Telecommunications Program Invoice Form (Nov 2023)

OMB 3060-0804
Editorial: Nov, 2023

Est. time per response: 0.30 hrs

Rural Health Care
Telecommunications Program
Invoice 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-filled in the system portal will be carried
forward and auto-populated into the form.
epres
what eac
Item # ation
Field of
Description
Service Provider Name
1
2

498 ID for the Service Provider

3
4
5
6

Invoice Number
Invoice Date
Health Care Provider (HCP)
Number
Funding Request Number (FRN)

7

Funding Year: Funding Start Date

8

Funding Year: Funding End Date

9

HCP Entered Billing Account
Number (BAN)
Service Start Date
Billing Period Start Date
Billing Period End Date
Support Amount to be Paid by
USAC

10
11
12
13

the
order in which th
Purpose/Instructions
Auto-generated by the system: This is the name of the service provider submitted on the FCC
Form 466.
Auto-generated by the system: The selected service provider’s 498 ID (formerly the Service
Provider Identification Number (SPIN) ID). The 498 ID is pulled from the FCC Form 466 for an FRN.
This number is listed on the service provider’s bill.
The date that the invoice is submitted to the Administrator.
Auto-generated by the system: This is the unique identifier included on the Request for Funding
(FCC Form 466).
Auto-generated by the system: This is a unique identifier auto-generated by the system on the
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 Request for Funding (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.
The BAN is listed on the service provider’s bill.
User enters the service date for the provided service.
The first date of the billing period for the invoice.
The last date of the billing period for the invoice.
The system will calculate and display the total amount of the line item expense that may be paid
by USAC for the line item.
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Consultant Disclosure

15

Supporting Documentation

16

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 the rural rate on the invoice
does not exceed the appropriate
rural rate determined by the
Administrator.
I certify under penalty of perjury
that I have complied with all RHC
Program requirements, including
all applicable Commission rules.

17

18

19

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.
Optional. Provides the option for the user to upload and submit documents to support its invoice
form.
The service provider’s representative must provide this certification to participate in the RHC
Program. The Authorized Person is required to provide all required certifications and signatures.
See Item 16 Purpose/Instructions above.

See Item #16 Purpose/Instructions above.

See Item #16 Purpose/Instructions above.

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21

22

23

I certify under penalty of perjury
that I have received and reviewed
the Health Care Provider Support
Schedule, invoice form and
accompanying documentation,
and that the rates charged for the
provided or delivered
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 I charged for only eligible
services provided or delivered 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).

See Item #16 Purpose/Instructions above.

See Item #16 Purpose/Instructions above.

See Item #16 Purpose/Instructions above.

See Item #16 Purpose/Instructions above.

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25

I certify under penalty of perjury
that any 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.
I certify under penalty of perjury,
as a condition of receiving
support, that I will provide to
applicants, on a timely basis, all
information and documents
regarding supported equipment,
facilities, or services that are
necessary for the applicant to
submit required forms or respond
to Commission or Administrator
inquiries.

See Item #16 Purpose/Instructions above.

See Item #16 Purpose/Instructions above.

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27

I understand that all
documentation related to the
delivery of supported services or
demonstrate compliance with the
rules must be retained for a
period of at least five years after
the last day of the delivery of
discounted services pursuant to
47 CFR § 54.631, or as otherwise
prescribed by the Commission’s
rules.
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.

See Item #16 Purpose/Instructions above.

See Item #16 Purpose/Instructions above.

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29

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

30
31
32

Date Certified and Submitted
Date Signed
Authorized Person Name

33

Authorized Person’s Employer

34

Authorized Person’s Title/Position

35

Authorized Person’s Mailing
Address
Authorized Person’s Telephone
Number
Authorized Person’s Email Address

36
37

See Item #16 Purpose/Instructions above.

The Authorized Person is required to provide all required certifications and signatures. The
invoice form must be certified electronically.
Auto populated by system.
Auto populated by system.
This is the name of the Authorized Person certifying the invoice form. This field will be autopopulated 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 invoice form. This field
will be auto-populated if already within the system.
This is the title of the Authorized Person certifying the invoice form. This field will be autopopulated if already within the system.
This is the address (can be physical address or mailing address) of the Authorized Person
certifying the invoice form. This field will be auto-populated if already within the system.
This is the telephone number of the Authorized Person certifying the invoice form. This field will
be auto-populated if already within the system.
This is the email address of the Authorized Person certifying the invoice form. This field will be
auto-populated if already within the system.
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Authorized Person’s Fax Number

This is the fax number of the Authorized Person certifying the invoice form. This field will be autopopulated if already within the system.

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