FCC Form 466 Funding Request and Certification Form

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Overview

Blocks 1-4
Blocks 5-8
Notice

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Sheet 1: Blocks 1-4

FCC Form

Health Care Providers Universal Service

Approval by OMB

466

Funding Request and Certification Form

3060—0804

The Deadline to submit this Form is the June 30th End of the Funding Year.

Estimated time per response: 3 hours

Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.

Block 1: HCP Information

1

HCP Name

2

HCP Number

3

Form 465 Application #

4

Consortium Name (If any)

Block 2: Bill Payer Information

5

Billed Entity Name

6

Billed Entity FCC RN

7

Contact Name

8

Address Line 1

9

Address Line 2

10

City

11

State

12

Zip

13

Contact Phone #

14

Fax #

15

E-Mail

Block 3: Funding Year Information

16

Funding Year - Check only one box

Year 2010 (7/1/2010-6/30/2011)

Year 2011 (7/1/2011-6/30/2012)

Year 2012 (7/1/2012-6/30/2013)

Block 4: Service Information

17

Type of Service & Circuit Bandwidth (Enclose documentation.)

18

Total Billed Miles

19

Maximum Allowable Distance (From Form 465)

20

Percentage of HCP's service used for the provision of health care.

(If less than 100%, please explain.)

If the HCP indicated it is a part-time eligible entity (on Form 465), describe method of allocating prorated support.

Connection Information

Carrier A

Carrier B

Carrier C

Carrier D

21

Service Provider Name

22

Service Provider Identification Number (SPIN)

23

Service Provider Contact Person Name

24

Service Provider Contact Person's Phone #

25

Service Provider Contact Person Email

26

Circuit Start Location

27

Circuit Termination Location

28

Billing Account Number

29

Tariff, Contract or other document reference number

30

Date Contract Signed or Date HCP Selected Carrier

31

Contract Expiration Date (mm/dd/yyyy or NA if MTM)

32

Service Installation Date

33

Actual Rural Rate per Month (Enclose Documentation)

34

If you are a consortium member OR have multiple carriers, please attach a Circuit Diagram to show how the sites

interconnect and which carrier(s) provides each circuit segment.

Circuit Diagram included:

Yes

No

35

Are you a mobile rural health care provider?

Yes

No

If yes, see instructions and attach a list of all sites to be served.

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Sheet 2: Blocks 5-8

IF YOU ARE REQUESTING SUPPORT FOR MILEAGE-BASED CHARGES, COMPLETE BLOCK 5 ONLY AND SKIP BLOCK 6. (PLEASE SEE

INSTRUCTIONS). IF YOU ARE REQUESTING SUPPORT BASED ON URBAN/RURAL RATE COMPARISON, SKIP BLOCK 5 AND

COMPLETE ONLY BLOCK 6. YOUR APPLICATION CANNOT BE PROCESSED IF BOTH BLOCKS ARE COMPLETED.

Block 5: Mileage-based Charge Discount Request

Complete this block if you are seeking support for mileage (distance-based) charges only. Do not enter any other charges in this block. You may need

to ask your service provider representative to provide this information.

Carrier A

Carrier B

Carrier C

Carrier D

36

Billed Circuit Miles

37

Monthly Mileage Charges (Exclude Channel Termination chgs, etc.)

38

Cost per Mile per Month

If Line 33 equals Line 37, please ensure that ONLY mileage-related charges are included in Line 37. (See instructions.)

Block 6: Comprehensive Rate Comparison Request

Complete Block 6 if you have not completed Block 5 and are requesting support for all elements of your telecommunications service necessary for

the provision of health care. The information in this block will establish the difference between the urban and rural rates for your requested service.

Please call RHCD at 1-800-229-5476 if you need assistance.

Carrier A

Carrier B

Carrier C

Carrier D

39

One-time Urban Rate Charge (in selected large city)

40

One-time Rural Rate Charge (in city where HCP is located)

41

Monthly Urban Rate (in selected large city). From RHCD

web site:

or Other rate documentation attached:

If your circuit includes charges for mileage over the Maximum Allowable Dist., (Line 19), please complete Lines 42 to 44. Otherwise, skip to Block 7.

