FCC Form 463 Description of Request for Funding Disbursement (FY2021+

Promoting Telehealth for Low-Income Consumers; COVID-19 Telehealth Program

2021 FCC Form 463 - 2.3.21 (clean) v2

OMB: 3060-1271

Document [docx]
Download: docx | pdf

OMB 3060-0804

X/X/2021


Rural Health Care

Healthcare Connect Fund Program

Description of Request for Funding Disbursement (FCC Form 463)

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-generated into the form.

This form is effective for funding year 2021 and beyond.

Item #

Field Description

Purpose/Instructions

1

Rural Health Care Invoice Number

Auto-generated by the system: This is the unique identifier for the Request for Funding Disbursement (FCC Form 463).

2

Funding Request Number (FRN)

Auto-generated by the system: This is a unique identifier auto-generated by the system on the FCC Form 462 and provided in the funding commitment letter to the applicant.

3

Funding Year: Funding Start Date

Auto-generated by the system: This displays the date funding began for this Funding Request Number (FRN). Taken from information provided on the Request for Funding (FCC Form 462). Funding years start on July 1 of each year and end on June 30 of the following year.

4

Funding Year: Funding End Date

Auto-generated by the system: This displays the date funding will end/ended for this FRN. Taken from information provided on the FCC Form 462.

5

Site Number

Auto-generated by the system: This is the unique Universal Service Administrative Company (USAC) assigned identifier for the site listed in Site Name. The Site Number was issued by USAC when the Description of Eligibility (FCC Form 460) was completed.

6

Site Name

Auto-generated by the system: This is the name of the site submitted on the FCC Form 460.

7

Consortium Number

Auto-generated by the system: This is the unique USAC assigned identifier for the consortium listed in Site 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 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, 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

498 ID of Service Provider

Auto-generated by the system: The selected service provider’s 498 ID (formerly Service Provider Identification Number (SPIN) ID). The 498 ID is pulled from the FCC Form 462 for an FRN.

12

Service Provider Name

Auto-generated by the system: Based on the 498 ID entered on the FCC Form 462 for the FRN.

13

Service Provider/Applicant Invoice Number

Optional. Allows the service provider and/or applicant to track the FCC Form 462 within their billing system.

14

Funding Request Number Identification Number (FRN ID)

Auto-generated by the system: Building upon the FRN, the system auto-generates an FRN ID to correspond to an individual line item.

15

Site Number: Line Item Details

Auto-generated by the system: Based on the line item’s FRN ID.

16

Site Name: Line Item Details

Auto-generated by the system: Based on the line item’s FRN ID.

17

Expense Category

Auto-generated by the system: Based on the line item’s FRN ID.

18

Expense Type

Auto-generated by the system: Based on the line item’s FRN ID.

19

Bandwidth

Auto-generated by the system: Based on the line item’s FRN ID.

20

Service Start Date

The date service is expected to start for the line item.

21

Quantity of Items

The number of items the applicant is seeking under the line item.

22

Billing Account Number (BAN)

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

23

Billing Period Start Date

The first date of the billing period for the invoice.

24

Billing Period End Date

The last date of the billing period for the invoice.

25

Billing Period Eligible Amount

Auto-generated by the system: The amount an applicant is eligible to receive for the billing period. This is derived from information provided on the FCC Form 462.

26

Total Actual Undiscounted Cost

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

27

Percentage of Expense Eligible

Auto-generated by the system: The percentage of the line item expense that is eligible for support. Taken from information provided on the FCC Form 462.

28

Percentage of Usage Eligible

Auto-generated by the system: The percentage of the line item expense that is used by an eligible site. Taken from information provided on the FCC Form 462.

29

Total Eligible Actual Cost

Auto-generated by the system: The system will calculate and display the total amount of the line item expense that is eligible for universal service fund (USF) support. Taken from information provided on the FCC Form 462.

30

Consultant Disclosure

If applicable. Provide the name of any consultants or third parties who helped identify the applicant’s Request for Proposals (RFP) or FCC Form 461, helped to connect you with the health care provider participating in the program, and/or is authorized to act on your behalf in the RHC Program.

31

USF Support To Be Paid

The system will calculate and display the total amount of the line item expense that USAC will pay the service provider for the line item.

32

Supporting Documentation

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

33

I certify under penalty of perjury that I am authorized to submit this request on behalf of the service provider.

The service provider’s representative must make this certification to participate in the RHC Program. The Authorized Person is required to provide all required certifications and signatures.

34

I understand that the service provider must apply the amount submitted, approved, and paid by USAC to the billing account of the applicant(s) and FRN/FRN ID listed on this invoice.

The service provider must make this certification in order to participate in the RHC Program.

