FCC Form 463 Description of Request for Funding Disbursement

OMB 3060-0804

X/X/2020

Rural Health Care

Healthcare Connect Fund Program

Description of Request for Funding Disbursement (FCC Form 463)

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 #	Field Description	Purpose/Instructions
1	Rural Health Care Invoice Number	Auto-generated by the system: This is the unique identifier for the Request for Funding Disbursement (FCC Form 463).
2	Funding Request Number (FRN)	Auto-generated by the system: This is a unique identifier auto-generated by the system on the FCC Form 462 and provided in the funding commitment letter to the applicant.
3	Funding Year: Funding Start Date	Auto-generated by the system: This displays the date funding began for this Funding Request Number (FRN). Taken from information provided on the Request for Funding (FCC Form 462). Funding years start on July 1 of each year and end on June 30 of the following year. *Pilot Program participants can request up to three-years of funding, but Funding Years do not apply to the Pilot Program.
4	Funding Year: Funding End Date	Auto-generated by the system: This displays the date funding will end/ended for this FRN. Taken from information provided on the FCC Form 462. *Pilot Program participants can request up to three-years of funding, but Funding Years do not apply to the Pilot Program.
5	Site Number	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 Description of Eligibility (FCC Form 460) was completed.
6	Site Name	Auto-generated by the system: This is the name of the site submitted on the FCC Form 460.
7	Consortium Number	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.
8	Consortium Name	Auto-generated by the system: This is the name the consortium submitted on the FCC Form 460.
9	Site Contact Information	Auto-generated by the system: This is the site’s physical address, county, city, state, zip code, telephone, website, and geolocation provided on the FCC Form 460. Geolocation only applies to a site that does not have a street address.
10	Consortium Contact Information	Auto-generated by the system: This is the consortium’s address, county, city, state, zip code, telephone, 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.
11	498 ID of Service Provider	Auto-generated by the system: The selected service provider’s 498 ID (formerly Service Provider Identification Number (SPIN) ID). The 498 ID is pulled from the FCC Form 462 for an FRN.
12	Service Provider Name	Auto-generated by the system: Based on the 498 ID entered on the FCC Form 462 for the FRN.
13	Service Provider/Applicant Invoice Number	Optional. Allows the service provider and/or applicant to track the FCC Form 462 within their billing system.
14	Funding Request Number Identification Number (FRN ID)	Auto-generated by the system: Building upon the FRN, the system auto-generates an FRN ID to correspond to an individual line item.
15	Site Number: Line Item Details	Auto-generated by the system: Based on the line item’s FRN ID.
16	Site Name: Line Item Details	Auto-generated by the system: Based on the line item’s FRN ID.
17	Expense Category	Auto-generated by the system: Based on the line item’s FRN ID.
18	Expense Type	Auto-generated by the system: Based on the line item’s FRN ID.
19	Bandwidth	Auto-generated by the system: Based on the line item’s FRN ID.
20	Service Start Date	The date service is expected to start for the line item.
21	Quantity of Items	The number of items the applicant is seeking under the line item.
22	Billing Account Number (BAN)	The line item BAN is listed on the service provider’s bill.
23	Billing Period Start Date	The first date of the billing period for the invoice.
24	Billing Period End Date	The last date of the billing period for the invoice.
25	Billing Period Eligible Amount	Auto-generated by the system: The amount an applicant is eligible to receive for the billing period. This is derived from information provided on the FCC Form 462.
26	Total Actual Undiscounted Cost	The actual total undiscounted cost (including taxes and fees) for the billing period.
27	Percentage of Expense Eligible	Auto-generated by the system: The percentage of the line item expense that is eligible for support. Taken from information provided on the FCC Form 462.
28	Percentage of Usage Eligible	Auto-generated by the system: The percentage of the line item expense that is used by an eligible site. Taken from information provided on the FCC Form 462.
29	Total Eligible Actual Cost	Auto-generated by the system: The system will calculate and display the total amount of the line item expense that is eligible for universal service fund (USF) support. Taken from information provided on the FCC Form 462.
30	Consultant Disclosure	If applicable. Provide the name of any consultants or third parties who helped identify the applicant’s Request for Proposals (RFP) or FCC Form 461, 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.
31	USF Support To Be Paid	The system will calculate and display the total amount of the line item expense that USAC will pay the service provider for the line item.
32	Supporting Documentation	Optional. Provides the option for the user to upload and submit documents to support their request.
33	I certify under penalty of perjury that I am authorized to submit this request on behalf of the service provider.	The service provider’s representative must make this certification to participate in the RHC Program. The Authorized Person is required to provide all required certifications and signatures.
34	I understand that the service provider must apply the amount submitted, approved, and paid by USAC to the billing account of the applicant(s) and FRN/FRN ID listed on this invoice.	The service provider must make this certification in order to participate in the RHC Program.
35	I certify under penalty of perjury that I have examined this form and attachments and that, to the best of my knowledge, information, and belief, the date, quantities, and costs provided are true and correct.	See Item #33 Purpose/Instructions above.
