FCC Form 5640 Reimbursement Claim Request, Section 1.50004(g)

OMB 3060-1270

September 2021

Secure and Trusted Communications Networks Reimbursement Program

FCC Form 5640: Reimbursement Claim Request, Section 1.50004(g)

Information Submitted Using Online Portal

Estimated Time Per Response: 1 hour

(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.)

Item Number	Field(s) Description	Purpose/Instructions
Applicant Information
1	Applicant FCC Registration Number (FRN)	An FRN is a 10-digit number that is assigned by the Commission Registration System (CORES) to a business or individual registering with the FCC. This unique FRN is used to identify the registrant’s business dealings with the FCC. This information will be auto-generated from the information provided in the Application Request for Funding Allocation.
2	Applicant Name	This is the name of the Applicant submitting this request. This information will be auto-generated from the information provided in the Application Request for Funding Allocation.
3	Applicant Information: Applicant Street Name; Applicant City; Applicant State; Applicant Zip Code; Applicant Phone Number; Applicant Email.	This information will be auto-generated from the information provided in the Application Request for Funding Allocation.
Contact Information
4	Contact different than Applicant: Contact Name; Contact Street Name; Contact City; Contact State; Contact Zip Code; Contact Phone #; Contact Email.	These items identify the contact representative, if different from the Applicant. This is usually the headquarters offices of a large company, the law firm or other representative of the Applicant, or the person or company that prepared or submitted the application on behalf of the Applicant. If there is a question about the application, an FCC representative will communicate with the Applicant’s contact representative. This information will be auto-generated from the information provided in the Application Request for Funding Allocation but filer will have the opportunity to change information to designate a different contact for the filing.
5	Contact same as Applicant: Contact Name; Contact Street Name; Contact City; Contact State; Contact Zip Code; Contact Phone #; Contact Email.	These items identify the contact representative. This is usually the headquarters offices of a large company, the law firm or other representative of the Applicant, or the person or company that prepared or submitted the application on behalf of the Applicant. If there is a question about the application, an FCC representative will communicate with the Applicant’s contact representative. This information will be auto-generated from the information provided in the Application Request for Funding Allocation but filer will have the opportunity to change information to designate a different contact for the filing.
Invoice Information
6	For each invoice submitted for reimbursement, provide the following information: Description of invoice to be reimbursed; Vendor Name; Vendor Employer Identification Number (EIN) or Tax Identification Number (TIN); Invoice Number; Invoice date; Invoice due date.	The applicant must answer these questions for each invoice that is seeking reimbursement on the same reimbursement request. Information will help the FCC evaluate accuracy and reasonableness of reimbursement request.
7	Does the attached invoice contain costs ineligible for reimbursement? (Yes or No)	The applicant must answer these questions for each invoice that is seeking reimbursement on the same reimbursement request. Information will help the FCC evaluate accuracy and reasonableness of reimbursement request.
8	Provide copy of invoice for demonstrating cost actually incurred for which you are seeking reimbursement.	Information will help FCC evaluate accuracy and reasonableness of reimbursement request. If invoice relates to quote issued by vendor that has not been previously submitted and reviewed by Fund Administrator, then filer will need to attach copy of associated quote from vendor.
9	Reimbursement Request Amount.	Recipients must show actual expenses on invoice reasonably incurred for the removal, replacement, and disposal of covered communications equipment or service. Information will help FCC evaluate accuracy and reasonableness of reimbursement request.
10	Description of equipment or services being reimbursed.	Information will help FCC evaluate accuracy and reasonableness of reimbursement request.
11	Does the invoice contain expense(s) related to a technology upgrade that are not eligible for reimbursement as a comparable replacement?	Information will help FCC evaluate accuracy and reasonableness of reimbursement request.
12	Identify if cost is associated with a single site, multiple sites, across all sites, or non-site-specific.	Information will help FCC evaluate accuracy and reasonableness of reimbursement request.
13	Identify locations associated with cost estimate.	Information will help FCC track where money is spent and help to evaluate money spent by location. For single or multiple sites, filer will need to identify sites by Location ID, i.e., site(s) previously identified by filer in system through Application Request for Funding Allocation or subsequently filed Modification application.
14	Identify percentage of cost allocated to location.	Information required if multiple sites identified and will help FCC evaluate accuracy and reasonableness of reimbursement request and track funding disbursements.
