FCC Form 466 RHC, Telecommunications Program Description of Request f

OMB 3060-0804

X/XX/2020

Rural Health Care

Telecommunications Program

Description of Request for Funding (FCC Form 466)

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.

This form is effective for funding year 2020.

Item #	Field Description	Purpose/Instructions
1	Funding Year	Auto-populated by the system: The funding year (FY) will auto-populate based on the funding year of the FCC Form 466. Depending on the timing of the request, multiple funding years may be available for the user to select.
2	FCC Form 466 Application Number	Auto-populated by the system: This is a unique Universal Service Administrative Company (USAC)-assigned identifier for this request.
3	Site Number	Auto-populated by the system: This is the unique USAC-assigned identifier for this site listed in Site Name. This number was issued by USAC when the FCC Form 465 was completed.
4	Site Name	Auto-populated by the system: This is the name of the site identified on the applicant’s submitted FCC Form 465.
5	Billed Entity Information	Auto-populated by the system: This is the site’s physical address, county, city, state, zip code, telephone, website, contact name, contact employer, email address 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.
6	FCC Form 465 Application Number	Auto-populated by the system: This is a unique USAC-assigned identifier for this request. This number was previously assigned on the FCC Form 465.
7	Legal Entity Name	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 may be different from the Site Name. This is the name identified on the applicant’s FCC Form 465.
8	Legal Entity FCC RN (FCC RN)	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 identifier was identified on the applicant’s FCC Form 465.
9	Legal Entity Contact	Auto-populated by the system: This is the Legal Entity’s physical address, county, city, state, zip code, telephone, website, contact name, email, phone number, contact employer and geolocation. Geolocation only applies to a site that does not have a street address. The applicant provided this information on the applicant’s FCC Form 465.
10	Billed Entity Name	If applicable. This is the entity that pays the bills of the service provider for the site. This may be the site itself or the “parent” organization, association, consortium, etc. to which the site belongs.
11	Billed Entity Contact Information	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.
12	Billed Entity FCC Registration Number (FCC RN)	Auto-populated by the system: This is the unique FCC identifier for the Legal Entity. This number was provided when the user completed the FCC Form 465.
13	Allowable Contract Selection Date (ACSD)	Auto-populated by the system: This is a USAC-assigned date (at least 28 days after the description set forth in the HCP’s Form 465 is posted on the RHC website). This date expresses the earliest date (ACSD) on which the health care provider may sign an agreement or otherwise select a service provider to provide services to the health care provider.
14	Number of Service Provider Bids	The number of service providers who bid on the request for services in response to the FCC Form 465.
15	Multiple Sites	If applicable. If the health care provider is a mobile rural health care provider, it must list the names, full addresses, expected schedule, duration of visits to all sites to be served, and number of patients served at each location by the mobile health care provider during the funding year. The health care provider must verify that each of the sites is rural or prorate the support request to cover only the time when the mobile health care provider will operate in the rural area.
16	498 ID of Selected Service Provider(s)	The selected Service Provider’s 498 ID (formerly the Service Provider Identification Number (SPIN)). There may be multiple service providers if the circuit has multiple connections.
17	Selected Service Provider Name(s)	Auto-populated by the system: This name is based on the 498 ID entered by the user. There may be multiple service providers if the circuit has multiple connections.
18	Selected Service Provider Contact	Auto-populated by the system: This contact information is based on the 498 ID entered. This is the service provider’s physical address, county, city, state, zip code, telephone, website, contact name, email, phone number, contact employer and geolocation. There may be multiple service providers if the circuit has multiple connections.
19	Service Provider Selection Date	The date that the service provider was selected. The health care provider or its authorized representative must not select a service provider or enter into a contract or purchase an agreement with a service provider until at least 28 days have elapsed since the FCC Form 465 was posted on the RHC website.
20	Continuation with Current Service Provider	The user indicates if the selected service provider is its current service provider.
21	Contract ID	The unique USAC-assigned identifier fora contract or service agreement. This identifier helps the applicant identify the contract in the future and apply in subsequent funding years.
22	Contract Reference Number	The user provides a tariff, contract and other document reference number for each segment of the circuit.
23	Contract Friendly Name	Optional. To create a unique identifier for this request, the user simply enters a nickname (e.g., Smith Telecommunications FY 2016).
24	Competitive Bidding Exemptions	Only completed if the user is claiming a competitive bidding exemption. If the applicant is claiming the “E-Rate Approved Contract” bidding exemption, then the applicant must provide: the E-Rate Contract ID (and friendly name), as requested on this FCC Form 466; the E-Rate FCC Form 470 number that initiated bidding for that contract; the E-Rate contact person for that contract (for quick access); and the contract expiration date.
