FCC Form 498 Service Provider And Billed Entity Identification Number

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Overview

ACTIVE VERSION
Sheet3

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Sheet 1: ACTIVE VERSION

File electronically at http://usac.org/about/tools/e-file.aspx/

FCC Form 498

OMB 3060-0824

Service Provider And Billed Entity Identification Number and General Contact Information Form

Estimated Average Burden Hours Per Response: 1.5 hours

FCC Form 498 is used to collect contact and remittance information for service providers and applicants that receive support from the Federal universal service support programs. For greater flexibility, this form allows service providers to use the same general contact information for all their contacts and the same remittance data collected for each of the four programs or multiple contact and remittance information. Please report any changes to this information on a revised FCC Form 498 to prevent any delays in notification and the timeliness of disbursements. Persons willfully making false statements on this form can be punished by fine or forfeiture, under the Communications Act, 47 U.S.C. Secs. 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.

Please read instructions, located at: http://usac.org/sp/tools/forms.aspx, before beginning this application.

Provider Type

Please check one box below

Service Provider

School/Library or other Billed Entity

Submission Type

Please check one box below

Original Application for FCC Form 498 ID

Revision to existing FCC Form 498 on file with USAC

Request for FCC Form 498 ID Merger/Consolidation

Request for FCC Form 498 ID Deactivation

Service Provider Identification Number (FCC Form 498 ID)

(To be inserted by USAC for first time applications. Required for subsequent revisions.)

499 Filer ID

(Required if your company is required to file the FCC Form 499)

Block 1: Organization Information [All Fields REQUIRED]

1

Company Name or Billed Entity

2

Name Entity or Company is Doing Business As (DBA) or Formerly Known As (FKA)

3

Check this Box if the Company is part of or maintains affiliate companies and complete page 2.

4

Street Address

5

Address Line 2

6

7

8

City

State

Zip Code + 4

Block 2: General Contact Information [All Fields REQUIRED]

9

First:

Middle Initial:

Last:

10

General Contact (Company Preparer Name)

Title

11

(

)

Phone Number

Ext.

12

Street Address

13

Address Line 2

14

15

16

City

State

Zip Code + 4

17

E-mail Address

Block 3: Federal EIN, DUNS and FCC Registration Number [All Fields REQUIRED]

18

19

Corporation

Partnership

Other

Enter Federal Employer Identification Number

(Check applicable corporate structure.)

(Federal EIN or Tax ID Number)

20

21

Enter Dun and Bradstreet Number (DUNS)

FCC Registration Number (CORES ID)

This is a Supplemental Page for Companies with Affiliate Relationships

Block 4: Affiliate Company Information

Please list all companies with which this FCC Form 498 ID is affiliated. The term "affiliate" means a person that (directly or indirectly) owns

or controls, is owned or controlled by, or is under common ownership or control with, another person. For purposes of this paragraph,

the term "own" means to own an equity interest (or the equivalent thereof) of more than 10 percent.

Affiliate FCC Form 498 ID Number

Affiliate Company Name

(Attach additional copies of this page if necessary)

This page is for High Cost Program participants only.

For more information about the High Cost Program, please refer to: http://www.usac.org/hc/

Block 5: High Cost Support Financial Institution and Remittance

Information [ALL Fields REQUIRED]

Check this box to discontinue use of this FCC Form 498 ID for High Cost Support.

Financial institution information is required. Electronic payment of universal service support payments

is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.

Check this box if this information is the same as the General Contact information (Block 2) and complete lines 33-35.

22

Remittance Company Name, if different from Company Name

23

First:

Middle Initial:

Last:

24

Remittance Contact Name - Statements will be sent to Remittance Contact's attention

Title

25

(

)

26

Phone Number

Ext

E-mail Address for receipt of remittance advice

27

Remittance Financial Institution for ACH or locked box transfer of funds (required)

28

29

Financial Institution Account Number for ACH (required)

ACH Financial Institution Transit Number - must be nine digits (required)

Block 6: Company Contact for High Cost Support

Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 7.

