Universal Service - Rural Health Care Program

Program Participant or Lead Project Coordinator Letterhead

Certification of [Program Participant]

I, _____________________[name of individual authorized to sign on behalf of Program Participant], on behalf of _____________[Program Participant] certify and swear under the penalty of perjury, that to the best of my knowledge, information and belief, all federal Rural Health Care Pilot Program support provided to us will be used only for eligible Pilot Program purposes for which the support is intended, as described in the Pilot Program Order (WC Docket 02-60; FCC 07-498, released November 19, 2007), and consistent with related FCC orders, section 254(h)(2)(A) of the Telecommunications Act of 1934, as amended, and Parts 54.601 et. seq. of the FCC’s rules.

____________________(signature)

Name:_______________

Title:________________

Date: ________

NOTARIZED BY: ___________________

____________________

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