FCC Form 467 RHC, Telecommunications Program, Connection Certificatio

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Estimated time per response: 30 mins

OMB 3060-0804
X/XX/2023

Rural Health Care
Telecommunications Program
Connection Certification Form (FCC Form 467)
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 #
1

Field Description
FCC Form 466 Application Number

2

Funding Request Number (FRN)

3
4

Funding Year: Funding Start Date
Funding Year: Funding End Date

5

Health Care Provider (HCP) Number

6
7

HCP Name
HCP Contact Information

8

Legal Entity Name

9

Legal Entity FCC RN

Purpose/Instructions
Auto-populated by the system: This is a unique identifier for each Request for Funding
(FCC Form 466).
Auto-populated by the system: This is the unique identifier for each Request for
Funding (FCC Form 466) provided in the funding commitment letter (FCL) issued by the
Universal Service Administrative Company (USAC) to the applicant.
Auto-populated by the system: This displays the date funding began for an FRN.
Auto-populated by the system: This displays the date funding will end/ended for an
FRN.
Auto-populated by the system: This is the unique USAC-assigned identifier for the site
listed in Site Name. The Site Number was issued by USAC when the FCC Form 465 was
completed.
Auto-populated by the system: This is the site name submitted on the FCC Form 465.
Auto-populated by the system: This is the site’s physical address, county, city, state, zip
code, telephone, website, contact name, contact employer and geolocation.
Geolocation only applies to a site that does not have a street address. This information
was previously submitted on the FCC Form 465.
Auto-populated by the system: If applicable. This is the name of the Legal Entity that
owns and/or operates the site. In some cases, the Legal Entity Name may be different
from the Site Name. This name was previously submitted on the FCC Form 465.
Auto-populated by the system: If applicable. This is the unique FCC identifier for the
Legal Entity that owns and/or operates the site. This unique identifier was previously
submitted on the FCC Form 465.
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Item #
10

Field Description
Billed Entity Name

11

Billed Entity Contact Information

12

Consortium Name

13

498 ID of Service Provider(s)

14

Service Provider Name(s)

15

Service Provider/Applicant Invoice Number

16

Action Taken

17

Expense/Service Type

18

Bandwidth

19

Date Service Started

Purpose/Instructions
Auto-populated by the system: If applicable. This is the entity that pays the bills of the
service provider for the site. This may be the site itself, or it may be the “parent”
organization, association, consortium, etc. to which the site belongs. This information
was previously submitted on the FCC Form 466.
Auto-populated by the system: If applicable. This is the Billed Entity’s physical address,
county, city, state, zip code, telephone, website, contact name, contact employer, email
address and geolocation. This information was previously submitted on the FCC Form
466.
Auto-populated by the system: If applicable. The user identifies as being a member of a
larger collective group (e.g., consortium, association, network, etc.) that participates in
either the Telecommunications or HCF Programs. This information was previously
submitted on the FCC Form 465.
Auto-populated by the system: The selected service provider’s 498 ID (formerly the
Service Provider Identification Number (SPIN) ID). This ID is pulled from the FCC Form
466 for an FRN. There may be multiple service providers should the circuit have
multiple connections.
Auto-populated by the system: Based on the 498 ID(s) entered on the FCC Form 466 for
an FRN. There may be multiple service providers if the circuit has multiple connections.
Optional. Allows the service provider and/or applicant to track their FCC Form 466/467
within their billing system.
User selects purpose of the FCC Form 467 which can be to: (1) confirm the accuracy of
all information provided on the FCC Form 466; (2) notify USAC of a disconnection of
service; or (3) inform USAC that service was not turned on during the funding year.
Auto-populates. This is the expense/service category the health care provider identified
on their submitted Form 466.
Auto-populates. User must confirm the site is receiving the same bandwidth identified
on their submitted FCC Form 466.
The date service began or is expected to begin. If the service start date is delayed, the
actual service start date should be indicated here.

