FCC Form 498 Service Provider And Billed Entity Identification Number

Service Provider and Billed Entity Identification Number and Contact Information Form

Copy of FCC FORM 498 3060-0824.xlsx

Service Provider and Bill Entity Identification Number and Contact Information Form

OMB: 3060-0824

Document [xlsx]
Download: xlsx | pdf

Overview

ACTIVE VERSION
Sheet3


Sheet 1: ACTIVE VERSION














File electronically at https://forms.universalservice.org/portal/login





















FCC Form 498
































OMB 3060-0824




































Service Provider And Billed Entity Identification Number and General Contact Information Form
Estimated Average Burden Hours Per Response: 1.5 hours
FCC Form 498 is used to collect contact and remittance information for service providers and applicants that receive support from the Federal universal service support programs. For greater flexibility, this form allows service providers to use the same general contact information for all their contacts and the same remittance data collected for each of the four programs or multiple contact and remittance information. Please report any changes to this information on a revised FCC Form 498 to prevent any delays in notification and the timeliness of disbursements. Persons willfully making false statements on this form can be punished by fine or forfeiture, under the Communications Act, 47 U.S.C. Secs. 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.




































Please read instructions, located at:https://www.usac.org/service-providers/resources/forms/, before beginning this application.
Provider Type
Please check one box below












































Service Provider













School/Library or other Billed Entity


















































Submission Type
Please check one box below












































Original Application for FCC Form 498 ID













Revision to existing FCC Form 498 on file with USAC























































Request for FCC Form 498 ID Merger/Consolidation













Request for FCC Form 498 ID Deactivation



























































































































Service Provider Identification Number (FCC Form 498 ID)


































(To be inserted by USAC for first time applications. Required for subsequent revisions.)






































































499 Filer ID



























(Required if your company is required to file the FCC Form 499)





































































Block 1: Organization Information [All Fields REQUIRED]





























1



































Company Name or Billed Entity

































2



































Name Entity or Company is Doing Business As (DBA) or Formerly Known As (FKA)









































































































3 Holding Company Name (For Service Providers)














4



































Federal EIN, or TAX ID Number of Holding Company
























































































5
Check this Box if the Company is part of or maintains affiliate companies and complete page 2.




































































6



































Street Address

































7



































Address Line 2

































8








9





10


















City








State





Zip Code + 4
























































































Block 2: General Contact Information [All Fields REQUIRED]








































































11 First:







Middle Initial:





Last:








12








General Contact (Company Preparer Name)

























Title






13 (

)































Phone Number







Ext.
























14



































Street Address




















15



































Address Line 2

































16








17





18


















City








State





Zip Code + 4
















19



































E-mail Address

































Block 3: Federal EIN, FCC Registration Number and Sam.gov UEI [All Fields REQUIRED]






































































20

















21
Corporation




Partnership




Other


Enter Federal Employer Identification Number

















(Check applicable corporate structure.)















(Federal EIN or Tax ID Number)









































































































22 FCC Registration Number (CORES ID)





































































23



































Enter SAM.GOV Unique Entity ID












EFT (Optional)



















This is a Supplemental Page for Companies with Affiliate Relationships




































Block 4: Affiliate Company Information










































































































Please list all companies with which this FCC Form 498 ID is affiliated. The term "affiliate" means a person that (directly or indirectly) owns
or controls, is owned or controlled by, or is under common ownership or control with, another person. For purposes of this paragraph,


































the term "own" means to own an equity interest (or the equivalent thereof) of more than 10 percent.








































































Affiliate FCC Form 498 ID Number





Affiliate Company Name

























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































(Attach additional copies of this page if necessary)




































































This page is for High Cost Program participants only.
For more information about the High Cost Program, please refer to: https://www.usac.org/high-cost/
Block 5: High Cost Support Financial Institution and Remittance


































Information [ALL Fields REQUIRED]












































































































Check this box to discontinue use of this FCC Form 498 ID for High Cost Support.




































































Financial institution information is required. Electronic payment of universal service support payments


































is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.
















































































































































Check this box if this information is the same as the General Contact information (Block 2) and complete lines 33-35.
































