Attachment 11 - Post-Commitment Request Form (004) 8.17

OMB 3060-0804

X/X/2020

Rural Health Care Program

Post-Commitment Request 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-filed in the system portal will be carried forward and auto-generated into the form.

Item #	Field Description	Purpose/Instructions
1	Applicant’s FCC Form Nickname	Optional. To create a unique identifier for this request, the user simply enters a nickname (e.g., 2016 Funding Year Homewood FCC Form 461).
2	Health Care Provider (HCP) Name	Auto-generated by the system: This is the name of the site submitted on the FCC Form 460 or FCC Form 465.
3	HCP 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 FCC Form 460 or FCC Form 465 was completed.
4	Site Contact Information	Auto-generated by the system: This is the site’s physical address, county, city, state, zip code, telephone, email address, website, and geolocation provided on the FCC Form 460 or FCC Form 465. Geolocation only applies to a site that does not have a street address.
5	Consortium Name	Auto-generated by the system: This is the name the consortium submitted on the FCC Form 460.
6	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.
7	Consortium Contact Information	Auto-generated by the system: This is the consortium’s address, county, city, state, zip code, telephone, email address, 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.
8	FCC Registration Number	Auto-populated by the system: This is either the consortium or the site’s unique FCC registration number (FCC RN) submitted via the FCC Form 460 or FCC Form 465.
9	Funding Year	Auto-populated by the system based on the funding year of the FRN line item(s) that are being adjusted.
10	Contact Person Name	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.
11	Contact Person Employer	The user must provide the employer of the person who should be contacted with questions about this request.
12	Contact Person Title	The user must provide the title of the person who should be contacted with questions about this request.
13	Contact Person Mailing Address	The user must provide the mailing address of the person who should be contacted with questions about this request.
14	Contact Person Telephone Number	The user must provide the telephone number of the person who should be contacted with questions about this request.
15	Contact Person Email Address	The user must provide the email address of the person who should be contacted with questions about this request.
16	Contact Person Fax Number	The user must provide the fax number of the person who should be contacted with questions about this request.
17	Type of Post-Commitment Request	Choices (choose all that apply; at least one is required): Service Delivery Extension Request; Service & Site Substitution; Service Provider Identification Number (SPIN) Change; Invoice Deadline Extension Request; Cancel Funding Request Number (FRN(s)); or Reduce Commitment Amount for FRN(s).
Service Delivery Extension Request (Healthcare Connect Fund Program only)
18	FCC Form 462	The system will pre-populate this information based on the Funding Request Numbers (FRNs) selected by the applicant.
19	FRN Information	The applicant will select one or more line item(s) on a given FCC Form 462 application that requires this change.
20	Non-Recurring Service Delivery Extension Criteria	Certify the reason for the non-recurring service delivery extension request. Check one that applies: □ The service provider is unable to complete implementation for reasons beyond the service provider’s control. □ The service provider has been unwilling to complete delivery and installation because the applicant’s funding request is under review by USAC for program compliance.
21	Extension Request Reason	The applicant will provide narrative and has option to upload supporting documents. The applicant will have option to input any FRNs under review by USAC.
Site & Service Substitution
22	Site & Service Substitution Requirements	Applicants must meet the following requirements: The substitution is provided for in the contract, within the change clause, or constitutes a minor modification; The site is an eligible health care provider and the service is an eligible service under the Telecom Program or the Healthcare Connect Fund Program. The substitution does not violate any contract provision or state, Tribal or local procurement laws; and The requested change is within the scope of the controlling request for services, including any applicable RFP used in the competitive bidding process. Support is restricted to qualifying site and service substitutions that do not increase the total amount of support under the applicable funding commitment.
23	FCC Form 462/466	The system will pre-populate this information based on the FRNs selected by the applicant.
24	FRN Information	The applicant will select one or more line item(s) on a given FCC Form 462 applications or one or more FCC Form 466 applications for which it seeks a substitution.
25	Expense Item(s)	The applicant will select the expense item(s) on a given FCC Form 462 or FCC Form 466 for which it seeks a substitution and enter the new information. Substitution modifications cannot change the overall funding disposition, i.e., exceed approved funding amount or de-commit money that has already been disbursed.
26	Site & Service Substitution Reason	The applicant will provide narrative of the substitution request and has option to upload supporting documents. The narrative should provide a brief explanation regarding the necessity of the change and why the request complies with the Site & Service Substitution Requirements.
SPIN Change
27	SPIN Change Type	Select if you are requesting a SPIN change. Check one that applies: □ Corrective SPIN change: Correcting data entry errors; Updating a SPIN that has changed due to the merger of companies or the acquisition of one company by another; or Effectuating a change that was not initiated by the applicant. □ Operational SPIN change: The applicant has a legitimate reason to change providers (e.g., breach of contract or the service provider is unable to perform); and The applicant’s newly selected service provider received the next highest point value in the original bid evaluation, assuming there were multiple bidders.
28	Old SPIN Information	The applicant will provide information for the SPIN that it seeks to change.
29	New SPIN Information	The applicant will provide information for the new SPIN.
30	SPIN Change Reason	The applicant will provide narrative for such change and has option to upload supporting documents.
Invoice Deadline Extension Request
31	FRN(s) Selection	The applicant or service provider will select one or more FRNs on a given FCC Form 463 or Telecom Program Invoice Form for an automatic 120-day extension.
Request to Cancel FRN(s)