30

First:

Middle Initial:

Last:

31

Contact Name for High Cost Program

Title

(Must be a company employee or designated representative)

32

Contact Address or PO Box for High Cost Program

33

Address Line 2

34

35

36

City

State

Zip Code + 4

37

(

)

38

Phone Number

Ext

E-mail Address of High Cost Program Contact

This page is for Lifeline Program participants only.

For more information about Lifeline Support, please refer to: http://www.usac.org/li/

Block 7: Lifeline Support Financial Institution and Remittance

Information [All Fields REQUIRED]

Check this box to discontinue use of this FCC Form 498 ID for LifelineSupport.

Financial institution information is required. Electronic payment of universal service support payments

is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.

Check this box if this information is the same as the General Contact information (Block 2) and complete lines 57-59.

39

Remittance Company Name, if different from Company Name

40

First:

Middle Initial:

Last:

41

Remittance Contact Name - Statements will be sent to Remittance Contact's attention

Title

42

(

)

43

Phone Number

Ext

E-mail Address for receipt of remittance advice

44

Remittance Financial Institution for ACH or locked box transfer of funds (required)

45

46

Financial Institution Account Number for ACH (required)

ACH Financial Institution transit Number - must be nine digits (required)

Block 8: Company Contact for Lifeline Support

Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 9.

47

First:

Middle Initial:

Last:

48

Contact address for Lifeline Program

Title

(Must be a company employee or designated representative)

49

Contact Address for Lifeline Program

50

Address Line 2

51

52

53

City

State

Zip Code + 4

54

(

)

55

Phone Number

Ext

E-mail Address of Lifeline Program Contact

This is a Supplemental Page for Participants in the High Cost and Lifeline Programs.

Block 9: High Cost and Lifeline Study Area/FCC Form 498 ID Association

This information will be used to associate the Study Area Codes (SAC) to this FCC Form 498 ID for the purposes of

High Cost and Lifeline Support.

Check this box if there is no change to the SAC data on file.

Check this box if you are changing your organization's

SAC data currently on file with USAC.

Study Area Code (SAC)

SAC Company Name

Study Area Type

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

Incumbent

Competitive

(Attach additional copies of this page if necessary)

This page is for Rural Health Care Support participants only.

For more information about Rural Health Care Support, please refer to: http://www.usac.org/rhc/

Block 10: Rural Health Care Support Financial Institution and Remittance

Information [ALL Fields REQUIRED]

Check this box to discontinue use of this FCC Form 498 ID for Rural Health Care Support.

Financial institution information is required. Electronic payment of universal service support payments

is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.

Check this box if this information is the same as the General Contact information (Block 2) and complete lines 81-83.

56

Remittance Company Name, if different from Company Name

57

First:

Middle Initial:

Last:

58

Remittance Contact Name - Statements will be sent to Remittance Contact's attention

Title

59

(

)

60

Phone Number

Ext

E-mail Address for receipt of remittance advice

61

Remittance Financial Institution for ACH or locked box transfer of funds (required)

62

63

Financial Institution Account Number for ACH (required)

ACH Financial Institution transit Number - must be nine digits (required)

Block 11: Company Contact for Rural Health Care Support

Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 12.

64

First:

Middle Initial:

Last:

86

Contact Name for Rural Health Care Program

Title

(Must be a company employee or designated representative)

65

Contact Address for Rural Health Care Program

66

Address Line 2

67

68

69

City

State

Zip Code + 4

70

(

)

71

Phone Number

Ext

E-mail Address of Rural Health Care Program Contact

This page is for Schools and Libraries Program participants only.

For more information about the Schools and Libraries Program, please refer to: http://www.usac.org/sl/

Block 12: Schools and Libraries Support Financial Institution and

Remittance Information [ALL Fields REQUIRED]

Check this box discontinue use of this FCC Form 498 ID for Schools and Libraries Support.

Financial institution information is required. Electronic payment of universal service support payments

is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.

Check this box if this information is the same as the General Contact information (Block 2) and complete lines 105-107.

