FCC Form 467 RHC - Telecommunications Program - Description of Reques

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 #	Field Description	Category	Purpose/Instructions
1	FCC Form 466 Application Number	System Populated	Auto-populated by the system: This is a unique identifier for each FCC Form 466.
2	Funding Request Number (FRN)	Request Information	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.
3	Funding Year: Funding Start Date	Request Information	Auto-populated by the system: This displays the date funding began for an FRN.
4	Funding Year: Funding End Date	Request Information	Auto-populated by the system: This displays the date funding will end/ended for an FRN.
5	Site Number	Request Information	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.
6	Site Name	Request Information	Auto-populated by the system: This is the name the site submitted on the FCC Form 465.
7	Site Contact Information	Request Information	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.
8	Legal Entity Name	Site Information	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.
9	Legal Entity FCC RN	Site Information	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.
10	Billed Entity Name	Bill Payer Information	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.
11	Billed Entity Contact Information	Bill Payer Information	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.
12	Organization Affiliation	Site Information	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.
13	498 ID of Service Provider(s)	Request Information	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.
14	Service Provider Name(s)	Request Information	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.
15	Service Provider/Applicant Invoice Number	Request Information	Optional. Allows the vendor and/or applicant to track their FCC Form 466/467 within their billing system.
16	Form Purpose	Request Information	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.
17	Expense/Service Type	Line Item Details	Auto-populates. This the expense/service category the health care provider (HCP) submitted on their Form 466.
18	Bandwidth	Line Item Details	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.
19	Date Service Started	Line Item Details	The date service began or is expected to begin.
20	Date Service Ended/Disconnected	Line Item Details	If applicable. The date service is to end.
21	Contract Status	Line Item Details	Displays the status of the contract (e.g. month-to-month, evergreen, etc.).
22	Quantity of Items	Line Item Details	The number of items the applicant is seeking under a line item.
23	Billing Account Number (BAN)	Line Item Details	The line item BAN listed on the service provider’s bill.
24	Total Actual Undiscounted Cost	Line Item Details	The actual total undiscounted cost (including taxes and fees) for the billing period.
25	Percentage of Expense Eligible	Line Item Details	Auto-populated by the system: The percentage of the item expense that is eligible for support.
26	Percentage of Usage Eligible	Line Item Details	Auto-populated by the system: The percentage of the line item expense that is used by an eligible site.
27	Total Eligible Actual Cost	Line Item Details	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.
28	USF Support To Be Paid	Line Item Details	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.
29	Supporting Documentation	Documentation	Optional. Provides the option for the user to upload and submit supporting documents to their request.
30	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.	Applicant Certifications	The applicant must make this certification in order to receive universal service fund support.
31	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.	Applicant Certifications	The applicant must make this certification in order to receive universal service fund support.
32	Signature	Applicant Certifications	The FCC Form 467 must be certified electronically.
33	Date Submitted	System Populated	Auto populated by system.
34	Date Signed	System Populated	Auto populated by system.
35	Authorized Person Name	Applicant Certifications	This is the name of the Authorized Person signing the FCC Form 467.
36	Authorized Person’s Employer	Applicant Certifications	This is the name of the employer of the Authorized Person signing the FCC Form 467.
37	Authorized Person’s Employer FCC RN	Applicant Certifications	This is the FCC RN of the Authorized Person signing the FCC Form 467.
38	Authorized Person’s Title/Position	Applicant Certifications	This is the title of the Authorized Person signing the FCC Form 467.
39	Authorized Person’s Mailing Address	Applicant Certifications	This is the address (can be physical address or mailing address) of the Authorized Person signing the FCC Form 467.
40	Authorized Person Telephone Number	Applicant Certifications	This is the telephone number of the Authorized Person signing the FCC Form 467.
41	Authorized Person Email Address	Applicant Certifications	This is the email address of the Authorized Person signing the FCC Form 467.

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