FCC Form 462 Request for Funding

OMB 3060-0804

X/X/2020

Rural Health Care

Healthcare Connect Fund Program

Description of Request for Funding (FCC Form 462)

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	Purpose/Instructions
1	Funding Request Number (FRN)	Auto-generated by the system: The system creates a unique identifier for this request.
2	Funding Year	This is the selection of the funding year the applicant is submitting the request for. A funding year runs from July 1 through June 30 of the following year. *Pilot Program participants can request up to three-years of funding, but Funding Years do not apply to the Pilot Program.
3	Site Number(s) for Single or Individual Expense(s)	Auto-generated by the system: This is the unique Universal Service Administrative Company (USAC) assigned identifier for the site(s) listed in Site Name(s). The Site Number was issued by USAC when the Description of Eligibility Form (FCC Form 460) was completed.
4	Site Name(s) for Single or Individual Expense(s)	Auto-generated by the system: This is the site name(s) submitted on the FCC Form 460.
5	Site Number for Multiple or Consortium Expense(s)	For multiple expense item requests or Consortium requests, the user can assign site numbers to line items.
6	Site Name for Multiple or Consortium Expense(s)	For multiple expense item requests or Consortium requests, the user can assign site names to line items.
7	Consortium Number	Auto-generated by the system: This is the unique USAC assigned identifier for the consortium listed in Consortium Name. The Consortium Number was issued by USAC when the FCC Form 460 was completed.
8	Consortium Name	Auto-generated by the system: This is the name of the consortium submitted on the FCC Form 460.
9	Site Contact Information	Auto-generated by the system: This is the site’s physical address, county, city, state, zip code, telephone, website, contact name, contact employer, and geolocation provided on the FCC Form 460. Geolocation only applies to a site that does not have a street address.
10	Consortium Contact Information	Auto-generated by the system: This is the consortium’s address, county, city, state, zip code, telephone, website, contact name, contact employer, and geolocation provided on the FCC Form 460. Geolocation only applies to a site that does not have a street address.
11	FCC Form 461 Application Number	Auto-generated by the system: This is a unique USAC-assigned identifier for the FCC Form 461 associated with this FCC Form 462.
12	Allowable Contract Selection Date (ACSD)	Auto-generated by the system: This is the first day in which an applicant may agree to or sign a contract with a service provider. This is calculated based on the number of days the FCC Form 461 was posted. The ACSD is no less than 29 calendar days after the date on which the FCC Form 461 was posted on USAC’s website.
13	Number of Service Provider Bids	The number of service providers who responded to or bid on the request for services (FCC Form 461).
14	Service Provider (SPIN)/498 ID	The selected service provider’s SPIN/498 ID.
15	Service Provider Name	Auto-generated by the system: Based on the SPIN/498 ID entered by the user. If requesting services from multiple service providers, one FCC Form 462 must be submitted per service provider.
16	Service Provider Selection Date	The date that the service provider was selected for the funding request.
17	Continuation with Current Service Provider	The user selects this if the selected service provider is their current service provider.
18	Pricing Confidentiality	Optional. The user indicates if there is a restriction that prevents the pricing information provided by the service provider from becoming public. If so, the applicant must describe the specific restriction and the legal source prohibiting publication.
19	Evergreen Review	The user requests that the contract submitted with the funding request be reviewed for an evergreen endorsement (thereby allowing a competitive bidding exemption for the life of the contract).
20	Competitive Bidding Exemption	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 462; 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. *Pilot Program applicants claiming a competitive bidding exemption for an existing contract that was competitively bid must provide a copy of the contract and underlying competitive bidding documentation. This exemption only applies to the Pilot Program.
21	Single, Multiple or Consortium Expense(s)	Allows the user to submit single and/or multiple eligible expense items, or Consortium expense items within the request.
22	Contract ID	This is the unique USAC assigned identifier for a contract or service agreement. This identifier helps the user identify the contract in the future.
23	Contract Friendly Name	This is a unique identifier/nickname created by the user for this request (e.g., Smith Telecommunications Funding Year 2016).
24	Date Contract Signed/Service Provider Selected	The date the contract with the service provider was signed.
25	Initial Contract Length	The length of the initial contract excluding voluntary options.
26	Number of Contract Extensions	If applicable. If the contract includes voluntary options to extend the term of the contract, then the user enters the number of such voluntary options.