72

Remittance Company Name, if different from Company or Billed Entity Name

73

First:

Middle Initial:

Last:

74

Remittance Contact Name - Statements will be sent to Remittance Contact's attention

Title

75

(

)

76

Phone Number

Ext

E-mail Address for receipt of remittance advice

77

Remittance Financial Institution for ACH or locked box transfer of funds (required)

78

79

Financial Institution Account Number for ACH (required)

ACH Financial Institution Transit Number - must be nine digits (required)

Block 13: Company Contact for Schools and Libraries Support

Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 14.

80

First:

Middle Initial:

Last:

81

Contact Name for Schools and Libraries Program

Title

(Must be a company, or entity employee or designated representative)

82

Contact Address for Schools and Libraries Program

83

Address Line 2

84

85

86

City

State

Zip Code + 4

87

(

)

88

Phone Number

Ext

E-mail Address of Schools and Libraries Program Contact

This is a Supplemental Page for Schools, Libraries and Other Applicant Payment Recipients

Block 14: Billed Entity Number/FCC Form 498 Association

Please list all Billed Entity Numbers with which this FCC Form 498 ID affiliated.

Billed Entity Number

Billed Entity Name

(Attach additional copies of this page if necessary)

Disbursement Offsets and Healthcare Connect Certification

Block 15: Offsetting Disbursement Payments Against Federal Universal Service

Contribution Obligations For High Cost Participants

The following information pertains only to telecommunications companies participating in the High Cost Program. A telecommunications company may choose to offset its payment against its Federal universal service contribution. A telecommunications company must have an FCC Form 499 Filer ID number in order to offset its High Cost Program payments against its Federal universal service contribution. In order to obtain an FCC Form 499 Filer ID number, visit http://www.usac.org/cont/tools/forms/default.aspx and select FCC Form 499. You do not need an FCC Form 499 Filer ID in order to be issued a FCC Form 498 ID.

89

Yes, I want my High Cost Program disbursement payments to be offset against my Federal

universal service contribution obligations. This box must be checked in order to receive offsets. The Default is "No."

Block 16: Offsetting Disbursement Payments Against Federal Universal Service

Contribution Obligations For Lifeline/Lifeline Participants

The following information pertains only to telecommunications companies participating in the Lifeline Program. A telecommunications company may choose to offset its payment against its Federal universal service contribution. A telecommunications company must have an FCC Form 499 Filer ID number in order to offset its Lifeline Program payments against its Federal universal service contribution. In order to obtain an FCC Form 499 Filer ID number, visit http://www.usac.org/cont/tools/forms/default.aspx and select FCC Form 499. You do not need an FCC Form 499 Filer ID in order to be issued a FCC Form 498 ID.

90

Yes, I want my High Cost Program disbursement payments to be offset against my Federal

universal service contribution obligations. This box must be checked in order to receive offsets. The Default is "No."

Block 17: Offsetting Disbursement Payments Against Federal Universal Service

Contribution Obligations For Rural Healthcare Participants

The following information pertains only to telecommunications companies participating in the Rural Health Care Program. In accordance with FCC rule section 54.679 regarding Rural Health Care payments, a telecommunications company may choose to offset its payment against its Federal universal service contribution. A telecommunications company must have an FCC Form 499 Filer ID number in order to offset its Rural Health Care Program payments against its Federal universal service contribution. In order to obtain an FCC Form 499 Filer ID number, visit http://www.usac.org/cont/tools/forms/default.aspx and select FCC Form 499. You do not need an FCC Form 499 Filer ID in order to be issued a FCC Form 498 ID.

91

Yes, I want my Rural Health Care Program disbursement payments to be offset against my Federal

universal service contribution obligations. This box must be checked in order to receive offsets. The Default is "No."

Block 18: Certification to Assist Health Care Providers

In accordance with FCC rule section 54.640(b), service providers participating in the Healthcare Connect Fund Program must certify, as a condition of receiving support, that they will provide to health care providers, on a timely basis, all information and documents regarding supported equipment, facilities, or services that are necessary for the health care provider to submit required forms or respond to FCC or USAC inquiries. USAC may withhold disbursements to the service provider if the service provider, after written notice from USAC, fails to comply with this requirement.

