FCC Form 466 RHC, Telecommunications Program, Description of Request

OMB 3060-0804
Editorial: Nov, 2023

Est. time per response: 2hrs

Rural Health Care
Telecommunications Program
Description of Request for Funding (FCC Form 466)
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
Funding Year

2

FCC Form 466 Application Number

3

Application Nickname

4

Site Number

5

Site Name

6

Billed Entity Information

Purpose/Instructions
Auto-populated by the system: The funding year (FY) will autopopulate based on the funding year of the FCC Form 466. Depending
on the timing of the request, multiple funding years may be available
for the user to select.
Auto-populated by the system: This is a unique Universal Service
Administrative Company (USAC)-assigned identifier for this request.
Optional. To create a unique identifier for this request, the user simply
enters a nickname (e.g., Smith Telecommunications FY 2016).
Auto-populated by the system: This is the unique USAC-assigned
identifier for this site listed in Site Name. This number was issued by
USAC when the FCC Form 465 was completed.
Auto-populated by the system: This is the name of the site identified
on the applicant’s submitted 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, email address 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.
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Item #

7

Field Description
FCC Form 465 Application Number

8

Billed Entity Name

9

Billed Entity Contact Information

10
11

Billed Entity FCC Registration Number (FCC
RN)
Funding Priority

12

Allowable Contract Selection Date (ACSD)

13

Number of Service Provider Bids

14

Multiple Sites

Purpose/Instructions
Auto-populated by the system: This is a unique USAC-assigned
identifier for this request. This number was previously assigned on the
FCC Form 465.
If applicable. This is the entity that pays the bills of the service provider
for the site. This may be the site itself or the “parent” organization,
association, consortium, etc. to which the site belongs.
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 is the unique FCC identifier for the Legal Entity. This number was
provided when the user completed the FCC Form 465.
Auto-populated by the system: This indicates the health care provider’s
rurality tier, which is used to prioritize funding in the event that
program demand exceeds available funding.
Auto-populated by the system: This is a USAC-assigned date (at least
28 days after the description set forth in the HCP’s Form 465 is posted
on the RHC website). This date expresses the earliest date (ACSD) on
which the health care provider may sign an agreement or otherwise
select a service provider to provide services to the health care
provider.
The number of service providers who bid on the request for services in
response to the FCC Form 465.
If applicable. If the health care provider is a mobile rural health care
provider, it must list the names, full addresses, expected schedule,
duration of visits to all sites to be served, and number of patients
served at each location by the mobile health care provider during the
funding year. The health care provider must verify that each of the
sites is rural or prorate the support request to cover only the time
when the mobile health care provider will operate in the rural area.
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Item #

15

Field Description
498 ID of Selected Service Provider(s)

16

Selected Service Provider Name(s)

17

Selected Service Provider Contact

18

Service Provider Selection Date / Contract
Sign Date

19

Continuation with Current Service Provider

20

Contract ID

21

Contract Reference Number

22

Contract Friendly Name

Purpose/Instructions
The selected Service Provider’s 498 ID (formerly the Service Provider
Identification Number (SPIN)). There may be multiple service providers
if the circuit has multiple connections.
Auto-populated by the system: This name is based on the 498 ID
entered by the user. There may be multiple service providers if the
circuit has multiple connections.
Auto-populated by the system: This contact information is based on
the 498 ID entered. This is the service provider’s physical address,
county, city, state, zip code, telephone, website, contact name, email,
phone number, contact employer and geolocation. There may be
multiple service providers if the circuit has multiple connections.
The date that the service provider was selected (contract sign date).
The health care provider or its authorized representative must not
select a service provider or enter into a contract or purchase an
agreement with a service provider until at least 28 days have elapsed
since the FCC Form 465 was posted on the RHC website.
The user indicates if the selected service provider is its current service
provider.
The unique USAC-assigned identifier for a contract or service
agreement. This identifier helps the applicant identify the contract in
the future and apply in subsequent funding years.
The user provides a tariff, contract and other document reference
number for each segment of the circuit.
Optional. To create a unique identifier for this contract, the user simply
enters a nickname.

