Form 467 RHCTP Description of Request for Fundiing Disbursement

Rural Health Care
Telecommunications Program
Description of Request for Funding Disbursement FCC Form 467
(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
FCC Form 466 Application Number

Category
System Populated

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

Site Contact Information

Request Information

Purpose/Instructions
Auto-populated by the system: This is a unique identifier for each
FCC Form 466.
Auto-populated by the system: This is the unique identifier for each
request for funding provided in the funding commitment letter sent
by the Universal Service Administrative Company (USAC) to the
applicant.
Auto-populated by the system: This displays the date funding began
for an FRN.
Auto-populated by the system: This displays the date funding will
end/ended for an FRN.
Auto-populated by the system: This is the unique identifier assigned
by USAC to the site listed in Site Name. The Site Number was issued
by USAC when the FCC Form 465 was completed.
Auto-populated by the system: This is the name the site submitted
on the FCC Form 465.
Auto-populated by the system: This is the site’s physical address,
county, city, state, zip code, telephone, website, contact name,
contact employer and geolocation. Geolocation only applies to a site
that does not have a street address. This information was previously
submitted on the FCC Form 465.

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Item #
8

Field Description
Legal Entity Name

Category
Site Information

9

Legal Entity FCC RN

Site Information

10

Billed Entity Name

Bill Payer Information

11

Billed Entity Contact Information

Bill Payer Information

12

Organization Affiliation

Site Information

13

498 ID of Service Provider(s)

Request Information

14

Service Provider Name(s)

Request Information

15

Service Provider/Applicant Invoice
Number

Request Information

Purpose/Instructions
Auto-populated by the system: If applicable. This is the name of the
Legal Entity that owns and/or operates the site. In some cases, the
Legal Entity Name will be different from the Site Name. This name
was previously submitted on the FCC Form 465.
Auto-populated by the system: If applicable. This is the unique FCC
identifier for the Legal Entity that owns and/or operates the site.
This unique identifier was previously submitted on the FCC Form
465.
Auto-populated by the system: If applicable. This is the entity that
pays the bills of the service provider for the site. This may be the site
itself, or it may be the “parent” organization, association,
consortium, etc. to which the site belongs. This information was
previously submitted on the FCC Form 466.
Auto-populated by the system: If applicable. This is the Billed
Entity’s physical address, county, city, state, zip code, telephone,
website, contact name, contact employer, email address and
geolocation. This information was previously submitted on the FCC
Form 466.
Auto-populated by the system: If applicable. The user identifies as
being a member of a larger collective group (e.g. consortium,
association, network, etc.) that participates in either the
Telecommunications or HCF Programs. This information was
previously submitted on the FCC Form 465.
Auto-populated by the system: The selected service provider’s 498
ID (formerly the Service Provider Identification Number (SPIN) ID).
This ID is pulled from the FCC Form 466 for an FRN. There may be
multiple service providers should the circuit have multiple
connections.
Auto-populated by the system: Based on the 498 ID(s) entered on
the FCC Form 466 for an FRN. There may be multiple service
providers should the circuit have multiple connections.
Optional. Allows the vendor and/or applicant to track their FCC Form
466/467 within their billing system.
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Item #
16

Field Description
Form Purpose

Category
Request Information

17

Expense/Service Type

Line Item Details

18

Bandwidth

Line Item Details

19
20
21

Date Service Started
Date Service Ended/Disconnected
Contract Status

Line Item Details
Line Item Details
Line Item Details

22
23
24

Quantity of Items
Billing Account Number (BAN)
Total Actual Undiscounted Cost

Line Item Details
Line Item Details
Line Item Details

25

Percentage of Expense Eligible

Line Item Details

26

Percentage of Usage Eligible

Line Item Details

27

Total Eligible Actual Cost

Line Item Details

28

USF Support To Be Paid

Line Item Details

29

Supporting Documentation

Documentation

Purpose/Instructions
User selects purpose of the FCC Form 467 which can be to: 1)
confirm the accuracy of all information provided on the FCC Form
466, 2) notify USAC of a disconnection of service or 3) inform USAC
that service was not turned on during the funding year.
Auto-populates. This the expense/service category the health care
provider (HCP) submitted on their Form 466.
Auto-populates. User must confirm they are receiving the same
bandwidth submitted via their FCC Form 466. If Bandwidth is not the
same, the user must submit a new FCC Form 466.
The date service began or is expected to begin.
If applicable. The date service is to end.
Displays the status of the contract (e.g. month-to-month, evergreen,
etc.).
The number of items the applicant is seeking under a line item.
The line item BAN listed on the service provider’s bill.
The actual total undiscounted cost (including taxes and fees) for the
billing period.
Auto-populated by the system: The percentage of the item expense
that is eligible for support.
Auto-populated by the system: The percentage of the line item
expense that is used by an eligible site.
Auto-populated by the system: The system will calculate and display
the total amount of the line item expense that is eligible for
universal service support.
Auto-populated by the system: The system will calculate and display
the total amount of the eligible 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
supporting documents to their request.

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Item #
30

31

Field Description
I certify that the service identified
above has been or is being
provided to the above-named
health care provider. I certify that
the universal service credit will be
applied to the
telecommunications service billing
account of the HCP or the billed
entity as directed by the HCP. I
certify that I am authorized to
submit this request on behalf of
the above-named HCP, and that I
have examined this request and
that to the best of my knowledge,
information and belief, all
statements of fact contained
herein are true.
Pursuant to 47 C.F.R. § 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.
§. 254. I understand that any
letter from RHC that erroneously
states that funds will be made
available for the benefit of the
applicant may be subject to
rescission.

Category
Applicant Certifications

Purpose/Instructions
The applicant must make this certification in order to receive
universal service fund support.

Applicant Certifications

The applicant must make this certification in order to receive
universal service fund support.

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Item #
32

Field Description
Signature

Category
Applicant Certifications

Purpose/Instructions
The FCC Form 467 must be certified electronically.

33
34
35
36

Date Submitted
Date Signed
Authorized Person Name
Authorized Person’s Employer

System Populated
System Populated
Applicant Certifications
Applicant Certifications

37

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

Applicant Certifications

Auto populated by system.
Auto populated by system.
This is the name of the Authorized Person signing the FCC Form 467.
This is the name of the employer of the Authorized Person signing
the FCC Form 467.
This is the FCC RN of the Authorized Person signing the FCC Form
467.
This is the title of the Authorized Person signing the FCC Form 467.
This is the address (can be physical address or mailing address) of
the Authorized Person signing the FCC Form 467.
This is the telephone number of the Authorized Person signing the
FCC Form 467.
This is the email address of the Authorized Person signing the FCC
Form 467.

38
39
40
41

Applicant Certifications
Applicant Certifications
Applicant Certifications
Applicant Certifications

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