15	Identify Cost Estimate to which this cost is related.	Information will help FCC evaluate accuracy and reasonableness of the reimbursement request. Filer will need to select a Cost Estimate as previously identified by filer in an earlier filed Application Request for Funding Allocation or subsequently filed Modification application.
16	If cost incurred for which reimbursement sought (combined with other expenses incurred) significantly exceeds original cost estimate, provide explanation for deviation.	Information will help FCC evaluate accuracy of cost estimates for future cost estimation.
Certifications
17	By checking the box and providing the electronic signature where indicated below, the Certifying Official on behalf of the Applicant certifies under penalty of perjury that: The Certifying Official is authorized to submit this request for reimbursement on behalf of the Applicant and, based on information known to me or provided to me by employees responsible for the information being submitted, the information set forth in this request for reimbursement has been examined and is true, accurate, and complete, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. The Certifying Official acknowledges that any false, fictitious, or fraudulent information or statement, or the omission of any material fact on this request for reimbursement or on any other document submitted by the Applicant may subject the Applicant and the undersigned to punishment by fine or forfeiture under the Communications Act (47 U.S.C. §§ 502, 503(b), 1606), or fine or imprisonment under Title 18 of the United States Code (18 U.S.C. § 1001, §§ 286-287, and § 1343), or can lead to liability under the False Claims Act (31 U.S.C. §§ 3729-3733, and §§ 3801-3812). The Applicant is in compliance with the statute, rules, and orders governing the Reimbursement Program, including but not limited to allocations, draw downs, payments, obligations and expenditures of money, and the Certifying Official acknowledges that failure to be in compliance and remain in compliance with those statutes, rules, and orders may result in the denial of funding, cancellation of funding commitments, and/or recoupment of past disbursements. The Certifying Official acknowledges that failure to comply with the statute, rules, and orders governing the Reimbursement Program could result in civil or criminal prosecution by law enforcement authorities. The Applicant has filed all required documentation for its expenses to be reimbursable under the Reimbursement Program rules. The amounts claimed for reimbursement are limited to only the portion of the costs that were or will be reasonably incurred for the removal, replacement, and disposal of covered communications equipment and services in accordance with the Secure and Trusted Communications Networks Act of 2019, as amended, Pub. L. 116-124 § 4 (47 U.S.C. § 1603) and the Commission’s rules (47 CFR § 1.50004). The Applicant as of the date of this submission has developed a specific plan and timeline for the permanent removal, replacement, and disposal of covered communications equipment or service. The Applicant: (1) will not purchase, rent, lease or otherwise obtain covered communications equipment or service published by the Commission under 47 U.S.C. § 1601(a), using reimbursement funds (including funds derived from private sources) and (2) in developing and tailoring risk management practices, will consult and consider the standards, guidelines, and best practices set forth in the cybersecurity framework developed by the National Institute of Standards and Technology. The Applicant will not use Reimbursement Program funds for any portion of expenses that have been or will be reimbursed by other sources of funding (e.g., Federal pandemic relief funding such as the Coronavirus Aid, Relief, and Economic Security (CARES) Act, Emergency Broadband Benefit Program, or other provisions of the American Rescue Plan; targeted state funding; other external sources of targeted funding; or other universal service support mechanisms). The Applicant recognizes that it may be subject to an audit, inspection or investigation pursuant to its request for reimbursement, that it will retain for ten years any and all records related to its participation in the program as required by 47 CFR § 1.50004(n), and will make such records and equipment purchased with Reimbursement Program reimbursement available at the request of any representative (including any auditor) appointed by the Administrator, the Commission and its Office of Inspector General, or any local, state, or Federal agency with jurisdiction over the entity. No kickbacks, as defined in 41 U.S.C. § 8701 and/or 42 U.S.C. § 1320a-7b, were paid or received by the Applicant to anyone in connection with the Reimbursement Program.	Certifications necessary to protect Reimbursement Program against waste, fraud, and abuse.
19	Certifying Official Name	Name of certifying official.
20	Certifying Official Title	Job title of certifying official.
21	Certifying Official Phone Number	Phone number of the certifying official.
22	Certifying Official Email Address	Email address of the certifying official.
23	Certifying Date Signed	The date on which the filing is certified will be auto-generated.

FCC Form 5640/ September 2021