FCC Form 469 RHC, Telecommunications Program, Description of Invoice

NOT YET APPROVED BY OMB
Estimated time per response: 2hrs

OMB 3060-0804
X/X/2023

Rural Health Care
Telecommunications Program
Description of Invoice and Request for Disbursement (FCC Form 469)
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 user 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

Purpose/Instructions
Auto-generated by the system: This is the unique identifier for the
Invoice and Request for Disbursement (FCC Form 469).
Auto-generated by the system: This is a unique identifier autogenerated by the system on the Funding Request and Certification Form
(FCC Form 466) and provided in the funding commitment letter to the
applicant.
Auto-generated by the system: This displays the date funding began for
this FRN. Taken from information provided on the FCC Form 466.
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 466.
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 Services
Requested and Certification Form (FCC Form 465) was completed.
Auto-generated by the system: This is the name of the site submitted on
the FCC Form 465.

1

OMB 0804-3060
X/X/2023
Item #
7

Field Description
Site Contact Information

8

498 ID of Service Provider

9

Service Provider Name

10

Service Provider/Applicant Invoice Number

11
12
13
14
15
16
17
18
19
20
21

Funding Request Number Identification
Number (FRN ID)
Service Category
Service 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

22

Monthly Rural Rate

23

Monthly Urban Rate

24

Total Actual Undiscounted Cost

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 465. 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 466 for an FRN.
Auto-generated by the system: Based on the 498 ID entered on the FCC
Form 466 for the FRN.
Optional. Allows the service provider and/or applicant to track the FCC
Form 466 within their billing system.
Auto-generated by the system: Building upon the FRN, the system autogenerates 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.
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 466.
Auto-generated by the system: The approved monthly rural rate from
the FCC Form 466.
Auto-generated by the system: The approved monthly urban rate from
the FCC Form 466.
The actual total undiscounted cost (including taxes and fees) for the
billing period.

2

OMB 0804-3060
X/X/2023
Item #
25

Field Description
Percent Eligible for Support

26

Total Eligible Actual Cost

27

One-time Rural Rate

28

One-Time Urban Rate

29

Consultant Disclosure

30

Support Amount To Be Paid by USAC

31

Supporting Documentation

32

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

33

34

Purpose/Instructions
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 466.
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 466.
Auto-generated by the system: The approved rural rate for one-time
installation charges
Auto-generated by the system: The approved urban rate for one-time
installation charges
If applicable. Provide the name of any consultants or third parties who
helped identify the applicant’s Request for Proposals (RFP) or FCC Form
465, 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.
See Item #32 Purpose/Instructions above.

See Item #32 Purpose/Instructions above.

3

OMB 0804-3060
X/X/2023
Item #
35

36

37

38

39

40

Field Description
I certify under penalty of perjury that I have
received and reviewed the invoice form and
accompanying documentation, and that the
rates charged for the telecommunications
services, to the best of my knowledge,
information and belief, are accurate and
comply with the Commission’s rules.
I certify under penalty of perjury that the
applicant paid the appropriate urban rate for
the telecommunications services.
I certify under penalty of perjury that the rural
rate on the invoice does not exceed the
appropriate rural rate.
I certify under penalty of perjury that I charged
only for eligible services delivered or provided
to the applicant prior to submitting the invoice
for payment and accompanying
documentation.
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.

Purpose/Instructions
See Item #32 Purpose/Instructions above.

See Item #32 Purpose/Instructions above.

See Item #32 Purpose/Instructions above.

See Item #32 Purpose/Instructions above.

See Item #32 Purpose/Instructions above.

See Item #32 Purpose/Instructions above.

4

OMB 0804-3060
X/X/2023
Item #
41

42

43

Field Description
I certify under penalty of perjury, as a
condition of receiving support, that I will
provide to applicants, on a timely basis, all
documents regarding supported equipment
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.
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.

Purpose/Instructions
See Item #32 Purpose/Instructions above.

See Item #32 Purpose/Instructions above.

See Item #32 Purpose/Instructions above.

5

OMB 0804-3060
X/X/2023
Item #

45

Field Description
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

50

Authorized Person’s Employer FCC RN

51

Authorized Person’s Title/Position

52

Authorized Person’s Mailing Address

44

Purpose/Instructions
See Item #32 Purpose/Instructions above.

The Authorized Person is required to provide all required certifications
and signatures. The FCC Form 469 must be certified electronically.
Auto generated by system.
Auto generated by system.
This is the name of the Authorized Person certifying the FCC Form 469
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 469 on behalf of the service provider. This field will be autopopulated if already within the system.
This is the FCC RN of the Authorized Person certifying the FCC Form 469
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 469 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 469 on behalf of the service
provider. This field will be auto-populated if already within the system.
6

OMB 0804-3060
X/X/2023
Item #
53

Field Description
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.
I certify under penalty of perjury that I have
examined this invoice form and supporting
documentation and, to the best of my
knowledge, information, and belief, all
statements of fact contained therein is true
and correct.
I certify under penalty of perjury that the
service identified above has been or is being
provided to the applicant.
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 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 Commission rules, with respect
to universal service benefits provided under 47
U.S.C. § 254.

56

57

58

59

Purpose/Instructions
This is the telephone number of the Authorized Person certifying the
FCC Form 469 on behalf of the service provider. This field will be autopopulated if already within the system.
This is the email address of the Authorized Person certifying the FCC
Form 469 on behalf of the service provider. This field will be autopopulated if already within the system.
The authorized representative of the Health Care Provider must provide
this certification.
See Item #55 Purpose/Instructions above.

See Item #55 Purpose/Instructions above.

See Item #55 Purpose/Instructions above.

See Item #55 Purpose/Instructions above.

7

OMB 0804-3060
X/X/2023
Item #

62

Field Description
I understand that any letter from the
Administrator 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 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

63
64
65

Date Submitted
Date Signed
Authorized Person Name

66

Authorized Person’s Employer

67

Authorized Person’s Employer FCC RN

68

Authorized Person’s Title/Position

69

Authorized Person’s Mailing Address

70

Authorized Person Telephone Number

60

61

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

See Item #55 Purpose/Instructions above.

The authorized representative of the Health Care Provider is required to
provide all required certifications and signatures. The FCC Form 469
must be certified electronically.
Auto generated by system.
Auto generated by system.
This is the name of the Authorized Person certifying the FCC Form 469
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 469 on behalf of the applicant. This field will be autopopulated if already within the system.
This is the FCC RN of the Authorized Person certifying the FCC Form 469
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 469 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 469 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 469 on behalf of the applicant. This field will be autopopulated if already within the system.
8

OMB 0804-3060
X/X/2023
Item #
71

Field Description
Authorized Person Email Address

Purpose/Instructions
This is the email address of the Authorized Person certifying the FCC
Form 469 on behalf of the applicant. This field will be auto-populated if
already within the system.

9