FCC Form 465 RHC, Telecommunications Program, Description of Eligibil

OMB 3060-0804
Editorial: Month, 2024

NOT YET APPROVED BY OMB
Est. time per response: 1hr

Rural Health Care
Telecommunications Program
Description of Eligibility and Request for Services (FCC Form 465)
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 will be
carried forward and auto-populated into the form.
Item #
1

Field Description
FCC Form 465 Application Number

2

Applicant’s FCC Form Nickname

3
4

Site Name
Site Number

4

FCC Form 460 Number

5

Site Address

6

Consortium Name

7

Funding Year

Purpose/Instructions
Auto generated by system. This is a unique Universal Service Administrative
Company (USAC)-assigned unique identifier for this request.
Optional. To create a unique identifier for this submission, the user simply enters a
nickname (e.g., Funding Year (FY) 2016 Homewood FCC Form 465).
This is the name of the site.
Auto generated by the system. This is the unique USAC assigned identifier for the site
listed in Site Name.
Auto-generated by the system: Based on information for the previously submitted
Description of Eligibility (FCC Form 460). This is a USAC-assigned unique identifier for
this request.
Auto generated by the system. This is the site’s physical address, county, city, state,
zip code and geolocation.
If applicable. User identifies as being a member of a larger collective group (e.g.
consortium, association, network, etc.) that participates in either the
Telecommunications or Healthcare Connect Fund Programs.
This is the selection of the FY the applicant is submitting the request for. Funding
years run from July 1 through June 30 of the following year. Available funding year
selections will be displayed by the system.

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8

Indicate Whether a Separate Request for
Proposals (RFP) will be Released for this
Request

9

Services Requested: Category

10
11

Services Requested: Type
Number of Months of Service Requested

12
13
14

Symmetrical Service
Upload Speed
Download Speed

15

Service Level Agreement (SLA)

16
17
18
19
20

Latency
Jitter
Packet Loss
Reliability
Services Requested: Additional Service
Details

21
22

Services Requested: Desired Contract Length
Services Requested: Bid Posting Period

Optional. The user indicates whether they are using an RFP. If an RFP is used, it
must be attached to the FCC Form 465 so that it can be “released” with the posting
of the FCC Form 465 and the RFP period must be opened for at least 28 days after
the posting of the FCC Form 465.
The user identifies the service category for which the site is requesting bids (e.g.,
voice, data).
The user identifies the service type for which the site is requesting bids (e.g., T-1).
The user indicates the number of months of service that is being requested for the
service.
The user indicates if the upload and download speeds must be equal.
The user enters the requested upload speed for the service.
If the service is not symmetrical, the user enters the requested download speed for
the service.
Optional. The user indicates whether it is seeking an SLA as part of the agreement
with the selected service provider.
The user indicates the latency requirement for the SLA.
The user indicates the jitter requirement for the SLA.
The user indicates the packet loss rate for the SLA.
The user indicates the reliability requirements for the SLA.
The user describes additional details regarding the services for which it is
requesting bids. The user shall provide sufficient information to enable bidders to
reasonably determine the needs of the user and provide responsive bids.
The user provides details on the length and type of contract requested.
Optional. The user may add days on to the posting period beyond the required
minimum 28-day posting period.

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Item #
23

Field Description
Bidding Evaluation

24

Primary Contact Name

25
26

Primary Contact Employer/Organization
Primary Contact Title

27

Primary Contact Mailing Address

28

Primary Contact Telephone Number

29

Primary Contact Email Address

30

Primary Contact Fax Number

31

Additional Contact(s)

Purpose/Instructions
The user develops weighted evaluation criteria (e.g., scoring matrix) that
demonstrates how the applicant will choose the most ‘cost-effective' bid before
submitting a request for services. “Cost-effective” is defined as the method that
costs the least after consideration of the features, quality of transmission,
reliability, and other factors that the health care provider deems relevant to
choosing a method of providing the required health care services. The user must
specify on their bid evaluation worksheet and/or scoring matrix the requested
services for which it seeks bids, the information provided to bidders to allow
bidders to reasonably determine the needs of the user, its minimum requirements
for each specified criterion, and each service provider’s proposed service levels for
the established criteria. The user must also specify its disqualification factors, if any,
that the user will use to remove bids or bidders from further consideration.
This is the name of the person who should be contacted with questions about this
request. This person must be employed by the Legal Entity listed on this form.
This will auto-populate to be the information listed within “Legal Entity Name.”
This is the title of the person who should be contacted with questions about this
request.
This is the mailing address, county, city, state, and zip code of the person who
should be contacted with questions about this request.
This is the telephone number of the person who should be contacted with
questions about this request.
This is the email address of the person who should be contacted with questions
about this request.
This is the fax number of the person who should be contacted with questions about
this request.
Allows the user to add additional contact person(s) to the request. To add an
additional contact person, the user must provide the contact’s name, employer,
mailing address, county, city, state, zip code, telephone number, email address and
website (optional). This person will be an account holder in MyPortal with access to
the site’s application forms.