36	I certify under penalty of perjury that I have abided by all RHC Program requirements and procedures, including all applicable Commission rules.	See Item #33 Purpose/Instructions above. *Not applicable to the Pilot Program
37	I certify under penalty of perjury that I charged only for eligible services delivered or provided to the applicant prior to submitting the form and accompanying documentation.	See Item #33 Purpose/Instructions above.
38	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 #33 Purpose/Instructions above.
39	I certify under penalty of perjury that the 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.	See Item #33 Purpose/Instructions above.
40	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 #33 Purpose/Instructions above.
41	I understand that all documentation associated with this application, including all billing records for services received, must be retained for a period of at least five years after the last day of the delivery of supported services, equipment or facilities pursuant to 47 CFR § 54.631.	See Item #33 Purpose/Instructions above.
42	Signature	The Authorized Person is required to provide all required certifications and signatures. The FCC Form 463 must be certified electronically.
43	Date Submitted	Auto generated by system.
44	Date Signed	Auto generated by system.
45	Authorized Person Name	This is the name of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if the name of the Authorized Person is already within the system.
46	Authorized Person’s Employer	This is the name of the employer of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.
47	Authorized Person’s Employer FCC RN	This is the FCC RN of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.
48	Authorized Person’s Title/Position	This is the title of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.
49	Authorized Person’s Mailing Address	This is the address (can be physical address or mailing address) of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.
50	Authorized Person Telephone Number	This is the telephone number of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.
51	Authorized Person Email Address	This is the email address of the Authorized Person certifying the FCC Form 463 on behalf of the service provider. This field will be auto-populated if already within the system.
52	I certify under penalty of perjury that I am authorized to submit this request on behalf of the applicant or consortium.	The authorized representative of the Consortium Leader (or, Health Care Provider, if participating individually) must provide this certification.
53	I certify under penalty of perjury that I have examined this form and attachments and, to the best of my knowledge, information, and belief, all information contained therein is true and correct.	See Item #52 Purpose/Instructions above.
54	I certify under penalty of perjury that the applicant or consortium members have received the related services, network equipment, and/or facilities itemized on the invoice form.	See Item #52 Purpose/Instructions above.
55	I certify under penalty of perjury that the required 35% minimum contribution for each item on the FCC Form 463 was funded by eligible sources as defined in the FCC rules and that the required contribution was remitted to the service provider.	See Item #52 Purpose/Instructions above. *Required minimum contribution for the Pilot is 15%.
56	I understand that all documentation associated with this application, 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.	See Item #52 Purpose/Instructions above.
57	Signature	The authorized representative of the Consortium Leader (or Health Care Provider) is required to provide all required certifications and signatures. The FCC Form 463 must be certified electronically.
58	Date Submitted	Auto generated by system.
59	Date Signed	Auto generated by system.
60	Authorized Person Name	This is the name of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if the name of the Authorized Person is already within the system.
61	Authorized Person’s Employer	This is the name of the employer of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.
62	Authorized Person’s Employer FCC RN	This is the FCC RN of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.
63	Authorized Person’s Title/Position	This is the title of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.
64	Authorized Person’s Mailing Address	This is the address (can be physical address or mailing address) of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.
65	Authorized Person Telephone Number	This is the telephone number of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.
66	Authorized Person Email Address	This is the email address of the Authorized Person certifying the FCC Form 463 on behalf of the applicant. This field will be auto-populated if already within the system.

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

Part 54 of the Federal Communications Commission’s (FCC) rules authorize the FCC to collect the information in this form. Responses to the questions herein are required to obtain the benefits sought by this form. Failure to provide all requested information will delay the processing of the form or result in the form being returned without action. Information requested by this form will be available for public inspection. The information provided will be used to determine whether approving the request is in the public interest.

We have estimated that your response to this collection of information will take 2 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 or response.  If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, Office of Managing Director, AMD‑PERM, Paperwork Reduction Act Project (3060‑0804), Washington, DC 20554.  We will also accept your comments via the Internet if you send them to PRA@fcc.gov.  Please DO NOT SEND COMPLETED FORMS 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 we fail to provide you with this notice.  This collection has been assigned an OMB control number of 3060‑0804.

THIS NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

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