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Item #

23

Field Description
Competitive Bidding Exemptions

24

Evergreen Determination

25
26

Service Category
Service Type

27

Number of Voice Grade Lines

28

Multiple Service Providers

29

Number of Months of Service Requested

30

Symmetrical Service

31

Upload Speed

Purpose/Instructions
Applicant is required to select Yes or No on the question whether the
applicant requests competitive bidding exemption. If the applicant
selects Yes, the applicant will see a new prompt to select one of
exemption types including “Government Master Services Agreement,”
“Pre-Approved Master Services Agreement,” “Evergreen Contract,”
and “E-Rate Master Contract.” Once the applicant selects an
exemption type, the applicant will see the Contracts table where the
applicant can add Contracts related to their selection.
User indicates whether they would like the applicable contract to be
considered for designation as an evergreen contract.
The user selects the service category: Voice or Data.
The user selects the service type (from a list) for the line item (e.g., T1).
If applicable. The user enters the number of Voice Grade lines that
they are requesting support for. This is an option when the applicant
selects Voice grade, private branch exchange (PBX), central office
terminal (COT), direct inward dialing (DID) or other similar services in
the “Expense/Service Type.”
The user indicates if its service is provided using multiple connections
and is provided by multiple service providers; If “YES,” then the user
provides further information on the individual service providers. The
information collected for multiple service providers is the same
fields/inputs as that which is collected for one service provider for the
entire circuit.
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 are equal for the
service.
If the service is not symmetrical, the user enters the upload
(bandwidth) speed for the service (in Mbps or Gbps).
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Item #

32

Field Description
Download Speed

33

Service Level Agreement (SLA)

34
35
36
37
38

Latency
Jitter
Packet Loss
Reliability
Circuit ID

39

Circuit Diagram

40

Total Billed Miles

41

Circuit Start Location

42

Circuit End Location

43
44

Satellite Delivery
Monthly Undiscounted Cost

Purpose/Instructions
The user enters the download (bandwidth) speed for the service (in
Mbps or Gbps).
Optional. The user indicates whether the applicant’s contract with the
service provider includes an SLA.
The user indicates the latency requirement per the contract SLA.
The user indicates the jitter requirement per the contract SLA.
The user indicates the packet loss rate per the contract SLA.
The user indicates the reliability requirements per the contract SLA.
The user enters a service provider-specific identifier assigned to the
connection between two locations for the line item. The Circuit ID is
located on the service provider invoice.
If applicable. If the health care provider is a consortium member or
uses multiple service providers for the service, then it must upload a
diagram to show how the sites interconnect and which carrier(s)
provide each circuit segment.
Auto-calculated by the system. The sum of all miles billed by all
services providers for that circuit.
Auto-populated by the system if the applicant indicates the circuit
starts at the site location. Otherwise, the applicant is required to enter
the location. The physical location and/or Site Number where the
circuit originates for the line item.
Auto-populated by the system if the applicant indicates the circuit ends
at the site location. Otherwise, the applicant is required to enter the
location. The physical location and/or Site Number where the circuit
terminates for the line item.
The user selects if the service is delivered by satellite.
The user enters the total monthly undiscounted cost.

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Item #

45

Field Description
Percentage of Expense Eligible

46

Percentage of Usage Eligible

47
48

Billing Account Number (BAN)
Initial Contract Length

49
50

Contract Start Date
Contract Expiration Date

51

Number of Contract Extensions, Options
and/or Upgrades

52

Combined Optional Extension(s) Length

53
54

Service Installation Date
Rural Rate per Month

Purpose/Instructions
The user is asked to answer the question if the entire expense is
eligible for support. If the entire expense is eligible, the user will select
“Yes.” If the user answers “No,” then the user is asked to enter the
“Percentage Eligible for Support” and provide an explanation. The user
may also upload supporting document for explanation. For example, a
service provider may provide a bundle that includes both eligible and
ineligible services. If percentage is less than 100%, then the user must
briefly explain how the percentage was derived.
The user enters the percentage of the usage that is eligible for support.
If all of the usage is eligible, enter “100%.” An applicant should use this
column to indicate the eligible portion of a connection that is used by
both eligible and ineligible sites.
The line item BAN listed on the service provider’s bill.
The length of the initial contract excluding voluntary options. Does not
include any optional extensions.
The date the signed contract will start.
The date the signed contract will expire. Does not include any optional
extensions.
If the contract includes voluntary options to extend the term of the
contract and/or upgrade services, then the user enters the number of
such voluntary options.
If the contract includes one or more voluntary options to extend the
term of the contract, then the user enters the combined length of all
the voluntary options.
The date service is expected to start.
The rural rate for the service for which the applicant is requesting
funding as determined using one of the three methods in 47 CFR §
54.605 (2024).
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Item #

