Post-Commitment Request Form (v.3 2.18.24) CLEAN

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

OMB 3060-0804
Editorial: Month, 2024

Rural Health Care Program
Post-Commitment Request Form

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
Applicant’s FCC Form Nickname

2

Health Care Provider (HCP) Name

3

HCP Number

4

Site Contact Information

5

Consortium Name

6

Consortium Number

7

Consortium Contact Information

8

FCC Registration Number

Purpose/Instructions
Optional. To create a unique identifier for this request, the user simply enters a
nickname (e.g., 2016 Funding Year Homewood FCC Form 461).
Auto-generated by the system: This is the name of the site submitted on the FCC
Form 460 or FCC Form 465.
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 FCC Form 460 or FCC Form
465 was completed.
Auto-generated by the system: This is the site’s physical address, county, city,
state, zip code, telephone, email address, website, and geolocation provided on
the FCC Form 460 or FCC Form 465. Geolocation only applies to a site that does
not have a street address.
Auto-generated by the system: This is the name the consortium 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 consortium’s address, county, city,
state, zip code, telephone, email address, 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-populated by the system: This is either the consortium or the site’s unique
FCC registration number (FCC RN) submitted via the FCC Form 460 or FCC Form
465.
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Item #
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10

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16
17

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19

Field Description
Funding Year

Purpose/Instructions
Auto-populated by the system based on the funding year of the FRN line item(s)
that are being adjusted.
Contact Person Name
The user must provide the name of the person who should be contacted with
questions about this request. This could be the Primary Contact, Additional
Contact(s) or another person qualified to answer questions relating to the
request.
Contact Person Employer
The user must provide the employer of the person who should be contacted with
questions about this request.
Contact Person Title
The user must provide the title of the person who should be contacted with
questions about this request.
Contact Person Mailing Address
The user must provide the mailing address of the person who should be
contacted with questions about this request.
Contact Person Telephone Number
The user must provide the telephone number of the person who should be
contacted with questions about this request.
Contact Person Email Address
The user must provide the email address of the person who should be contacted
with questions about this request.
Contact Person Fax Number
The user must provide the fax number of the person who should be contacted
with questions about this request.
Type of Post-Commitment Request
Choices (choose all that apply; at least one is required): Service Delivery
Extension Request; Service & Site Substitution; Service Provider Identification
Number (SPIN) Change; Invoice Deadline Extension Request; Cancel Funding
Request Number (FRN(s)); Change in Evergreen Contract Dates; or Reduce
Commitment Amount for FRN(s).
Service Delivery Extension Request
(Healthcare Connect Fund Program only)
FCC Form 462
The system will pre-populate this information based on the Funding Request
Numbers (FRNs) selected by the applicant.
FRN Information
The applicant will select one or more line item(s) on a given FCC Form 462
application that requires this change.

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Item #
20

Field Description
Non-Recurring Service Delivery Extension Criteria

21

Extension Request Reason

22

Site & Service Substitution Requirements

23

FCC Form 462/466

24

FRN Information

25

Expense Item(s)

Purpose/Instructions
Certify the reason for the non-recurring service delivery extension request.
Check one that applies:
□ The service provider is unable to complete implementation for reasons
beyond the service provider’s control.
□ The service provider has been unwilling to complete delivery and installation
because the applicant’s funding request is under review by USAC for program
compliance.
The applicant will provide narrative and has option to upload supporting
documents. The applicant will have option to input any FRNs under review by
USAC.
Site & Service Substitution
Applicants must meet the following requirements:
 The substitution is provided for in the contract, within the change clause, or
constitutes a minor modification;
 The site is an eligible health care provider and the service is an eligible service
under the Telecom Program or the Healthcare Connect Fund Program.
 The substitution does not violate any contract provision or state, Tribal or
local procurement laws; and
 The requested change is within the scope of the controlling request for
services, including any applicable RFP used in the competitive bidding process.
Support is restricted to qualifying site and service substitutions that do not
increase the total amount of support under the applicable funding commitment.
The system will pre-populate this information based on the FRNs selected by the
applicant.
The applicant will select one or more line item(s) on a given FCC Form 462
applications or one or more FCC Form 466 applications for which it seeks a
substitution.
The applicant will select the expense item(s) on a given FCC Form 462 or FCC
Form 466 for which it seeks a substitution and enter the new information.
Substitution modifications cannot change the overall funding disposition, i.e.,
exceed approved funding amount or de-commit money that has already been
disbursed.