27	Duration of Each Contract Extension	If applicable. The duration of each contract extension.
28	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.
29	Expense Category	The user selects the expense category of a line item.
30	Expense Type	The user selects the expense type of a line item.
31	Expense Frequency	The user indicates the frequency of the expense (e.g., monthly, yearly, quarterly) for which support is sought.
32	Quantity of Expense Periods	The user indicates the number of expense periods (e.g., 12 months, 36 months, etc.) that are included within this request.
33	Billing Account Number (BAN)	Optional. The line item BAN listed on the service provider’s bill.
34	Circuit ID	Optional. 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. *Not applicable to the Pilot Program
35	Circuit Start Location	The physical location and/or Site Number where the circuit originates for the line item. *Not applicable to Pilot Program
36	Circuit End Location	The physical location and/or Site Number where the circuit terminates for the line item. *Not applicable to the Pilot Program
37	New Circuit Installation	The user indicates if the circuit is newly installed. *Not applicable to Pilot Program
38	Bandwidth	If applicable. The user enters the bandwidth for the service.
39	Symmetrical Service	The user indicates if upload and download speeds are equal for the service.
40	Upload Speed	The user enters upload speed for the service.
41	Download Speed	If service is not symmetrical (different upload and download speeds,) then the user enters the download speed for the service.
42	Expected Service Start Date	The date service is expected to start for the line item expense.
43	Service Level Agreement (SLA)	Optional. The user indicates whether the applicant’s contract with the service provider includes an SLA.
44	Latency	The latency requirement per the contract SLA.
45	Jitter	The jitter requirement per the contract SLA.
46	Packet Loss	The packet loss rate requirement per the contract SLA.
47	Reliability	The reliability requirements per the contract SLA.
48	Total Number of Fiber Strands	The total number of fiber strands that are part of the fiber lease or similar agreement for this line item. *Not applicable to the Pilot Program
49	Number of Fiber Strands Eligible	The number of fiber strands that are eligible for support for this line item. *Not applicable to Pilot Program
50	Quantity of Expenses	The number of expenses the applicant is seeking under this line item.
51	Processing: Type of Funding Request	The user indicates the type of funding an applicant is requesting (e.g., multi-year contract, month-to-month services, etc.).
52	Multi-Year Contracts	If applicable. The user indicates the amount requested by funding year for each expense type. *Pilot Program participants can request up to three-years of funding, but Funding Years do not apply to the Pilot Program.
53	Percentage of Expense Eligible	The percentage of the line item expense that is eligible for support.
54	Percentage of Usage Eligible	The percentage of the line item expense that is used by an eligible site.
55	Percentage of Expense Ineligible	The percentage of the line item expense that is ineligible for support.
56	Percentage of Usage Ineligible	The percentage of the line item expense that is used by an ineligible site.
57	Total Undiscounted Cost Per Expense Period	The total undiscounted cost per expense period (excluding taxes and fees).
58	Total Undiscounted Cost For Eligible (Recurring) Expenses	The system will calculate and display the total undiscounted cost for recurring eligible expenses.
59	Total Undiscounted Cost For Eligible (Non-Recurring) Expenses	The system will calculate and display the total undiscounted cost for non-recurring eligible expenses.
60	Total Discounted Cost Per Expense Period	The total discounted cost per expense period (excluding taxes and fees).
61	Total Discounted Cost For Eligible (Recurring) Expenses	The system will calculate and display the total discounted cost for recurring eligible expenses.
62	Total Discounted Cost For Eligible (Non-Recurring) Expenses	The system will calculate and display the total discounted cost for non-recurring eligible expenses.
63	One-Time Installation Charges	The user indicates any one-time installation charges.
64	Taxes & Fees Per Expense Period	The taxes and fees for the line item.
65	Source of Health Care Provider Contribution	The sources from which the Site or Consortium will fund its 35% contribution for this line item. *Pilot Program Participants receive an 85% discount and must still identify the source of the non-discount share
66	Supporting Documentation	There is additional documentation required to be submitted (where applicable) with the FCC Form 462 to support the request for funding. Specifically, consortium and individual applicants must submit: contracts, terms of service agreements (if applicable), competitive bidding documents (including documentation to support its certification that it has selected the most cost-effective option), and written descriptions of cost allocation (if applicable). Consortium applicants must also submit: revisions to financial agreements (if submitted with the FCC Form 460), revisions to the Network Plan (submitted with the FCC Form 461), a narrative description of how the network will be managed (if not previously provided), a network cost worksheet listing all participating health care providers, evidence of a viable source for the 35% contribution, sustainability plans (if applicable), revisions to sustainability plans (if previously submitted) and letters of agency (if not previously submitted).
