FCC Form 463 RHC, HCFP, Description of Request for Funding Disburseme

OMB 3060-0804
XX/XX/2023

NOT YET APPROVED BY OMB
Estimated time per response: 1hr

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.

Item #
1

Field Description
Rural Health Care Invoice Number

2

Funding Request Number (FRN)

3

Funding Year: Funding Start Date

4

Funding Year: Funding End Date

5

Site Number

6

Site Name

7

Consortium Number

8

Consortium Name

Purpose/Instructions
Auto-generated by the system: This is the unique identifier for the Request for
Funding Disbursement (FCC Form 463).
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.
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.
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.
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.
Auto-generated by the system: This is the name of the site submitted on the FCC
Form 460.
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.
Auto-generated by the system: This is the name the consortium submitted on the
FCC Form 460.
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Item #
9

Field Description
Site Contact Information

10

Consortium Contact Information

11

498 ID of Service Provider

12

Service Provider Name

13

Service Provider/Applicant Invoice Number

14
15
16
17
18
19
20
21
22
23
24
25
26

Funding Request Number Identification Number
(FRN ID)
Site Number: Line Item Details
Site Name: Line Item Details
Expense Category
Expense Type
Upload Speed
Download Speed
Service Start Date
Quantity of Items
Billing Account Number (BAN)
Billing Period Start Date
Billing Period End Date
Billing Period Eligible Amount

27
28

Total Actual Undiscounted Cost
Percentage of Expense Eligible

Purpose/Instructions
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.
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.
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.
Auto-generated by the system: Based on the 498 ID entered on the FCC Form 462
for the FRN.
Optional. Allows the service provider and/or applicant to track the FCC Form 462
within their billing system.
Auto-generated by the system: Building upon the FRN, the system auto-generates
an FRN ID to correspond to an individual line item.
Auto-generated by the system: Based on the line item’s FRN ID.
Auto-generated by the system: Based on the line item’s FRN ID.
Auto-generated by the system: Based on the line item’s FRN ID.
Auto-generated by the system: Based on the line item’s FRN ID.
Auto-generated by the system: Based on the line item’s FRN ID.
Auto-generated by the system: Based on the line item’s FRN ID.
The date service is expected to start for the line item.
The number of items the applicant is seeking under the line item.
The line item BAN is listed on the service provider’s bill.
The first date of the billing period for the invoice.
The last date of the billing period for the invoice.
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.
The actual total undiscounted cost (including taxes and fees) for the billing period.
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.
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Item #
29

Field Description
Percentage of Usage Eligible

30

Total Eligible Actual Cost

31

Consultant Disclosure

32

USF Support To Be Paid

33

Supporting Documentation

34

I certify under penalty of perjury that I am
authorized to submit this request on behalf of the
service provider.
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.
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.
I certify under penalty of perjury that I have
abided by all RHC Program requirements and
procedures, including all applicable Commission
rules.
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.

35

36

37

38

Purpose/Instructions
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.
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.
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.
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.
Optional. Provides the option for the user to upload and submit documents to
support their request.
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.
The service provider must make this certification in order to participate in the
RHC Program.

See Item #34 Purpose/Instructions above.

See Item #34 Purpose/Instructions above.

See Item #34 Purpose/Instructions above.

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Item #
39

40

41

42

Field Description
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).
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.
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.
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.

Purpose/Instructions
See Item #34 Purpose/Instructions above.

See Item #34 Purpose/Instructions above.

See Item #34 Purpose/Instructions above.

See Item #34 Purpose/Instructions above.

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Item #
43

45

Field Description
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.
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.
Signature

46
47
48

Date Submitted
Date Signed
Authorized Person Name

49

Authorized Person’s Employer

44

Purpose/Instructions
See Item #34 Purpose/Instructions above.

See Item #34 Purpose/Instructions above.

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

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Item #
50

Field Description
Authorized Person’s Employer FCC RN

51

Authorized Person’s Title/Position

52

Authorized Person’s Mailing Address

53

Authorized Person Telephone Number

54

Authorized Person Email Address

55

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

56

57

58

Purpose/Instructions
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.
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.
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.
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.
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.
The authorized representative of the Consortium Leader (or, Health Care
Provider, if participating individually) must provide this certification.
See Item #55 Purpose/Instructions above.

See Item #55 Purpose/Instructions above.

See Item #55 Purpose/Instructions above.

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Item #
59

60

Field Description
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.
Signature

61
62
63

Date Submitted
Date Signed
Authorized Person Name

64

Authorized Person’s Employer

65

Authorized Person’s Employer FCC RN

66

Authorized Person’s Title/Position

67

Authorized Person’s Mailing Address

68

Authorized Person Telephone Number

69

Authorized Person Email Address

Purpose/Instructions
See Item #55 Purpose/Instructions above.

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.
Auto generated by system.
Auto generated by system.
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.
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.
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.
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.
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.
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.
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.

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