1
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Applicant’s FCC Form Nickname
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Optional. To create a unique identifier for this request, the
user simply enters a nickname (e.g., 2016 Funding Year Homewood
FCC Form 461).
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2
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Funding Year
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This is the selection of the funding year the applicant is
submitting the request for.
*Pilot Program participants can request up to three-years of
funding, but Funding Years do not apply to the Pilot Program.
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3
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FCC Form 461 Application Number
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Auto-generated by the system: This is a unique Universal Service
Administrative Company (USAC)-assigned identifier for this
request.
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4
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FCC Form 460 Number
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Auto-generated by the system: Based on information for the
previously submitted Description of Eligibility (FCC Form 460).
This is a USAC-assigned unique identifier for this request.
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5
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FCC Form 461 Posting Start Date
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Auto-generated by the system: This is a USAC-assigned date based
on the date of submission of the request and review of the
request.
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6
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FCC Form 461 Posting End Date
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Auto-generated by the system: This is a USAC-assigned date based
on no less than 28 days from the FCC Form 461 posting start date.
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7
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Allowable Contract Selection Date (ACSD)
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Auto-generated by the system: This is a USAC-assigned date, plus
any time added by the user, after which the applicant is able to
enter into an agreement with a service provider. This date must
be a date after the RFP and/or FCC Form 461 posting end date.
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8
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Site Name
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Auto-populated by the system: This is the site name submitted on
the FCC Form 460.
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9
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Site Number
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Auto-populated by the system: This is the unique USAC-assigned
identifier for this site listed in Site Name on the FCC Form 460.
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10
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Site Address
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Auto-populated by the system: This is the site’s physical
address, county, city, state, zip code, and geolocation submitted
on the FCC Form 460. Geolocation only applies to a site that does
not have a street address.
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11
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Consortium Name
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Auto-populated by the system: This is the name the consortium
submitted on the FCC Form 460.
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12
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Consortium Number
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Auto-populated by the system: This is the unique USAC-assigned
identifier for consortium listed in Site Name on the FCC Form
460.
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13
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Consortium Address
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Auto-populated by the system: This is the consortium’s
address, county, city, state, zip code and geolocation submitted
on the FCC Form 460. Geolocation only applies to a consortium
that does not have a street address.
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14
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FCC Registration Number
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Auto-populated by the system: This is either the consortium or
the site’s unique FCC registration number submitted via the
FCC Form 460.
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15
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Indicate Whether a Separate Request for Proposals (RFP) will be
Released for this Request
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The
user indicates whether they are issuing an RFP for the requested
services. If an RFP is used, it must be attached to the FCC Form
461 so that it can be “released” with the posting of
the FCC Form 461 and the RFP must be opened for at least 28 days
after the posting of the FCC Form 461.
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16
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Letter of Agency (LOA)
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For consortia only. The Consortium Leader
is required to submit an LOA for each eligible health care
provider participating in the consortium no later than when it
submits its Request for Services (FCC Form 461).
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17
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Network Plan
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For consortia only. If an applicant is a consortium, they must
submit a narrative of its Network Plan with the FCC Form 461.
*Not applicable to Pilot Program
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18
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Services and/or Equipment Requested: Category
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The user identifies the services and/or equipment for which the
site is requesting bids (e.g., Internet access).
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19
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Services and/or Equipment Requested: Service Details
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The user describes the services and/or equipment for which it is
requesting bids (e.g., minimum bandwidth needs, maximum bandwidth
that will be considered, needed functionality of equipment, how
the services will be used, quantity of the product or service
sought, requested pricing ranges). The user shall provide
sufficient information to enable bidders to reasonably determine
the needs of the user and provide responsive bids.
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20
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Services and/or Equipment Requested: Site(s) Listing
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The user provides information on the sites/entities included in
the request.
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21
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Services and/or Equipment Requested: Desired Contract Length
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The user provides details on the length and type of contract
requested.
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22
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Services and/or Equipment Requested: Bid Evaluation Period
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Optional. The user can express how long after the end of the FCC
Form 461 28-day posting period they will need to evaluate bids.
The expected bid evaluation period is not part of the ACSD
calculation.
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23
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Services and/or Equipment Requested: USAC Bid Posting Period
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Optional.
The user may add days to the posting period beyond the required
minimum 28-day posting period. The system will only allow the
applicant to enter a date that meets or exceeds the 28-day
minimum requirement.
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24
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Bidding Evaluation
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The user develops a weighted
evaluation criteria (e.g., scoring matrix) that demonstrates how
the applicant will choose the most ‘cost-effective' bid
before submitting a
request for services. Price must be a primary factor, but need
not be the only primary factor. A non-price factor can receive an
equal weight to price, but may not receive a greater weight than
price. The user must specify on their bid evaluation worksheet
and/or scoring matrix the requested services for which it seeks
bids, the information provided to bidders to allow bidders to
reasonably determine the needs of the user, its minimum
requirements for each specified criterion, and each service
provider’s proposed service levels for the established
criteria. The user must also specify its disqualification
factors, if any, that the user will use to remove bids or bidders
from further consideration.
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25
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Aggregate Purchasing Arrangement
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Optional. If the user has an aggregate purchasing arrangement,
the user shall provide full details of any arrangement involving
the purchasing of a service or services and/or equipment as part
of an aggregated purchase with other entities or individuals.