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Month, 2024
Item #
26

Field Description
Site & Service Substitution Reason

27

SPIN Change Type

28
29
30

Old SPIN Information
New SPIN Information
SPIN Change Reason

31

FRN(s) Selection

Purpose/Instructions
The applicant will provide narrative of the substitution request and has option to
upload supporting documents. The narrative should provide a brief explanation
regarding the necessity of the change and why the request complies with the Site
& Service Substitution Requirements.

SPIN Change
Select if you are requesting a SPIN change. Check one that applies:
□ Corrective SPIN change:
 Correcting data entry errors;
 Updating a SPIN that has changed due to the merger of companies or the
acquisition of one company by another; or
 Effectuating a change that was not initiated by the applicant.
□ Operational SPIN change:
 The applicant has a legitimate reason to change providers (e.g., breach
of contract or the service provider is unable to perform); and
 The applicant’s newly selected service provider received the next highest
point value in the original bid evaluation, assuming there were multiple
bidders.
The applicant will provide information for the SPIN that it seeks to change.
The applicant will provide information for the new SPIN.
The applicant will provide narrative for such change and has option to upload
supporting documents.
Invoice Deadline Extension Request
The applicant or service provider will select one or more FRNs on a given FCC
Form 463, FCC Form 469 (funding year 2024 and beyond), or Telecom Program
Invoice Form (funding year 2023 and earlier) for an automatic 120-day extension.
Request to Cancel FRN(s)

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Item #
32

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34
35
36
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39
40
41

Field Description
FRN Information

Purpose/Instructions
The applicant will select one or more FRNs that it would like to be cancelled. This
action is irrevocable and the FRN or FRNS cannot be reinstated later. This action
will allow the requested funding to be returned to the Universal Service Fund for
possible commitments to other applicants.
FCC Form 462/466
The system will pre-populate this information based on the FRNs selected by the
applicant.
Change in Evergreen Contract Dates
FRN Information
The applicant will select one or more FRNs where it would like the evergreen
contract dates changed.
Approved Evergreen Contract Start Date
Auto-populated by the system based on evergreen contract start date listed on
Funding Commitment Letter.
Approved Evergreen Contract End Date
Auto-populated by the system based on evergreen contract end date listed on
Funding Commitment Letter.
Contract Provision
The applicant will indicate whether the contract allows for a different start date
than the date that was listed on the Funding Commitment Letter.
Approved Evergreen Contract Start Date
The applicant will provide the date that the contract that USAC designated as
evergreen actually started.
Approved Evergreen Contract End Date
The applicant will provide the date that the contract that USAC designated as
evergreen will end.
Request to Reduce Commitments for FRN(s)
FRN Information
The applicant will select one or more FRNs where it would like the amount of
funding committed to be reduced.
FCC Form 462/466
The system will pre-populate this information based on the FRNs selected by the
applicant.

42

Rural Rate per Month

43

Installation Rural Rate Charge

Telecommunications Program
If authorized and allowed by the Commission rules, if there is a change in the
amount for the rural rate per month, provide the updated monthly rural rate.
The rural rate cannot exceed the original requested rural rate for the service.
If there is a change in the installation rural rate charge, provide the updated
installation rural rate charge. The installation charge cannot exceed the original
requested installation charge for the service.
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44

Rural Taxes and Fees per Month

45

Total Undiscounted Cost per Month

46

Urban Rate per Month

47

Installation Urban Rate Charge

48

Urban Taxes and fees per Month

If there is a change in the amount of the rural taxes and fees, provide the
updated rural taxes and fees amount. The rural taxes and fees charge cannot
exceed the original requested monthly rural taxes and fees.
The user indicates the monthly rural rate and any requested rural monthly taxes
and fees and/or installation charge. The updated amount cannot exceed the
original requested undiscounted cost per month.
The system will pre-populate this information. Any modification cannot increase
the amount of the original funding commitment.
If there is a change in the amount in the installation urban rate charge, provide
the updated installation urban rate charge. The modification cannot increase the
amount of the original funding commitment.
If there is a change in the amount of urban taxes and fees per month, provide the
updated urban taxes and fees amount. The modification cannot increase the
amount of the original funding commitment.