55

Field Description
Rural Rate per the Service Agreement

56
57

Rural Rate Method
Billed Circuit Miles

58

Installation Urban Rate Charge

59

Installation Rural Rate Charge

60
61

Rural Taxes & Fees Per Month
Total Undiscounted Cost Per Month

62

Urban Taxes and Fees Per Month

63

Total Amount for Monthly Urban Rate

64

Total Amount of Support Requested

65

Supporting Documentation

Purpose/Instructions
The rural rate for the service agreed provided for in the service
agreement between the health care provider and the service provider
if lower than the rural rate per month under 47 CFR § 54.605 (2024).
The user indicates what method was used to determine the rural rate.
The billed miles for each connection.
The one-time urban rate installation charge for the requested service
listed in any city in the site’s state with a population of 50,000 or more.
The one-time rural rate installation charge for the requested service
listed.
The applicable rural monthly taxes and fees for the requested service.
The user indicates the monthly rural rate and any requested rural
monthly taxes and fees and/or installation charge.
The applicable urban monthly taxes and fees for the requested service. If
support is sought for the rural taxes and fees, the applicable urban
monthly taxes and fees must also be entered.
The user indicates the monthly urban rate and any requested urban
monthly taxes and fees and/or installation charge.
The user indicates the total amount of support requested (total rural
rate minus total urban rate) times the number of months requested.
There is additional documentation required to be submitted with the
FCC Form 466 to support the request for funding. Specifically, an
applicant is required to submit documentation (e.g., cost of service,
copy of the signed contract (if applicable), copies of bids (if more than
one bid is received) and other competitive bidding documents to
support its certification that it has selected the most cost-effective
option, and written descriptions of cost allocation (if applicable).

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Item #

66

67

68
69

Field Description
I certify under penalty of perjury that the
above-named entity has considered all bids
received and selected the most costeffective method of providing the requested
service or services. "Cost-effective" is
defined in 47 CFR § 54.622(c) of the
Commission’s rules as the method that costs
the least after consideration of the features,
quality of transmission, reliability, and other
factors that the applicant deems relevant to
choosing a method of providing the
required health services.
I certify under penalty of perjury that the
applicant that I am representing satisfies all
of the requirements under section 254 of
the Act and applicable Commission rules
and understand that any letter from USAC
that erroneously commits funds for the
benefit of the applicant may be subject to
rescission.
I certify under penalty of perjury that all
RHC Program support will be used only for
eligible health care purposes.
I certify under penalty of perjury that I have
reviewed all applicable rules and
requirements for the RHC Program and will
comply with those rules and requirements.

Purpose/Instructions
The Authorized Person is required to provide all 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 #67 Purpose/Instructions above.

See Item #67 Purpose/Instructions above.
See Item #67 Purpose/Instructions above.

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Item #

70

71
72

73

74
75

Field Description
I certify under penalty of perjury that the
applicant is not requesting support for the
same service from both the
Telecommunications Program and the
Healthcare Connect Fund Program.
I certify under penalty of perjury that the
rural rate provided on this form does not
exceed the appropriate rural rate.
I certify under penalty of perjury that the
applicant and/or its consultant, if applicable,
has not solicited or accepted a gift or any
other thing of value from a service provider
participating in or seeking to participate in
the RHC Program.
I hereby certify under penalty of perjury
that the applicant will retain all
documentation associated with the
application, including all bids, contracts,
scoring matrices, and other information
associated with the competitive bidding
process, and all billing records for services
received, for a period of at least five years.
I certify under penalty of perjury that I am
authorized to submit this request on behalf
of the named billed entity and applicant.
I certify under penalty of perjury that I have
examined this form and all attachments and
that to the best of my knowledge,
information, and belief, all statements of
fact contained herein are true.

Purpose/Instructions
See Item #67 Purpose/Instructions above.

See Item #67 Purpose/Instructions above.
See Item #67 Purpose/Instructions above.

See Item #67 Purpose/Instructions above.

See Item #67 Purpose/Instructions above.
See Item #67 Purpose/Instructions above.

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Item #

77

Field Description
I certify under penalty of perjury that the
consultants or third parties the applicant
has hired 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.
Signature

78
79
80

Date Submitted
Date Signed
Authorized Person Name

81

Authorized Person’s Employer

82

Authorized Person’s Employer FCC RN

83
84

Authorized Person’s Title/Position
Authorized Person’s Mailing Address

85

Authorized Person Telephone Number

76

Purpose/Instructions
See Item #67 Purpose/Instructions above.

The Authorized Person is required to provide all required signatures
and certifications. The FCC Form 466 must be certified electronically.
Auto populated by system.
Auto populated by system.
This is the name of the Authorized Person certifying the FCC Form 466.
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 466. This field will be auto-populated if already within
the system.
This is the FCC RN of the Authorized Person certifying the FCC Form
466. This field will be auto-populated if already within the system.
This is the title of the Authorized Person certifying the FCC Form 466.
This is the address (can be physical address or mailing address) of the
Authorized Person certifying the FCC Form 466. This field will be autopopulated if already within the system.
This is the telephone number of the Authorized Person certifying the
FCC Form 466. This field will be auto-populated if already within the
system.
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Item #

86

Field Description
Authorized Person Email Address

Purpose/Instructions
This is the email address of the Authorized Person certifying the FCC
Form 466. This field will be auto-populated if already within the
system.

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