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Item #
20

Field Description
Date Service Ended/Disconnected

21
22

Contract Status
Billing Account Number (BAN)

23
24

Total Actual Undiscounted Cost
Percentage of Expense Eligible

25

Percentage of Usage Eligible

26

Total Eligible Actual Cost

27

USF Support Committed

28

Supporting Documentation

29

I certify under penalty of perjury that the
service identified above has been or is being
provided to the above-named applicant.

30

I certify under penalty of perjury that the
universal service credit will be applied to the
telecommunications service billing account
of the applicant or the billed entity as
directed by the applicant.
I certify under penalty of perjury that I am
authorized to submit this request on behalf
of the above-named applicant.

31

Purpose/Instructions
The date service is to end or was disconnected. If the actual end date or disconnection
date occurred before the original reported service end/disconnection date, the actual
service end or disconnection date should be indicated here.
Displays the status of the contract (e.g., month-to-month, evergreen, etc.).
The line item BAN listed on the service provider’s bill.
The actual total undiscounted cost (including taxes and fees) for the billing period.
Auto-populated by the system: The percentage of the item expense that is eligible for
support.
Auto-populated by the system: The percentage of the line item expense that is used by
an eligible site.
Auto-populated by the system: The system will calculate and display the total amount
of the line item expense that is eligible for universal service support.
Auto-populated by the system: The system will calculate and display the total amount
of the eligible line item expense that USAC may pay the service provider for the line
item.
Optional. Provides the option for the user to upload and submit supporting documents
to their request.
The Authorized Person is required to provide all required certifications and signatures.
For individual applicants, certifications must be signed by an officer or director of the
applicant. For consortium applicants, an officer, director, or other authorized employee
of the Consortium Leader must sign the required certifications. The applicant must
provide this certification in order to receive universal service fund support.
See Item #29 Purpose/Instructions above.

See Item #29 Purpose/Instructions above.

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Item #
32

36

Field Description
I certify under penalty of perjury that I have
examined the invoice and supporting
documentation and that, to the best of my
knowledge, information and belief, all
statements contained herein are true.
I certify under penalty of perjury that the
applicant or consortium that I am
representing satisfies all of the requirements
and will abide by all of the relevant
requirements, including all applicable FCC
rules, with respect to universal service
benefits provided under 47 U.S.C. § 254.
I understand that any letter from USAC that
erroneously states that funds will be made
available for the benefit of the applicant
may be subject to rescission.
I understand that all documentation
associated with this request must be
retained for a period of at least five years
pursuant to 47 CFR § 54.631, or as otherwise
prescribed by the Commission’s rules.
Signature

37
38
39

Date Submitted
Date Signed
Authorized Person Name

40

Authorized Person’s Employer

41

Authorized Person’s Employer FCC RN

42

Authorized Person’s Title/Position

33

34

35

Purpose/Instructions
See Item #29 Purpose/Instructions above.

See Item #29 Purpose/Instructions above.

See Item #29 Purpose/Instructions above.

See Item #29 Purpose/Instructions above.

The Authorized Person is required to provide all required signatures and certifications.
The FCC Form 467 must be certified electronically.
Auto populated by system.
Auto populated by system.
This is the name of the Authorized Person certifying the FCC Form 467. 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 467.
This field will be auto-populated if already within the system.
This is the FCC RN of the Authorized Person certifying the FCC Form 467. This field will
be auto-populated if already within the system.
This is the title of the Authorized Person signing the FCC Form 467. This field will be
auto-populated if already within the system.
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Item #
43

Field Description
Authorized Person’s Mailing Address

44

Authorized Person Telephone Number

45

Authorized Person Email Address

Purpose/Instructions
This is the address (can be physical address or mailing address) of the Authorized
Person certifying the FCC Form 467. This field will be auto-populated if already within
the system.
This is the telephone number of the Authorized Person certifying the FCC Form 467.
This field will be auto-populated if already within the system.
This is the email address of the Authorized Person certifying the FCC Form 467. This
field will be auto-populated if already within the system.

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