24



































Remittance Company Name, if different from Company Name

































25 First:







Middle Initial:





Last:








26








Remittance Contact Name - Statements will be sent to Remittance Contact's attention

























Title










































27 (

)









28




















Phone Number









Ext


E-mail Address for receipt of remittance advice


























































































29



































Remittance Financial Institution for ACH or locked box transfer of funds (required)

































30















31


















Financial Institution Account Number for ACH (required)















ACH Financial Institution Transit Number - must be nine digits (required)
























































































Block 6: Company Contact for High Cost Support
















































































































































Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 7.




































































32 First:







Middle Initial:





Last:








33








Contact Name for High Cost Program

























Title







(Must be a company employee or designated representative)

































34
































Contact Address or PO Box for High Cost Program





























35



































Address Line 2

































36















37




38











City















State




Zip Code + 4










39 (

)









40




















Phone Number









Ext


E-mail Address of High Cost Program Contact


























































































This page is for Lifeline Program participants only.
For more information about Lifeline Support, please refer to: https://www.usac.org/lifeline/




































Block 7: Lifeline Support Financial Institution and Remittance


































Information [All Fields REQUIRED]












































































































Check this box to discontinue use of this FCC Form 498 ID for LifelineSupport.




































































Financial institution information is required. Electronic payment of universal service support payments


































is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.












































































































Check this box if this information is the same as the General Contact information (Block 2) and complete lines 57-59.
































41



































Remittance Company Name, if different from Company Name





































































42 First:







Middle Initial:





Last:








43








Remittance Contact Name - Statements will be sent to Remittance Contact's attention

























Title










































44 (

)









45




















Phone Number









Ext

E-mail Address for receipt of remittance advice























































46



































Remittance Financial Institution for ACH or locked box transfer of funds (required)

































47















48


















Financial Institution Account Number for ACH (required)















ACH Financial Institution transit Number - must be nine digits (required)
























































































Block 8: Company Contact for Lifeline Support








































































Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 9.




































































49 First:







Middle Initial:





Last:








50








Contact address for Lifeline Program

























Title







(Must be a company employee or designated representative)

































51
































Contact Address for Lifeline Program





























52



































Address Line 2

































53















54




55











City















State




Zip Code + 4










56 (

)










57



















Phone Number










Ext


E-mail Address of Lifeline Program Contact





















































This is a Supplemental Page for Participants in the High Cost and Lifeline Programs.




































Block 9: High Cost and Lifeline Study Area/FCC Form 498 ID Association






































































This information will be used to associate the Study Area Codes (SAC) to this FCC Form 498 ID for the purposes of
High Cost and Lifeline Support.









































































Check this box if there is no change to the SAC data on file.


















Check this box if you are changing your organization's


































SAC data currently on file with USAC.
















































Study Area Code (SAC)


SAC Company Name










Study Area Type































































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive























































Incumbent




Competitive






















































Incumbent




Competitive
























































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive
























Incumbent




Competitive


























































Incumbent




Competitive

























































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive


























































Incumbent




Competitive






(Attach additional copies of this page if necessary)





































































This page is for Rural Health Care Support participants only.
For more information about Rural Health Care Support, please refer to: https://www.usac.org/rural-health-care/




































Block 10: Rural Health Care Support Financial Institution and Remittance


































Information [ALL Fields REQUIRED]
















































































































































Check this box to discontinue use of this FCC Form 498 ID for Rural Health Care Support.




































































Financial institution information is required. Electronic payment of universal service support payments


































is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.












































































































Check this box if this information is the same as the General Contact information (Block 2) and complete lines 81-83.




































































58



































Remittance Company Name, if different from Company Name





































































59 First:







Middle Initial:





Last:








60








Remittance Contact Name - Statements will be sent to Remittance Contact's attention

























Title






61 (

)










62



















Phone Number









Ext


E-mail Address for receipt of remittance advice






















































63



































Remittance Financial Institution for ACH or locked box transfer of funds (required)





































































64















65


















Financial Institution Account Number for ACH (required)















ACH Financial Institution transit Number - must be nine digits (required)
























































































Block 11: Company Contact for Rural Health Care Support








































































Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 12.




































































66 First:







Middle Initial:





Last:








67








Contact Name for Rural Health Care Program

























Title







(Must be a company employee or designated representative)

































68
































Contact Address for Rural Health Care Program





























69



































Address Line 2

































70















71




72











City















State




Zip Code + 4










73 (

)










74



















Phone Number









Ext


E-mail Address of Rural Health Care Program Contact






















































This page is for Schools and Libraries Program participants only.
For more information about the Schools and Libraries Program, please refer to:https://www.usac.org/e-rate/




































Block 12: Schools and Libraries Support Financial Institution and


































Remittance Information [ALL Fields REQUIRED]








































































Check this box discontinue use of this FCC Form 498 ID for Schools and Libraries Support.




































































Financial institution information is required. Electronic payment of universal service support payments


































is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.












































































































Check this box if this information is the same as the General Contact information (Block 2) and complete lines 105-107.
