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26
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Supporting Documentation
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Optional. Users may also upload and submit any other supporting
documents to support their request.
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27
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Contact Person Name
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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.
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28
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Contact Person Employer
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The user must provide the employer of the person who should be
contacted with questions about this request.
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29
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Contact Person Title
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The user must provide the title of the person who should be
contacted with questions about this request.
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30
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Contact Person Mailing Address
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The user must provide the mailing address of the person who
should be contacted with questions about this request.
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31
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Contact Person Telephone Number
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The user must provide the telephone number of the person who
should be contacted with questions about this request.
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32
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Contact Person Email Address
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The user must provide the email address of the person who should
be contacted with questions about this request.
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33
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Contact Person Fax Number
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The user must provide the fax number of the person who should be
contacted with questions about this request.
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34
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Declaration of Assistance/Consultant or Outside Expert
Information
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If applicable. If the user uses a consultant, service provider,
or any other outside expert, whether paid or unpaid, who aided in
the preparation of its request and/or RFP, the user must provide
the name of the company, name of the person representing the
applicant, title of the person representing the applicant,
telephone number, email address, and physical address. The user
must also describe the nature of the relationship it has with any
consultant, vendor, or other outside expert identified in its
declaration of assistance.
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35
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I certify under penalty of perjury that I am authorized to submit
this request on behalf of the health care provider or consortium.
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The Authorized Person is required to provide all certifications
and signatures. For individual applicants, certifications must
be signed by an officer or director of the applicant. For
consortium applicants, an officer, director, or other authorized
employee of the Consortium Leader must sign the required
certification. The applicant is required to provide this
certification in order to receive universal service support.
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36
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I certify under penalty of perjury that I have examined this
request and all attachments, and to the best of my knowledge,
information, and belief, all statements contained herein and in
any attachments are true.
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See Item #35 Purpose/Instructions above.
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37
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I certify under penalty of perjury that the applicant seeking
supported services is a nonprofit or public entity that falls
within one of the seven categories set forth in the definition of
health care provider listed in 47 CFR §54.600 of the
Commission’s rules.
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See Item #35 Purpose/Instructions above.
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38
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I certify under penalty of perjury that the applicant seeking
supported services is physically located in a rural area as
defined in section 47 CFR § 54.600 of the Commission’s
rules, or is a member of a consortium which satisfies the
majority-rural composition requirements set forth in 47 CFR §
54.607 of the Commission’s rules.
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See Item #35 Purpose/Instructions above.
*Not applicable to Pilot Program
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39
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I certify under penalty of perjury that the applicant seeking
supported services has complied with any applicable state,
Tribal, or local procurement rules.
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See Item #35 Purpose/Instructions above.
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40
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I certify under penalty of perjury that all requested RHC Program
support will be used solely for purposes reasonably related to
the provision of health care service or instruction that the
health care provider is legally authorized to provide under the
law of the state in which the services are provided.
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See Item #35 Purpose/Instructions above.
*Not applicable to Pilot Program
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41
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I certify under penalty of perjury that the services will not be
sold, resold, or transferred in consideration for money or any
other thing of value.
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See Item #35 Purpose/Instructions above.
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42
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I certify under penalty of perjury that the applicant seeking
supported services satisfies all of the requirements under
section 254 of the Communications Act, 47 U.S.C. § 254, and
applicable Commission rules.
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See Item #35 Purpose/Instructions above.
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43
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I certify under penalty of perjury that the applicant seeking
support has reviewed and is compliant with all applicable RHC
Program requirements.
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See Item #35 Purpose/Instructions above.
*Not applicable to Pilot Program
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44
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I understand that all documentation associated with this request,
including a copy of the signed Request for Services (FCC Form
461), any bids/contracts resulting from the FCC Form 461 posting,
scoring sheet, and other information that was used in the
decision making process, must be retained for a period of at
least five years pursuant to 47 CFR § 54.631, or as
otherwise prescribed by the Commission’s rules.
|
See Item #35 Purpose/Instructions above.
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45
|
Signature
|
The FCC Form 461 must be signed electronically.
|
46
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Date Submitted
|
Auto generated by system.
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47
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Date Signed
|
Auto generated by system.
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48
|
Authorized Person Name
|
The Authorized Person is required to provide all required
certifications and signatures. This is the name of the Authorized
Person certifying the FCC Form 461. This field will be
auto-populated if the name of the Authorized Person is already
within the system.
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49
|
Authorized Person’s Employer
|
This is the name of the employer of the Authorized Person
certifying the FCC Form 461. This field will be auto-populated if
already within the system.
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50
|
Authorized Person’s Employer FCC Registration Number
|
This is the FCC registration number of the Authorized Person
certifying the FCC Form 461. This field will be auto-populated if
already within the system.
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51
|
Authorized Person’s Title/Position
|
This is the title of the Authorized Person certifying the FCC
Form 461. This field will be auto-populated if already within the
system.
|
52
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Authorized Person’s Mailing Address
|
This is the address (can be physical address or mailing address)
of the Authorized Person certifying the FCC Form 461. This field
will be auto-populated if already within the system.
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53
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Authorized Person Telephone Number
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This is the telephone number of the Authorized Person certifying
the FCC Form 461. This field will be auto-populated if already
within the system.
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54
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Authorized Person Email Address
|
This is the email address of the Authorized Person certifying the
FCC Form 461. This field will be auto-populated if already
within the system.
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