92

I certify, as a condition of receiving support under the Healthcare Connect Fund Program, that the above-named service provider will provide to

health care providers, on a timely basis, all information and documents regarding the supported equipment, facility(ies), or service(s)

that are necessary for the health care provider to submit required forms or respond to FCC or USAC inquiries.

Block 19: Offsetting Disbursement Payments Against Federal Universal Service

Contribution Obligations For Schools and Libraries Participants

The following information pertains only to telecommunications companies participating in the Schools and Libraries Program. In accordance with FCC rule section 54.515 regarding Schools and Libraries Program payments, a telecommunications company may choose to offset its Schools and Libraries Program payment against its Federal universal service contribution. A telecommunications company must have an FCC Form 499 Filer ID number in order to offset its Schools and Libraries payments against its Federal universal service contribution. In order to obtain an FCC Form 499 Filer ID number, visit http://www.usac.org/cont/tools/forms/default.aspx and select FCC Form 499. You do not need an FCC Form 499 Filer ID in order to be issued a FCC Form 498 ID.

93

Yes, I want my Schools and Libraries Program disbursement payments to be offset against my Federal

universal service contribution obligations. This box must be checked in order to receive offsets. The Default is "No."

Service Identification

Block 20: Principal Communications Types [REQUIRED Field]

Select up to 5 boxes that best describe the reporting entity. Enter numbers starting with "1" to show the order of importance -- see instructions.

Audio Bridging Provider

Interconnected VoIP

Coaxial Cable

Paging and Messaging

Non-Interconnected VoIP

SMR (Dispatch)

Private Service Provider

Shared-Tenant Service Provider

Toll Reseller

Cellular/PCS/SMR

Incumbent LEC

Interexchange Carrier

Operator Service Provider

Payphone Service Provider

Satellite Service Provider

Local Reseller

Wireless Data

Internet Service Provider

School/Library or other Billed Entity Recipient

DATA Act Business Types

Block 21: DATA Act Business Type (REQUIRED Field]

Select up to 3 boxes that best describe the reporting entity. Enter check marks. For additional description -- see instructions.

State Government

Nonprofit with 501C3 IRS Status (Other than an Institution of Higher Education)

County Government

Nonprofit without 501C3 IRS Status (Other than an Institution of Higher Education)

City or Township Government

Private Institution of Higher Education

Special District Government

Individual

Regional Organization

For-profit Organization (Other than Small Business)

U.S. Territory or Possession

Small Business

Independent School District

Hispanic-serving Institution

Public/State Controlled Institution of Higher Education

Historically Black College or University (HBCU)

Indian/Native American Tribal Government(Federally-Recognized)

Tribally Controlled College or University (TCCU)

Indian/Native American Tribal Government (Other than Federally-Recognized)

Alaska Native and Native Hawaiian Serving Institution

Indian /Native American Tribal Designated Organization

Non-domestic (non-U.S.) Entity

Public/Indian Housing Authority

Other

Officer Certification

Block 22: Officer Certification [All Fields REQUIRED]

I certify that I am an officer of the above-named service provider, that I am authorized to submit this FCC Form 498 on behalf of the above named service provider, and that to the best of my knowledge, the data set forth in this form is true, accurate, and complete.

Persons willfully making false statements on this form can be punished by fine or forfeiture, under the Communications Act, as amended, 47 U.S.C. Secs. 220(e), 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.

Officer Information

Check this box if this information is the same as the General Contact information (Block 2)

Signature of the Officer

Date

First:

Middle Initial:

Last:

Title

Printed Name

Reminder: You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid Office of Management and Budget (OMB) control number. This collection has been assigned an OMB control number of 3060-0824.

The Commission is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. We will use the information you provide for the Federal universal service billing, collections, and disbursement purposes. In addition, the Name, Address, DUNNS Number and Business Type will be disclosed in accordance with FFATA/DATA Act reporting requirements. If we believe there may be a violation or a potential violation of a state or Federal statute, or of a Commission regulation, rule, or order, your form may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. In certain cases, the information in your application may be disclosed to the Department of Justice, a court, or adjudicative body when (a) the Commission; or (b) any employee of the Commission; or (c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding. In addition, consistent with the Communications Act of 1934, FCC regulations and orders, the Freedom of Information Act, 5 U.S.C. § 552, or other applicable law, information provided in or submitted with this form or in response to subsequent inquiries may be disclosed to the public.