75



































Remittance Company Name, if different from Company or Billed Entity Name





































































76 First:







Middle Initial:





Last:








77








Remittance Contact Name - Statements will be sent to Remittance Contact's attention

























Title






78 (

)










79



















Phone Number









Ext


E-mail Address for receipt of remittance advice






















































80



































Remittance Financial Institution for ACH or locked box transfer of funds (required)





































































81
















82
















Financial Institution Account Number for ACH (required)

















ACH Financial Institution Transit Number - must be nine digits (required)






















































































Block 13: Company Contact for Schools and Libraries Support




































Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 14.




































































83 First:







Middle Initial:





Last:








84







Contact Name for Schools and Libraries Program

























Title







(Must be a company, or entity employee or designated representative)

































85
































Contact Address for Schools and Libraries Program































86



































Address Line 2

































87















88



89










City















State




Zip Code + 4










90
(

)









91


















Phone Number









Ext


E-mail Address of Schools and Libraries Program Contact






















































This is a Supplemental Page for Schools, Libraries and Other Applicant Payment Recipients




































Block 14: Billed Entity Number/FCC Form 498 Association






































































Please list all Billed Entity Numbers with which this FCC Form 498 ID affiliated.














































































































Billed Entity Number





Billed Entity Name












































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































(Attach additional copies of this page if necessary)
































Disbursement Offsets and Healthcare Connect Certification
Block 15: Offsetting Disbursement Payments Against Federal Universal Service


































Contribution Obligations For High Cost Participants






































































The following information pertains only to telecommunications companies participating in the High Cost Program. A telecommunications company may choose to offset its payment against its Federal universal service contribution. A telecommunications company must have an FCC Form 499 Filer ID number in order to offset its High Cost Program payments against its Federal universal service contribution. In order to obtain an FCC Form 499 Filer ID number, visit https://www.usac.org/service-providers/resources/forms/ and select FCC Form 499. You do not need an FCC Form 499 Filer ID in order to be issued a FCC Form 498 ID.





































92
Yes, I want my High Cost Program disbursement payments to be offset against my Federal


































universal service contribution obligations. This box must be checked in order to receive offsets. The Default is "No."







































































































Block 16: Offsetting Disbursement Payments Against Federal Universal Service


































Contribution Obligations For Lifeline/Lifeline Participants


































The following information pertains only to telecommunications companies participating in the Lifeline Program. A telecommunications company may choose to offset its payment against its Federal universal service contribution. A telecommunications company must have an FCC Form 499 Filer ID number in order to offset its Lifeline Program payments against its Federal universal service contribution. In order to obtain an FCC Form 499 Filer ID number, visit https://www.usac.org/service-providers/resources/forms/ and select FCC Form 499. You do not need an FCC Form 499 Filer ID in order to be issued a FCC Form 498 ID.

93
Yes, I want my High Cost Program disbursement payments to be offset against my Federal


































universal service contribution obligations. This box must be checked in order to receive offsets. The Default is "No."







































































































Block 17: Offsetting Disbursement Payments Against Federal Universal Service


































Contribution Obligations For Rural Healthcare Participants


































The following information pertains only to telecommunications companies participating in the Rural Health Care Program. In accordance with FCC rule section 54.679 regarding Rural Health Care payments, a telecommunications company may choose to offset its payment against its Federal universal service contribution. A telecommunications company must have an FCC Form 499 Filer ID number in order to offset its Rural Health Care Program payments against its Federal universal service contribution. In order to obtain an FCC Form 499 Filer ID number, visit https://www.usac.org/service-providers/resources/forms/ and select FCC Form 499. You do not need an FCC Form 499 Filer ID in order to be issued a FCC Form 498 ID.





