OMB 3060-0804
Month, 2024
Item #
32

Field Description
Aggregated Purchasing Agreement

Purpose/Instructions
Optional. If applicable, user shall provide full details of any arrangement involving
the purchasing of service/s as part of an aggregated purchase with other entities or
individuals. User may also upload and submit any other supporting documents to
support its request.

33

Declaration of Assistance/Consultant or
Outside Expert Information

34

Letter of Authorization

35

Supporting Documentation

36

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

37

I certify under penalty of perjury that I have
examined this request and all attachments,
and to the best of my knowledge,
information, and belief, all statements
contained herein and in any attachments are
true.
I certify under penalty of perjury that the
applicant has complied with all applicable
state, Tribal, or local procurement rules.

If applicable. Users must submit a declaration of assistance identifying each and
every consultant, vendor, or other outside expert, whether paid or unpaid, who
aided in the preparation of their applications and, as part of this declaration, users
must describe the nature of their relationship with the consultant, vendor, or other
outside expert providing the assistance. The user must provide the name of the
consultant’s or outside expert’s firm name; consultant registration number; name
of the consultant or outside expert representing the applicant; consulting firm
street address, city, state, and zip code; consulting firm telephone number; and
consulting firm email address. If this information has already been entered into the
user’s profile, it will be pre-populated into the system.
If applicable, the user must provide a letter of authorization which provides written
authorization to a third party/consultant to complete and submit FCC Forms on
behalf of the health care provider for the Telecommunications Program.
Optional. This provides an option for the user to upload and submit any other
documents to support their request.
The Authorized Person is required to provide all required certifications and
signatures. An officer or director of the applicant must sign all certifications. The
applicant must provide this certification in order to receive universal service
support.
See Item #36 Purpose/Instructions above.

38

See Item #36 Purpose/Instructions above.

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Item #
39

40

41

42

43

Field Description
I certify under penalty of perjury that all
requested RHC Program support will be used
solely for purposes reasonably related to the
provision of health care service or
instruction that the applicant is legally
authorized to provide under the law of the
state in which the services are provided.
I certify under penalty of perjury that the
supported services will not be sold, resold,
or transferred in consideration for money or
any other thing of value.
I certify under penalty of perjury that the
applicant seeking supported services is a
public or non-profit entity that falls within
one of the categories set forth in the
definition of health care provider listed in 47
CFR § 54.600 of the Commission’s rules or
expects to fall within one of the categories
before the end of the funding year for which
the supported services will be requested.
I certify under penalty of perjury that the
applicant seeking support services is
physically located in a rural area as defined
in section 47 CFR § 54.600 of the
Commission’s rules or expects to be physically
located in a rural area before the end of the
funding year for which supported services will
be requested.
I certify under penalty of perjury that the
applicant satisfies all of the requirements
under section 254 of the Communications
Act and applicable Commission rules.

Purpose/Instructions
See Item #36 Purpose/Instructions above.

See Item #36 Purpose/Instructions above.

See Item #36 Purpose/Instructions above.

See Item #36 Purpose/Instructions above.

See Item #36 Purpose/Instructions above.

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44

I certify under penalty of perjury that the
applicant has reviewed and will comply with
all applicable RHC Program requirements.

See Item #36 Purpose/Instructions above.

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Month, 2024
Item #
60

61
62
63
64

Field Description
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
Date Submitted
Date Signed
Authorized Person

65

Authorized Person’s Employer

66

Authorized Person’s Employer FCC RN

67

Authorized Person’s Title/Position

68

Authorized Person’s Mailing Address

69

Authorized Person Telephone Number

70

Authorized Person Email Address

Purpose/Instructions
See Item #50 Purpose/Instructions above.

The FCC Form 465 must be certified electronically.
Auto generated by system.
Auto generated by system.
The Authorized Person is required to provide all required signatures and
certifications. The FCC Form 465 must be certified electronically. 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
465. This field will be auto-populated if already within the system.
This is the FCC RN of the Authorized Person certifying the FCC Form 465. This field
will be auto-populated if already within the system.
This is the title of the Authorized Person certifying the FCC Form 465. 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 465. This field will be auto-populated if already
within the system.
This is the telephone number of the Authorized Person certifying the FCC Form 465.
This field will be auto-populated if already within the system.
This is the email address of the Authorized Person signing the FCC Form 465. This
field will be auto-populated if already within the system.