35

I certify under penalty of perjury that I have examined this form and attachments and that, to the best of my knowledge, information, and belief, the date, quantities, and costs provided are true and correct.

See Item #33 Purpose/Instructions above.

36

I certify under penalty of perjury that I have abided by all RHC Program requirements and procedures, including all applicable Commission rules.

See Item #33 Purpose/Instructions above.

37

I certify under penalty of perjury that I charged only for eligible services delivered or provided to the applicant prior to submitting the form and accompanying documentation.

See Item #33 Purpose/Instructions above.

38

I certify under penalty of perjury that I have not offered or provided a gift or any other thing of value to the applicant (or to the applicant’s personnel, including its consultant).

See Item #33 Purpose/Instructions above.

39

I certify under penalty of perjury that the consultants or third parties associated with this funding request or application 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 #33 Purpose/Instructions above.

40

I certify under penalty of perjury, as a condition of receiving support, that I will provide to applicants, on a timely basis, all information and documents regarding supported equipment, facilities, or services that are necessary for the applicant to submit required forms or respond to Commission or Administrator inquiries.

See Item #33 Purpose/Instructions above.

41

I understand that all documentation associated with this application, including all billing records for services received, must be retained for a period of at least five years after the last day of the delivery of supported services, equipment or facilities pursuant to 47 CFR § 54.631.

See Item #33 Purpose/Instructions above.

42

I certify under penalty of perjury that no universal service support has been or will be used to purchase, obtain, maintain, improve, modify, or otherwise support any equipment or services produced or provided by any company designated by the Federal Communications Commission as posing a national security threat to the integrity of communications networks or the communications supply chain since the effective date of the designations.

See Item #33 Purpose/Instructions above.

43

I certify under penalty of perjury that no Federal subsidy made available through a program administered by the Commission that provides funds to be used for the capital expenditures necessary for the provision of advanced communications services has been or will be used to purchase, rent, lease, or otherwise obtain, any covered communications equipment or service, or maintain any covered communications equipment or service previously purchased, rented, leased, or otherwise obtained, as required by 47 C.F.R. § 54.10.

See Item #33 Purpose/Instructions above.

44

Signature

The Authorized Person is required to provide all required certifications and signatures. The FCC Form 463 must be certified electronically.

45

Date Submitted

Auto generated by system.

46

Date Signed

Auto generated by system.

47

Authorized Person Name

This is the name of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if the name of the Authorized Person is already within the system.

48

Authorized Person’s Employer

This is the name of the employer of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.

49

Authorized Person’s Employer FCC RN

This is the FCC RN of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.

50

Authorized Person’s Title/Position

This is the title of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.

51

Authorized Person’s Mailing Address

This is the address (can be physical address or mailing address) of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.

52

Authorized Person Telephone Number

This is the telephone number of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.

53

Authorized Person Email Address

This is the email address of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.

54

I certify under penalty of perjury that I am authorized to submit this request on behalf of the applicant or consortium.

The authorized representative of the Consortium Leader (or, Health Care Provider, if participating individually) must provide this certification.

55

I certify under penalty of perjury that I have examined this form and attachments and, to the best of my knowledge, information, and belief, all information contained therein is true and correct.

See Item #54 Purpose/Instructions above.

56

I certify under penalty of perjury that the applicant or consortium members have received the related services, network equipment, and/or facilities itemized on the invoice form.

See Item #54 Purpose/Instructions above.

57

I certify under penalty of perjury that the required 35% minimum contribution for each item on the FCC Form 463 was funded by eligible sources as defined in the FCC rules and that the required contribution was remitted to the service provider.

See Item #54 Purpose/Instructions above.

58

I understand that all documentation associated with this application, including all billing records for services received, 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.

See Item #54 Purpose/Instructions above.

59

Signature

The authorized representative of the Consortium Leader (or Health Care Provider) is required to provide all required certifications and signatures. The FCC Form 463 must be certified electronically.

60

Date Submitted

Auto generated by system.

61

Date Signed

Auto generated by system.

62

Authorized Person Name

This is the name of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if the name of the Authorized Person is already within the system.

63

Authorized Person’s Employer

This is the name of the employer of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.

64

Authorized Person’s Employer FCC RN

This is the FCC RN of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.

65

Authorized Person’s Title/Position

This is the title of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.

66

Authorized Person’s Mailing Address

This is the address (can be physical address or mailing address) of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.

67

Authorized Person Telephone Number

This is the telephone number of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.

68

Authorized Person Email Address

This is the email address of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.



5


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCatriona Ayer
File Modified0000-00-00
File Created2021-04-06

© 2024 OMB.report | Privacy Policy