94
Yes, I want my Rural Health Care Program disbursement payments to be offset against my Federal


































universal service contribution obligations. This box must be checked in order to receive offsets. The Default is "No."



































































Block 18: Certification to Assist Health Care Providers


































In accordance with FCC rule section 54.640(b), service providers participating in the Healthcare Connect Fund Program must certify, as a condition of receiving support, that they will provide to health care providers, on a timely basis, all information and documents regarding supported equipment, facilities, or services that are necessary for the health care provider to submit required forms or respond to FCC or USAC inquiries. USAC may withhold disbursements to the service provider if the service provider, after written notice from USAC, fails to comply with this requirement.





































95
I certify, as a condition of receiving support under the Healthcare Connect Fund Program, that the above-named service provider will provide to


































health care providers, on a timely basis, all information and documents regarding the supported equipment, facility(ies), or service(s)


































that are necessary for the health care provider to submit required forms or respond to FCC or USAC inquiries.



































































Block 19: Offsetting Disbursement Payments Against Federal Universal Service


































Contribution Obligations For Schools and Libraries Participants


































The following information pertains only to telecommunications companies participating in the Schools and Libraries Program. In accordance with FCC rule section 54.515 regarding Schools and Libraries Program payments, a telecommunications company may choose to offset its Schools and Libraries Program payment against its Federal universal service contribution. A telecommunications company must have an FCC Form 499 Filer ID number in order to offset its Schools and Libraries payments against its Federal universal service contribution. In order to obtain an FCC Form 499 Filer ID number, visit http://www.usac.org/cont/tools/forms/default.aspx and select FCC Form 499. You do not need an FCC Form 499 Filer ID in order to be issued a FCC Form 498 ID.





































96
Yes, I want my Schools and Libraries Program disbursement payments to be offset against my Federal


































universal service contribution obligations. This box must be checked in order to receive offsets. The Default is "No."



































































Service Identification




































Block 20: Principal Communications Types [REQUIRED Field]


































Select up to 5 boxes that best describe the reporting entity. Enter numbers starting with "1" to show the order of importance -- see instructions.






































Audio Bridging Provider













Interconnected VoIP



















Coaxial Cable













Paging and Messaging



















Non-Interconnected VoIP













SMR (Dispatch)



















Private Service Provider













Shared-Tenant Service Provider



















Toll Reseller













Cellular/PCS/SMR



















Incumbent LEC













Interexchange Carrier



















Operator Service Provider













Payphone Service Provider



















Satellite Service Provider













Local Reseller



















Wireless Data













Internet Service Provider



















Networking/Infrastructure













School/Library or other Billed Entity Recipient















DATA Act Business Types
Block 21: DATA Act Business Type (REQUIRED Field]


































Select up to 3 boxes that best describe the reporting entity. Enter check marks. For additional description -- see instructions.






































State Government













Nonprofit with 501C3 IRS Status (Other than an Institution of Higher Education)



















County Government













Nonprofit without 501C3 IRS Status (Other than an Institution of Higher Education)



















City or Township Government













Private Institution of Higher Education



















Special District Government













Individual



















Regional Organization













For-profit Organization (Other than Small Business)



















U.S. Territory or Possession













Small Business



















Independent School District













Hispanic-serving Institution



















Public/State Controlled Institution of Higher Education













Historically Black College or University (HBCU)



















Indian/Native American Tribal Government(Federally-Recognized)













Tribally Controlled College or University (TCCU)



















Indian/Native American Tribal Government (Other than Federally-Recognized)













Alaska Native and Native Hawaiian Serving Institution



















Indian /Native American Tribal Designated Organization













Non-domestic (non-U.S.) Entity



















Public/Indian Housing Authority













Other















Officer Certification
Block 22: Officer Certification [All Fields REQUIRED]


































I certify that I am an officer of the above-named service provider, that I am authorized to submit this FCC Form 498 on behalf of the above named service provider, and that to the best of my knowledge, the data set forth in this form is true, accurate, and complete.




































Persons willfully making false statements on this form can be punished by fine or forfeiture, under the Communications Act, as amended, 47 U.S.C. Secs. 220(e), 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.




































Officer Information


Check this box if this information is the same as the General Contact information (Block 2)








































































Signature of the Officer






















Date














































First:







Middle Initial:





Last:






Title










Printed Name















































































































Reminder: You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid Office of Management and Budget (OMB) control number. This collection has been assigned an OMB control number of 3060-0824.