25	Expense/Service Type	The user selects the expense/service type (from a list) for the line item (e.g., T-1).
26	Number of Voice Grade Lines	If applicable. The user enters the number of Voice Grade lines that they are requesting support for. This is an option when the applicant selects Voice grade, private branch exchange (PBX), central office terminal (COT), direct inward dialing (DID) or other similar services in the “Expense/Service Type.”
27	Multiple Service Providers	The user indicates if its service is provided using multiple connections and is provided by multiple service providers; If “YES,” then the user provides further information on the individual service providers. The information collected for multiple service providers is the same fields/inputs as that which is collected for one service provider for the entire circuit.
28	Bandwidth	The user enters the bandwidth for expense/service type.
29	Circuit ID	The user enters a service provider-specific identifier assigned to the connection between two locations for the line item. The Circuit ID is located on the service provider invoice.
30	Circuit Diagram	If applicable. If the health care provider is part of a large organization (e.g., consortium, network, etc.) or uses multiple service providers for the service, then it must include a diagram to show how the sites interconnect and which carrier(s) provide each circuit segment.
31	Total Billed Circuit Miles	The sum of all miles billed by all service providers for that circuit.
32	Maximum Allowable Distance	Auto-populated by the system: Based on information provided on the FCC Form 465.
33	Circuit Start Location	The physical location and/or Site Number where the circuit originates for the line item.
34	Circuit End Location	The physical location and/or Site Number where the circuit terminates for the line item.
35	Satellite Delivery	The user selects if the service is delivered by satellite
36	Percentage of Expense Eligible	The user enters the percentage of the expense that is eligible for support. If the entire expense is eligible, enter “100%.” For example, a service provider may provide a bundle that includes both eligible and ineligible services. If percentage is less than 100%, then the user must briefly explain how the percentage was derived.
37	Percentage of Usage Eligible	The user enters the percentage of the usage that is eligible for support. If all of the usage is eligible, enter “100%.” An applicant should use this column to indicate the eligible portion of a connection that is used by both eligible and ineligible sites.
38	Percentage of Expense Ineligible	The user enters the percentage of the expense that is ineligible for support.
39	Percentage of Usage Ineligible	The user enters the percentage of the usage that is ineligible for support. An applicant should use this column to indicate the ineligible portion of a connection that is used by both eligible and ineligible sites.
40	Billing Account Number (BAN)	The line item BAN listed on the service provider’s bill.
41	Initial Contract Length	The length of the initial contract excluding voluntary options. Does not include any optional extensions.
42	Contract Expiration Date	The date the signed contract will expire. Does not include any optional extensions.
43	Number of Contract Extensions, Options and/or Upgrades	If the contract includes voluntary options to extend the term of the contract and/or upgrade services, then the user enters the number of such voluntary options.
44	Combined Optional Extension(s) Length	If the contract includes one or more voluntary options to extend the term of the contract, then the user enters the combined length of all the voluntary options.
45	Service Installation Date	The date service is expected to start.
46	Actual Rural Rate per Month	The amount the site pays per month or the expected amount to be paid per month for the service.
47	Service Level Agreement (SLA)	The indication that the applicant’s contract with the service provider includes an SLA.
48	Billed Circuit Miles	The billed miles for each connection.
49	Monthly Mileage Charges	The monthly mileage charges for the service.
50	Cost per Mile per Month	The cost per mile per month for each connection.
51	Installation Urban Rate Charge	The one-time urban rate installation charge for the requested service listed in any city in the site’s state with a population of 50,000 or more.
52	Installation Rural Rate Charge	The one-time rural rate installation charge for the requested service listed.
53	Rural Taxes & Fees Per Month	The applicable rural monthly taxes and fees for the requested service.
54	Total Undiscounted Cost Per Month	The user indicates the monthly rural rate and any requested rural monthly taxes and fees and/or installation charge.
55	Monthly Urban Rate Charge	The monthly urban rate for the service listed.
56	Urban Taxes and Fees Per Month	The applicable urban monthly taxes and fees for the requested service. If support is sought for the rural taxes and fees, the applicable urban monthly taxes and fees must also be entered.
57	Total Amount for Monthly Urban Rate	The user indicates the monthly urban rate and any requested rural monthly taxes and fees and/or installation charge.
58	Total Amount of Support Requested	The user indicates the total amount of support requested (total rural rate minus total urban rate) times the number of months requested.
59	Supporting Documentation	Optional. This option allows the user to upload and submit documents to support their request.
