Item #
|
Field Description
|
Purpose/Instructions
|
1
|
Service Provider Name
|
Auto-generated by the system: This is the name of the service
provider submitted on the FCC Form 466.
|
2
|
498 ID for the Service Provider
|
Auto-generated by the system: The selected service provider’s
498 ID (formerly the Service Provider Identification Number (SPIN)
ID). The 498 ID is pulled from the FCC Form 466 for an FRN.
|
3
|
Invoice Number
|
This number is listed on the service provider’s bill.
|
4
|
Invoice Date
|
The date that the invoice is submitted to the Administrator.
|
6
|
Health Care Provider (HCP) Number
|
Auto-generated by the system: This is the unique identifier
included on the Request for Funding (FCC Form 466).
|
7
|
Funding Request Number (FRN)
|
Auto-generated by the system: This is a unique identifier
auto-generated by the system on the FCC Form 466 and provided in
the funding commitment letter to the applicant.
|
8
|
Funding Year: Funding Start Date
|
Auto-generated by the system: This displays the date funding began
for this FRN. Taken from information provided on the Request for
Funding (FCC Form 466). Funding years start on July 1 of each year
and end on June 30 of the following year.
|
9
|
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 466.
|
10
|
HCP Entered Billing Account Number (BAN)
|
The BAN is listed on the service provider’s bill.
|
11
|
Service Start Date
|
User enters the service date for the provided service.
|
12
|
Billing Period Start Date
|
The first date of the billing period for the invoice.
|
13
|
Billing Period End Date
|
The last date of the billing period for the invoice.
|
14
|
Support Amount to be Paid by USAC
|
The system will calculate and display the total amount of the line
item expense that may be paid by USAC for the line item.
|
16
|
Supporting Documentation
|
Optional. Provides the option for the user to upload and submit
documents to support its invoice form.
|
17
|
I certify under penalty of perjury that I am authorized to submit
this invoice form on behalf of the service provider.
|
The service provider’s representative must provide this
certification to participate in the RHC Program. The Authorized
Person is required to provide all required certifications and
signatures.
|
18
|
I certify under penalty of perjury that the information contained
in the invoice is correct and the applicant(s) and the Billed
Account Number(s) listed above have been credited with the amounts
shown under “Support Amount to be Paid by USAC.”
|
See Item 17 Purpose/Instructions above.
|
20
|
I certify under penalty of perjury that I have complied with all
RHC Program requirements, including all applicable Commission
rules.
|
See Item #17 Purpose/Instructions above.
|
21
|
I certify under penalty of perjury that I have received and
reviewed the Health Care Provider Support Schedule, invoice form
and accompanying documentation, and that the rates charged for the
provided or delivered telecommunications services, to the best of
my knowledge, information and belief, are accurate and comply with
the Commission’s rules.
|
See Item #17 Purpose/Instructions above.
|
22
|
I certify under penalty of perjury that the applicant paid the
appropriate urban rate for the telecommunications services.
|
See Item #17 Purpose/Instructions above.
|
23
|
I certify under penalty of perjury that I charged for only
eligible services provided or delivered to the applicant prior to
submitting the invoice for payment and accompanying documentation.
|
See Item #17 Purpose/Instructions above.
|
24
|
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 #17 Purpose/Instructions above.
|
25
|
I certify under penalty of perjury that any 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 #17 Purpose/Instructions above.
|
26
|
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 #17 Purpose/Instructions above.
|
27
|
I understand that all documentation related to the delivery of
supported services or demonstrate compliance with the rules must
be retained for a period of at least five years after the last day
of the delivery of discounted services pursuant to 47 CFR §
54.631, or as otherwise prescribed by the Commission’s
rules.
|
See Item #17 Purpose/Instructions above.
|
28
|
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 #17 Purpose/Instructions above.
|
29
|
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 #17 Purpose/Instructions above.
|
30
|
Signature
|
The Authorized Person is required to provide all required
certifications and signatures. The invoice form must be certified
electronically.
|
31
|
Date Certified and Submitted
|
Auto populated by system.
|
32
|
Date Signed
|
Auto populated by system.
|
33
|
Authorized Person Name
|
This is the name of the Authorized Person certifying the invoice
form. This field will be auto-populated if the name of the
Authorized Person is already within the system.
|
34
|
Authorized Person’s Employer
|
This is the name of the employer of the Authorized Person
certifying the invoice form. This field will be auto-populated if
already within the system.
|
35
|
Authorized Person’s Title/Position
|
This is the title of the Authorized Person certifying the invoice
form. This field will be auto-populated if already within the
system.
|
36
|
Authorized Person’s Mailing Address
|
This is the address (can be physical address or mailing address)
of the Authorized Person certifying the invoice form. This field
will be auto-populated if already within the system.
|
37
|
Authorized Person’s Telephone Number
|
This is the telephone number of the Authorized Person certifying
the invoice form. This field will be auto-populated if already
within the system.
|
38
|
Authorized Person’s Email Address
|
This is the email address of the Authorized Person certifying the
invoice form. This field will be auto-populated if already within
the system.
|
39
|
Authorized Person’s Fax Number
|
This is the fax number of the Authorized Person certifying the
invoice form. This field will be auto-populated if already within
the system.
|
The public reporting for this
collection of information is estimated to be up to 8 hours per
response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the required data,
and completing and reviewing the collection of information. If you
have any comments on this burden estimate, or how we can improve the
collection and reduce the burden it causes you, please write to the
Federal Communications Commission, AMD-PERM, Paperwork Reduction Act
Project (3060-0804), Washington, DC 20554. We will also accept your
comments regarding the Paperwork Reduction Act aspects of this
collection via the Internet if you send them to [email protected]. PLEASE
DO NOT SEND YOUR RESPONSE TO THIS FORM 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 if we fail to provide you with this notice. This collection has
been assigned an OMB control number of 3060-0804.