
I declare under penalty of perjury
that the required 35 percent
minimum contribution for each
item on the Form 463 was funded
by eligible sources as defined in
the FCC rules and that the required
contribution was remitted to the
service provider.
49
Signature
50
Date Submitted
51
Date Signed
52
Authorized Person Name

Category
Applicant Certifications

Purpose/Instructions
The authorized representative of the Consortium Leader (or,
Healthcare Provider, if participating individually) must make this
certification.

Applicant Certifications

See Item # 46, Purpose/Instructions.

Applicant Certifications

See Item # 46, Purpose/Instructions.

Applicant Signature
System Generated
System Generated
Applicant Signature

The FCC Form 463 must be certified electronically by the applicant.
Auto generated by system.
Auto generated by system.
This is the name of the Authorized Person signing the FCC Form 463
on behalf of the applicant.
This is the name of the employer of the Authorized Person signing the
FCC Form 463 on behalf of the applicant.
This is the FCC RN of the Authorized Person signing the FCC Form 463
on behalf of the applicant.
This is the title of the Authorized Person signing the FCC Form 463 on
behalf of the applicant.

53

Authorized Person’s Employer

Applicant Signature

54

Authorized Person’s Employer FCC
RN
Authorized Person’s Title/Position

Applicant Signature

55

Applicant Signature

5

Item # Field Description
56
Authorized Person’s Mailing
Address
57
58

Authorized Person Telephone
Number
Authorized Person Email Address

Category
Applicant Signature

Purpose/Instructions
This is the address (can be physical address or mailing address) of the
Authorized Person signing the FCC Form 463 on behalf of the
applicant.
This is the telephone number of the Authorized Person signing the
FCC Form 463 on behalf of the applicant.
This is the email address of the Authorized Person signing the FCC
Form 463 on behalf of the applicant.

Applicant Signature
Applicant Signature

6