60	I certify under penalty of perjury that the above-named entity has considered all bids received and selected the most cost-effective method of providing the requested service or services. "Cost-effective" is defined in 47 CFR § 54.622(c) of the Commission’s rules as the method that costs the least after consideration of the features, quality of transmission, reliability, and other factors that the applicant deems relevant to choosing a method of providing the required health services.	The Authorized Person is required to provide all certifications and signatures. An officer or director of the applicant must sign all certifications. The applicant must provide this certification in order to receive universal service support.
61	I certify under penalty of perjury that the applicant that I am representing satisfies all of the requirements under section 254 of the Act and applicable Commission rules and understand that any letter from USAC that erroneously commits funds for the benefit of the applicant may be subject to rescission.	See Item #60 Purpose/Instructions above.
62	I certify under penalty of perjury that all RHC Program support will be used only for eligible health care purposes.	See Item #61 Purpose/Instructions above.
63	I certify under penalty of perjury that I have reviewed all applicable rules and requirements for the RHC Program and will comply with those rules and requirements.	See Item #62 Purpose/Instructions above.
64	I certify under penalty of perjury that the applicant is not requesting support for the same service from both the Telecommunications Program and the Healthcare Connect Fund Program.	See Item #63 Purpose/Instructions above.
65	I certify under penalty of perjury that the applicant and/or its consultant, if applicable, has not solicited or accepted a gift or any other thing of value from a service provider participating in or seeking to participate in the RHC Program.	See Item #64 Purpose/Instructions above.
66	I hereby certify under penalty of perjury that the applicant will retain all documentation associated with the application, including all bids, contracts, scoring matrices, and other information associated with the competitive bidding process, and all billing records for services received, for a period of at least five years.	See Item #65 Purpose/Instructions above.
67	I certify under penalty of perjury that I am authorized to submit this request on behalf of the named billed entity and applicant.	See Item #66 Purpose/Instructions above.
68	I certify under penalty of perjury that I have examined this form and all attachments and that to the best of my knowledge, information, and belief, all statements of fact contained herein are true.	See Item #67 Purpose/Instructions above.
69	I certify under penalty of perjury that the consultants or third parties the applicant has hired do not have an ownership interest, sales commission arrangement, or other financial stake in the service provider chosen to provide the requested services, and that they have otherwise complied with RHC Program rules, including the Commission’s rules requiring fair and open competitive bidding.	See Item #68 Purpose/Instructions above.
70	Signature	The Authorized Person is required to provide all required signatures and certifications. The FCC Form 465 must be certified electronically.
71	Date Submitted	Auto populated by system.
72	Date Signed	Auto populated by system.
73	Authorized Person Name	This is the name of the Authorized Person certifying the FCC Form 465. This field will be auto-populated if the name of the Authorized Person is already within the system.
74	Authorized Person’s Employer	This is the name of the employer of the Authorized Person certifying the FCC Form 465. This field will be auto-populated if already within the system.
75	Authorized Person’s Employer FCC RN	This is the FCC RN of the Authorized Person certifying the FCC Form 465. This field will be auto-populated if already within the system.
76	Authorized Person’s Title/Position	This is the title of the Authorized Person certifying the FCC Form 465.
77	Authorized Person’s Mailing Address	This is the address (can be physical address or mailing address) of the Authorized Person certifying the FCC Form 465. This field will be auto-populated if already within the system.
78	Authorized Person Telephone Number	This is the telephone number of the Authorized Person certifying the FCC Form 465. This field will be auto-populated if already within the system.
79	Authorized Person Email Address	This is the email address of the Authorized Person certifying the FCC Form 465. This field will be auto-populated if already within the system.

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 54 of the Federal Communications Commission’s (FCC) rules authorize the FCC to collect the information in this form. Responses to the questions herein are required to obtain the benefits sought by this form. Failure to provide all requested information will delay the processing of the form or result in the form being returned without action. Information requested by this form will be available for public inspection. The information provided will be used to determine whether approving the request is in the public interest.

We have estimated that your response to this collection of information will take 2 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 or response.  If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, Office of Managing Director, AMD‑PERM, Paperwork Reduction Act Project (3060‑0804), Washington, DC 20554.  We will also accept your comments via the Internet if you send them to [email protected].  Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.  

Remember – 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 OMB control number or we fail to provide you with this notice.  This collection has been assigned an OMB control number of 3060‑0804.

THIS NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

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