42

Billed Circuit Miles

43

Monthly Mileage Based Charges

44

Cost per Mile per Month

Block 7: Bid Documentation

45

Did you receive any bids in response to the Form 465 Request for Services posted on the RHCD website?

Yes

No

If you checked yes, copies of the bids MUST be mailed to RHCD.

Block 8: Certification

46

I certify that the above named entity has considered all bids received and selected the most cost-effective method of providing the

requested service or services. The "most cost-effective service" is defined in the Universal Service Order as the service available at the lowest cost after consideration of the features, quality of transmission, reliability, and other factors that the health care provider deems necessary for the service to adequately transmit the health care services required by the health care provider.

47

Pursuant to 47 C.F.R. Secs. 54.601 and 54.603, I certify that the HCP or consortium that I am representing satisfies all of the

requirements herein and will abide by all of the relevant requirements, including all applicable FCC rules, with respect to universal service benefits provided under 47 U.S.C. Sec. 254. I understand that any letter from RHCD that erroneously states that funds will be made available for the benefit of the applicant may be subject to rescission.

48

I hereby certify that the billed entity will maintain complete billing records for the service for five years.

49

I certify that I am authorized to submit this request on behalf of the above-named Billed Entity and HCP, and that I have examined this

form and attachments and that to the best of my knowledge, information, and belief, all statements of fact contained herein are true.

50

Signature

51

Date

52

Printed name of authorized person

53

Title or position of authorized person

54

Employer of authorized person

55

Employer's FCC RN

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Sheet 3: Notice

Please remember:

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You must submit one Form 466 for each service (i.e., circuit) for which you request reduced rates. For example:

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If you are requesting reduced rates for two T1 lines, you must submit two Forms 466.

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If you are requesting reduced rates for two ISDN lines & one Frame Relay line, you must submit three Forms 466.

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If the service described on this form is subject to the 28-day competitive bidding requirement, do not select a carrier or

complete the Form 466 before or during the 28-day posting period.

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You must provide evidence of the urban rate if you have completed Block 6 and have not used the urban rates from the website.

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This form, attachments, and supporting documents should be combined in one envelope and sent to the RHCD.

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If the service described on this form changes (e.g., rate change) during the funding year, you must notify RHCD immediately

and submit a revised Form 466.

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If you have any questions, call RHCD at 1-800-229-5476.

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.

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 3 of the Commission's Rules authorize the FCC to request the information on this form. The data reported will be used to ensure that health

care providers have selected the most cost-effective method of providing the requested services as set forth in 47 C.F.R. § 54.603(b)(4). The

information will be used by the Universal Service Administrative Company and/or the staff of the Federal Communications Commission, to evaluate

this form, to provide information for enforcement and rulemaking proceedings and to maintain a current inventory of applicants, health care

providers, billed entities, and service providers. No authorization can be granted unless all information requested is provided. Failure to provide all

requested information will delay the processing of the application or result in the application being returned without action. Information requested

by this form will be available for public inspection. Your response is required to obtain the requested authorization.

The public reporting for this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions,

searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you

have any comments on this burden estimate, or how we can improve the collection and reduce the burden it causes you, please write to the

Federal Communications Commission, AMD-PERM, Paperwork Reduction Act Project (3060-0804), Washington, DC 20554. We will also accept

your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to pra@fcc.gov. PLEASE

DO NOT SEND YOUR RESPONSE TO THIS ADDRESS.

Remember - 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 OMB control number or if we fail to provide you with this notice. This

collection has been assigned an OMB control number of 3060-0804.

THE FOREGOING NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. 552a(e)(3)

AND THE PAPEWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

This form should be submitted to:

Rural Health Care Division

30 Lanidex Plaza West, P.O.Box 685

Parsippany NJ 07054-0685