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Item #
49

50
51
52

53

54
55
56
57
58

Field Description
Total Amount for Urban Rate

Purpose/Instructions
The applicant indicates the monthly urban rate and any requested urban taxes
and fees and/or installation charge. The modification cannot increase the
amount of the original funding commitment.
Healthcare Connect Fund Program
Installation Charges
If there is a change in the amount for the installation charge, provide the
updated installation charge. The installation charge cannot exceed the original
requested installation charge for the service.
Expense Line Item(s)
The user indicates which expense line item(s) from the FRN that need to be
modified.
Total Undiscounted Cost for the Expense Line
If there is a change in the cost for the expense line item(s), provide the updated
Item(s)
undiscounted cost for each applicable expense line item(s). The updated amount
cannot exceed the original requested undiscounted cost for the expense line
item.
If there is a change in the taxes and fees for the expense line item(s), provide the
Taxes and Fees for the Expense Line Item(s)
updated taxes and fees for each applicable expense line item(s). The updated
amount cannot exceed the original requested taxes and fees for each expense
line item.
Total Undiscounted Cost for Eligible Recurring
The system will calculate and display the updated total undiscounted cost for
Expenses
recurring eligible expenses.
Total Undiscounted Cost for Eligible Non-recurring The system will calculate and display the updated total undiscounted cost for
Expenses
eligible non-recurring expenses.
Service Start Date
If the original service start date was delayed, please enter the actual start date
here.
Service End/Termination Date
If the service was ended or terminated earlier than the original service
end/termination date, please enter the actual end or termination date here.
Certifications
I certify that I am authorized to submit this
The authorized representative of the applicant, or service provider if requesting
request, that I have examined this request, and
an invoicing extension, must provide this certification.
that, to the best of my knowledge, information,
and belief, all statements of fact contained herein
are true.

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Item #
59

60

Field Description
I understand that all documentation associated
with this request, 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
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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

Purpose/Instructions
The authorized representative of the applicant, or service provider if requesting
an invoicing extension, must provide this certification.

The authorized representative of the applicant, or service provider if requesting
an invoicing extension, is required to provide all required certifications and
signatures The Post-Commitment Request Form must be certified electronically.
Auto generated by system.
Auto generated by system.
This is the name of the Authorized Person certifying the Post-Commitment
Request Form on behalf of the applicant (or service provider if requesting an
invoicing extension). 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 PostCommitment Request Form on behalf of the applicant (or service provider if
requesting an invoicing extension). This field will be auto-populated if already
within the system.
This is the FCC RN of the Authorized Person certifying the Post-Commitment
Request Form on behalf of the applicant (or service provider if requesting an
invoicing extension). This field will be auto-populated if already within the
system.
This is the title of the Authorized Person certifying the Post-Commitment Request
Form on behalf of the applicant (or service provider if requesting an invoicing
extension). 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 Post-Commitment Request Form on behalf of the applicant
(or service provider if requesting an invoicing extension). This field will be autopopulated if already within the system.

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Item #
68

69

Field Description
Authorized Person Telephone Number

Authorized Person Email Address

Purpose/Instructions
This is the telephone number of the Authorized Person certifying the PostCommitment Request Form on behalf of the applicant (or service provider if
requesting an invoicing extension). This field will be auto-populated if already
within the system.
This is the email address of the Authorized Person certifying the PostCommitment Request Form on behalf of the applicant (or service provider if
requesting an invoicing extension). This field will be auto-populated if already
within the system.

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