The Commission is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. We will use the information you provide for the Federal universal service billing, collections, and disbursement purposes. In addition, the Name, Address, and Business Type will be disclosed in accordance with FFATA/DATA Act reporting requirements. If we believe there may be a violation or a potential violation of a state or Federal statute, or of a Commission regulation, rule, or order, your form may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. In certain cases, the information in your application may be disclosed to the Department of Justice, a court, or adjudicative body when (a) the Commission; or (b) any employee of the Commission; or (c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding. In addition, consistent with the Communications Act of 1934, FCC regulations and orders, the Freedom of Information Act, 5 U.S.C. § 552, or other applicable law, information provided in or submitted with this form or in response to subsequent inquiries may be disclosed to the public.








If you owe a past due debt to the Federal government, the information you provide may also be disclosed to the Department of the Treasury Financial Management Service, other Federal agencies, and/or your employer to offset your salary, IRS tax refund, or other payments to collect that debt. The Commission may also provide the information to these agencies through the matching of computer records where authorized.



If you do not provide the information we request on the form, the Commission may delay processing of your application, or may return your application without action.

This Notice is required by the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. 3501 et seq. We have estimated that each response to this collection of information will take, on average, 1.5 hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form for response. If you have any comments on this estimate, or how we can improve the collections and reduce the burden it causes you, please write to the Federal Communications Commission, AMD-PERM, Washington D.C. 20554, Paperwork Reduction Project (3060-0824). We will also accept your comments via Internet if you send them to [email protected]. Please DO NOT SEND COMPLETED DATA COLLECTION FORMS TO THIS ADDRESS.

































































































































































































































































Questions?











































See the FCC Form 498 Instructions found at https://www.usac.org/service-providers/resources/forms





































































Use this form for:



































New application for a Service Provider Identification Number


































Revision to existing Service Provider data currently on file with USAC









Merger or Consolidation of Existing Service Provider Identification Number (Additional documentation is required, please see page 2 of the instructions)









Deactivation of a Service Provider Identification Number (Please see page 2 of the instructions)


Sheet 2: Sheet3

Block 4: High Cost Banking and Remittance Payment Information

































See Instructions Page (4)




































Check this box if this information is the same as the general contact information (Lines 3-15 above).






























19


































Remittance Company Name
































20

































Remittance Contact Name- Checks will be sent to Remittance Contact's attention
































21































Remittance Address





























22


































Address 2
































23















24




25










City















State




Zip Code









26 (

)











27 (

)













Phone Number









Ext




Fax Number















28


































Remittance Bank for ACH or locked box transfer of funds
































29















30

















Bank Account Number for ACH















ACH Bank Transfer Number















31

































Email Address of Remittance Contact if requesting electronic remittance statements instead of mailed paper copy statements

































Block 5: Company Contact for High Cost Support Mechanism

































See Instructions Page (11)



































Same as general contact from lines (3-15) above































32

































Contact Name for High Cost Mechanism - Must be a company employee or designated representative
































33































Contact Address for High Cost Mechanism




























34


































Address 2
































35















36




37










City















State




Zip Code









38 (

)











39 (

)













Phone Number









Ext




Fax Number















40


































Email Address of Remittance Contact if requesting electronic remittance statements instead of mailed paper copy statements



































































Block 6: Low Income Banking and Remittance Payment Information

































See Instructions Page (11)




































This information is the same as the general contact information (Lines 3-15 above)






























41


































Remittance Company Name
































42

































Remittance Contact Name- Checks will be sent to Remittance Contact's attention
































43































Remittance Address





























44


































Address 2
































45















46




47










City















State




Zip Code









48 (

)











49 (

)













Phone Number









Ext




Fax Number















50


































Remittance Bank for ACH or locked box transfer of funds
































51















52

















Bank Account Number for ACH















ACH Bank Transfer Number















53


































Email Address of Remittance Contact if requesting electronic remittance statements instead of mailed paper copy statements
































Block 7: Company Contact for Low Income Support Mechanism

































See Instructions Page (11)



































Same as general contact from lines (3-15) above































54

































Contact Name for Low Income Mechanism - Must be a company employee or designated representative
































55































Contact Address for Low Income Mechanism




























56


































Address 2
































57















58




59










City















State




Zip Code









60 (

)











61 (

)













Phone Number









Ext




Fax Number















62


































Email Address of Remittance Contact if requesting electronic remittance statements instead of mailed paper copy statements
































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