FCC Form 467 RHC, Telecommunications Program, Connection Certificatio

Universal Service - Rural Health Care Program

2020 FCC Form 467 for OMB submission.11.7.19_RHC.effective FY2020 and beyond (4.3.20)

Universal Service - Rural Health Care Program

OMB: 3060-0804

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OMB 3060-0804

X/XX/2020


Rural Health Care

Telecommunications Program

Connection Certification Form (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.

This form is effective funding year 2020 and beyond.

Item #

Field Description

Purpose/Instructions

1

FCC Form 466 Application Number

Auto-populated by the system: This is a unique identifier for each Request for Funding (FCC Form 466).

2

Funding Request Number (FRN)

Auto-populated by the system: This is the unique identifier for each Request for Funding (FCC Form 466) provided in the funding commitment letter (FCL) issued by the Universal Service Administrative Company (USAC) to the applicant.

3

Funding Year: Funding Start Date

Auto-populated by the system: This displays the date funding began for an FRN.

4

Funding Year: Funding End Date

Auto-populated by the system: This displays the date funding will end/ended for an FRN.

5

Health Care Provider (HCP) Number

Auto-populated by the system: This is the unique USAC-assigned identifier for the site listed in Site Name. The Site Number was issued by USAC when the FCC Form 465 was completed.

6

HCP Name

Auto-populated by the system: This is the site name submitted on the FCC Form 465.

7

HCP Contact 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

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 name was previously submitted on the FCC Form 465.

9

Legal Entity 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 unique identifier was previously submitted on the FCC Form 465.

10

Billed Entity Name

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

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

Consortium Name

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)

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)

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 if the circuit has multiple connections.

15

Service Provider/Applicant Invoice Number

Optional. Allows the service provider and/or applicant to track their FCC Form 466/467 within their billing system.

16

Action Taken

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

Auto-populates. This is the expense/service category the health care provider identified on their submitted Form 466.

18

Bandwidth

Auto-populates. User must confirm the site is receiving the same bandwidth identified on their submitted FCC Form 466.

19

Date Service Started

The date service began or is expected to begin. If the service start date is delayed, the actual service start date should be indicated here.

20

Date Service Ended/Disconnected

The date service is to end or was disconnected. If the actual end date or disconnection date occurred before the original reported service end/disconnection date, the actual service end or disconnection date should be indicated here.

21

Contract Status

Displays the status of the contract (e.g., month-to-month, evergreen, etc.).

22

Billing Account Number (BAN)

The line item BAN listed on the service provider’s bill.

23

Total Actual Undiscounted Cost

The actual total undiscounted cost (including taxes and fees) for the billing period.

24

Percentage of Expense Eligible

Auto-populated by the system: The percentage of the item expense that is eligible for support.

25

Percentage of Usage Eligible

Auto-populated by the system: The percentage of the line item expense that is used by an eligible site.

26

Total Eligible Actual Cost

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.

27

USF Support Committed

Auto-populated by the system: The system will calculate and display the total amount of the eligible line item expense that USAC may pay the service provider for the line item.

28

Supporting Documentation

Optional. Provides the option for the user to upload and submit supporting documents to their request.

29

I certify under penalty of perjury that the service identified above has been or is being provided to the above-named applicant.

The Authorized Person is required to provide all required certifications and signatures. For individual applicants, certifications must be signed by an officer or director of the applicant. For consortium applicants, an officer, director, or other authorized employee of the Consortium Leader must sign the required certifications. The applicant must provide this certification in order to receive universal service fund support.

30

I certify under penalty of perjury that the universal service credit will be applied to the telecommunications service billing account of the applicant or the billed entity as directed by the applicant.

See Item #29 Purpose/Instructions above.

31

I certify under penalty of perjury that I am authorized to submit this request on behalf of the above-named applicant.

See Item #29 Purpose/Instructions above.

32

I certify under penalty of perjury that I have examined the invoice and supporting documentation and that, to the best of my knowledge, information and belief, all statements contained herein are true.

See Item #29 Purpose/Instructions above.

33

I certify under penalty of perjury that the applicant or consortium that I am representing satisfies all of the requirements 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.

See Item #29 Purpose/Instructions above.

34

I understand that any letter from USAC that erroneously states that funds will be made available for the benefit of the applicant may be subject to rescission.

See Item #29 Purpose/Instructions above.

35

I understand that all documentation associated with this request must be retained for a period of at least five years pursuant to 47 CFR § 54.631, or as otherwise prescribed by the Commission’s rules.

See Item #29 Purpose/Instructions above.

36

Signature

The Authorized Person is required to provide all required signatures and certifications. The FCC Form 467 must be certified electronically.

37

Date Submitted

Auto populated by system.

38

Date Signed

Auto populated by system.

39

Authorized Person Name

This is the name of the Authorized Person certifying the FCC Form 467. This field will be auto-populated if the name of the Authorized Person is already within the system.

40

Authorized Person’s Employer

This is the name of the employer of the Authorized Person certifying the FCC Form 467. This field will be auto-populated if already within the system.

41

Authorized Person’s Employer FCC RN

This is the FCC RN of the Authorized Person certifying the FCC Form 467. This field will be auto-populated if already within the system.

42

Authorized Person’s Title/Position

This is the title of the Authorized Person signing the FCC Form 467. This field will be auto-populated if already within the system.

43

Authorized Person’s Mailing Address

This is the address (can be physical address or mailing address) of the Authorized Person certifying the FCC Form 467. This field will be auto-populated if already within the system.

44

Authorized Person Telephone Number

This is the telephone number of the Authorized Person certifying the FCC Form 467. This field will be auto-populated if already within the system.

45

Authorized Person Email Address

This is the email address of the Authorized Person certifying the FCC Form 467. 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 0.3 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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