32	FRN Information	The applicant will select one or more FRNs that it would like to be cancelled. This action is irrevocable and the FRN or FRNS cannot be reinstated later. This action will allow the requested funding to be returned to the Universal Service Fund for possible commitments to other applicants.
33	FCC Form 462/466	The system will pre-populate this information based on the FRNs selected by the applicant.
Request to Reduce Commitments for FRN(s)
34	FRN Information	The applicant will select one or more FRNs where it would like the amount of funding committed to be reduced.
35	FCC Form 462/466	The system will pre-populate this information based on the FRNs selected by the applicant.
Telecommunications Program
36	Rural Rate per Month	If authorized and allowed by the Commission rules, if there is a change in the amount for the rural rate per month, provide the updated monthly rural rate. The rural rate cannot exceed the original requested rural rate for the service.
37	Installation Rural Rate Charge	If there is a change in the installation rural rate charge, provide the updated installation rural rate charge. The installation charge cannot exceed the original requested installation charge for the service.
38	Rural Taxes and Fees per Month	If there is a change in the amount of the rural taxes and fees, provide the updated rural taxes and fees amount. The rural taxes and fees charge cannot exceed the original requested monthly rural taxes and fees.
39	Total Undiscounted Cost per Month	The user indicates the monthly rural rate and any requested rural monthly taxes and fees and/or installation charge. The updated amount cannot exceed the original requested undiscounted cost per month.
40	Urban Rate per Month	The system will pre-populate this information. Any modification cannot increase the amount of the original funding commitment.
41	Installation Urban Rate Charge	If there is a change in the amount in the installation urban rate charge, provide the updated installation urban rate charge. The modification cannot increase the amount of the original funding commitment.
42	Urban Taxes and fees per Month	If there is a change in the amount of urban taxes and fees per month, provide the updated urban taxes and fees amount. The modification cannot increase the amount of the original funding commitment.
43	Total Amount for Urban Rate	The applicant indicates the monthly urban rate and any requested urban taxes and fees and/or installation charge. The modification cannot increase the amount of the original funding commitment.
Healthcare Connect Fund Program
46	Installation Charges	If there is a change in the amount for the installation charge, provide the updated installation charge. The installation charge cannot exceed the original requested installation charge for the service.
47	Expense Line Item(s)	The user indicates which expense line item(s) from the FRN that need to be modified.
48	Total Undiscounted Cost for the Expense Line Item(s)	If there is a change in the cost for the expense line item(s), provide the updated undiscounted cost for each applicable expense line item(s). The updated amount cannot exceed the original requested undiscounted cost for the expense line item.
49	Taxes and Fees for the Expense Line Item(s)	If there is a change in the taxes and fees for the expense line item(s), provide the updated taxes and fees for each applicable expense line item(s). The updated amount cannot exceed the original requested taxes and fees for each expense line item.
50	Total Undiscounted Cost for Eligible Recurring Expenses	The system will calculate and display the updated total undiscounted cost for recurring eligible expenses.
51	Total Undiscounted Cost for Eligible Non-recurring Expenses	The system will calculate and display the updated total undiscounted cost for eligible non-recurring expenses.
52	Service Start Date	If the original service start date was delayed, please enter the actual start date here.
53	Service End/Termination Date	If the service was ended or terminated earlier than the original service end/termination date, please enter the actual end or termination date here.
Certifications
54	I certify that I am authorized to submit this request, that I have examined this request, and that, to the best of my knowledge, information, and belief, all statements of fact contained herein are true.	The authorized representative of the applicant, or service provider if requesting an invoicing extension, must provide this certification.
55	I understand that all documentation associated with this request, 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.	The authorized representative of the applicant, or service provider if requesting an invoicing extension, must provide this certification.
56	Signature	The authorized representative of the applicant, or service provider if requesting an invoicing extension, is required to provide all required certifications and signatures The Post-Commitment Request Form must be certified electronically.
57	Date Submitted	Auto generated by system.
58	Date Signed	Auto generated by system.
59	Authorized Person Name	This is the name of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant (or service provider if requesting an invoicing extension). This field will be auto-populated if the name of the Authorized Person is already within the system.
60	Authorized Person’s Employer	This is the name of the employer of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant (or service provider if requesting an invoicing extension). This field will be auto-populated if already within the system.
61	Authorized Person’s Employer FCC RN	This is the FCC RN of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant (or service provider if requesting an invoicing extension). This field will be auto-populated if already within the system.
62	Authorized Person’s Title/Position	This is the title of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant (or service provider if requesting an invoicing extension). This field will be auto-populated if already within the system.
63	Authorized Person’s Mailing Address	This is the address (can be physical address or mailing address) of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant (or service provider if requesting an invoicing extension). This field will be auto-populated if already within the system.
64	Authorized Person Telephone Number	This is the telephone number of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant (or service provider if requesting an invoicing extension). This field will be auto-populated if already within the system.
65	Authorized Person Email Address	This is the email address of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant (or service provider if requesting an invoicing extension). 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 0.3 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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