67	I certify under penalty of perjury that I am authorized to submit this request on behalf of the applicant or consortium.	Applicants are required to provide this certification in order to receive Healthcare Connect Fund support. For individual Health Care Provider applicants, certifications must be signed by an officer or director of the Healthcare Provider or other authorized employee of the Health Care Provider. For consortia applicants, an officer, director, or other authorized employee of the Consortium Leader must sign the required certification.
68	I certify under penalty of perjury that I have examined this request and all attachments and to the best of my knowledge, information, and belief, all statements of fact contained therein are true.	See Item #67 Purpose/Instructions above.
69	I certify under penalty of perjury that the applicant or consortium has considered all bids received and selected the most cost-effective method of providing the requested services. “Cost-effective” is defined 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 care services.” 47 CFR § 54.622(c).	See Item #67, Purpose/Instructions above.
70	I certify under penalty of perjury that the applicant or consortium is not requesting support for the same service from both the Telecommunications Program and the Healthcare Connect Fund Program.	See Item #67, Purpose/Instructions above. *Not applicable to Pilot Program
71	I certify under penalty of perjury that all RHC Program support will be used only for eligible health care purposes.	See Item #67, Purpose/Instructions above. *Not applicable to Pilot Program
72	I certify under penalty of perjury that the applicant or consortium 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 #67, Purpose/Instructions above.
73	I certify under penalty of perjury that the applicant or consortium satisfies all of the requirements under Section 254 of the Act and applicable Commission rules, and understand that any letter from the Administrator that erroneously commits funds for the benefit of the applicant may be subject to rescission.	See Item #67, Purpose/Instructions above.
74	I certify under penalty of perjury that I have reviewed all applicable rules and requirements for the RHC Program and complied with those rules and requirements.	See Item #67, Purpose/Instructions above. *Not applicable to Pilot Program
75	I understand that all documentation associated with this application, including all bids, contracts, scoring matrices, and other information associated with the competitive bidding process, all billing records for services received and any other documentation demonstrating compliance with the rules must be retained for a period of at least five years after the last date of service delivered in a particular funding year pursuant to 47 CFR §§ 54.631 or as otherwise prescribed by the Commission’s rules.	See Item #67, Purpose/Instructions above.
76	I certify under penalty of perjury that any consultants or third parties associated with this request or RFP do not have an ownership interest, sales commission arrangement, or other financial stake in the vendor 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 #67, Purpose/Instructions above.
77	Signature	The Authorized Person is required to provide all required certifications and signatures. The FCC Form 462 must be certified electronically.
78	Date Submitted	Auto generated by system. This date is assigned based on the date the user submits the FCC Form 462.
79	Date Signed	Auto generated by system. This date is assigned based on the date the user certifies the FCC Form 462.
80	Authorized Person Name	This is the name of the Authorized Person certifying the FCC Form 462. This field will be auto-populated if already within the system.
81	Authorized Person’s Employer	This is the name of the employer of the Authorized Person certifying the FCC Form 462. This field will be auto-populated if already within the system.
82	Authorized Person’s Employer FCC Registration Number	This is the FCC registration number of the Authorized Person certifying the FCC Form 462. This field will be auto-populated if already within the system.
83	Authorized Person’s Title/Position	This is the title of the Authorized Person certifying the FCC Form 462. This field will be auto-populated if already within the system.
84	Authorized Person’s Mailing Address	This is the address (can be physical address or mailing address) of the Authorized Person certifying the FCC Form 462. This field will be auto-populated if already within the system.
85	Authorized Person Telephone Number	This is the telephone number of the Authorized Person certifying the FCC Form 462. This field will be auto-populated if already within the system.
86	Authorized Person Email Address	This is the email address of the Authorized Person certifying the FCC Form 462. 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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