If you owe a past due debt to the Federal government, the information you provide may also be disclosed to the Department of the Treasury Financial Management Service, other Federal agencies, and/or your employer to offset your salary, IRS tax refund, or other payments to collect that debt. The Commission may also provide the information to these agencies through the matching of computer records where authorized.

If you do not provide the information we request on the form, the Commission may delay processing of your application, or may return your application without action.

This Notice is required by the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. 3501 et seq. We have estimated that each response to this collection of information will take, on average, 1.5 hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form for response. If you have any comments on this estimate, or how we can improve the collections and reduce the burden it causes you, please write to the Federal Communications Commission, AMD-PERM, Washington D.C. 20554, Paperwork Reduction Project (3060-0824). We will also accept your comments via Internet if you send them to [email protected]. Please DO NOT SEND COMPLETED DATA COLLECTION FORMS TO THIS ADDRESS.

Mail this signed form to:

USAC Customer Operations, Forms Processing

700 12th Street NW, Suite 900

Washington, DC 20005

Questions?

See the FCC Form 498 Instructions found at http://usac.org/sp/tools/forms.aspx

Use this form for:

New application for a Service Provider Identification Number

Revision to existing Service Provider data currently on file with USAC

Merger or Consolidation of Existing Service Provider Identification Number (Additional documentation is required, please see page 2 of the instructions)

Deactivation of a Service Provider Identification Number (Please see page 2 of the instructions)

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Sheet 2: Sheet3

Block 4: High Cost Banking and Remittance Payment Information
See Instructions Page (4)
			Check this box if this information is the same as the general contact information (Lines 3-15 above).
19
	Remittance Company Name
20
	Remittance Contact Name- Checks will be sent to Remittance Contact's attention
21
	Remittance Address
22
	Address 2
23																	24						25
	City																	State						Zip Code
26	(			)													27	(			)
	Phone Number											Ext						Fax Number
28
	Remittance Bank for ACH or locked box transfer of funds
29																	30
	Bank Account Number for ACH																	ACH Bank Transfer Number
31
Email Address of Remittance Contact if requesting electronic remittance statements instead of mailed paper copy statements
Block 5: Company Contact for High Cost Support Mechanism
See Instructions Page (11)
		Same as general contact from lines (3-15) above
32
	Contact Name for High Cost Mechanism - Must be a company employee or designated representative
33
	Contact Address for High Cost Mechanism
34
	Address 2
35																	36						37
	City																	State						Zip Code
38	(			)													39	(			)
	Phone Number											Ext						Fax Number
40
	Email Address of Remittance Contact if requesting electronic remittance statements instead of mailed paper copy statements
Block 6: Low Income Banking and Remittance Payment Information
See Instructions Page (11)
			This information is the same as the general contact information (Lines 3-15 above)
41
	Remittance Company Name
42
	Remittance Contact Name- Checks will be sent to Remittance Contact's attention
43
	Remittance Address
44
	Address 2
45																	46						47
	City																	State						Zip Code
48	(			)													49	(			)
	Phone Number											Ext						Fax Number
50
	Remittance Bank for ACH or locked box transfer of funds
51																	52
	Bank Account Number for ACH																	ACH Bank Transfer Number
53
	Email Address of Remittance Contact if requesting electronic remittance statements instead of mailed paper copy statements
Block 7: Company Contact for Low Income Support Mechanism
See Instructions Page (11)
		Same as general contact from lines (3-15) above
54
	Contact Name for Low Income Mechanism - Must be a company employee or designated representative
55
	Contact Address for Low Income Mechanism
56
	Address 2
57																	58						59
	City																	State						Zip Code
60	(			)													61	(			)
	Phone Number											Ext						Fax Number
62
	Email Address of Remittance Contact if requesting electronic remittance statements instead of mailed paper copy statements