FCC Form 462 RHC, HCFP, Description of Request for Funding

OMB 3060-0804
Editorial: Nov, 2023

Est. time per response: 2hrs

Rural Health Care
Healthcare Connect Fund Program
Description of Request for Funding (FCC Form 462)
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-populated into the form.
Item #
1
2

Field Description
Funding Request Number (FRN)
Funding Year

3

Site Number(s) for Single or Individual
Expense(s)

4

7

Site Name(s) for Single or Individual
Expense(s)
Site Number for Multiple or Consortium
Expense(s)
Site Name for Multiple or Consortium
Expense(s)
Consortium Number

8

Consortium Name

9

Site Contact Information

5
6

Purpose/Instructions
Auto-generated by the system: The system creates a unique identifier for this request.
This is the selection of the funding year the applicant is submitting the request for. A
funding year runs from July 1 through June 30 of the following year.
Auto-generated by the system: This is the unique Universal Service Administrative
Company (USAC) assigned identifier for the site(s) listed in Site Name(s). The Site
Number was issued by USAC when the Description of Eligibility Form (FCC Form 460)
was completed.
Auto-generated by the system: This is the site name(s) submitted on the FCC Form 460.
For multiple expense item requests or Consortium requests, the user can assign site
numbers to line items.
For multiple expense item requests or Consortium requests, the user can assign site
names to line items.
Auto-generated by the system: This is the unique USAC assigned identifier for the
consortium listed in Consortium Name. The Consortium Number was issued by USAC
when the FCC Form 460 was completed.
Auto-generated by the system: This is the name of the consortium submitted on the FCC
Form 460.
Auto-generated by the system: This is the site’s physical 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.
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Item #
10

Field Description
Consortium Contact Information

11

Funding Priority

12

FCC Form 461 Application Number

13

Allowable Contract Selection Date
(ACSD)

14

Number of Service Provider Bids

15
16

Service Provider (SPIN)/498 ID
Service Provider Name

17
18
19

Service Provider Selection Date
Continuation with Current Service
Provider
Pricing Confidentiality

20

Evergreen Determination

21

Competitive Bidding Exemption

Purpose/Instructions
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.
Auto-populated by the system: This indicates the health care provider’s rurality tier,
which is used to prioritize funding in the event that program demand exceeds available
funding.
Auto-generated by the system: This is a unique USAC-assigned identifier for the FCC
Form 461 associated with this FCC Form 462.
Auto-generated by the system: This is the first day in which an applicant may agree to or
sign a contract with a service provider. This is calculated based on the number of days
the FCC Form 461 was posted. The ACSD is no less than 29 calendar days after the date
on which the FCC Form 461 was posted on USAC’s website.
The number of service providers who responded to or bid on the request for services
(FCC Form 461).
The selected service provider’s SPIN/498 ID.
Auto-generated by the system: Based on the SPIN/498 ID entered by the user. If
requesting services from multiple service providers, one FCC Form 462 must be
submitted per service provider.
The date that the service provider was selected for the funding request.
The user selects this if the selected service provider is their current service provider.
Optional. The user indicates if there is a restriction that prevents the pricing information
provided by the service provider from becoming public. If so, the applicant must
describe the specific restriction and the legal source prohibiting publication.
The user requests that the contract submitted with the funding request be reviewed for
an evergreen endorsement (thereby allowing a competitive bidding exemption for the
life of the contract).
Only completed if the user is claiming a competitive bidding exemption. If the applicant
is claiming the “E-Rate Approved Contract” bidding exemption, then the applicant must
provide: the E-Rate Contract ID (and friendly name), as requested on this FCC Form 462;
the E-Rate FCC Form 470 number that initiated bidding for that contract; the E-Rate
contact person for that contract (for quick access); and the contract expiration date.
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Item #
22
23

Field Description
Single, Multiple or Consortium
Expense(s)
Contract ID

24

Contract Friendly Name

25
26
27
28

Date Contract Signed/Service Provider
Selected
Contract State Date
Initial Contract Length
Number of Contract Extensions

29
30

Duration of Each Contract Extension
Combined Optional Extension(s) Length

31
32
33

Expense Category
Expense Type
Expense Frequency

34

Quantity of Expense Periods

35
36

Billing Account Number (BAN)
Circuit ID

37
38
39
40
41
42

Circuit Start Location
Circuit End Location
New Circuit Installation
Symmetrical Service
Upload Speed
Download Speed

Purpose/Instructions
Allows the user to submit single and/or multiple eligible expense items, or Consortium
expense items within the request.
This is the unique USAC assigned identifier for a contract or service agreement. This
identifier helps the user identify the contract in the future.
This is a unique identifier/nickname created by the user for this request (e.g., Smith
Telecommunications Funding Year 2016).
The date the contract with the service provider was signed.
The date the signed contract will start.
The length of the initial contract excluding voluntary options.
If applicable. If the contract includes voluntary options to extend the term of the
contract, then the user enters the number of such voluntary options.
If applicable. The duration of each contract extension.
If the contract includes one or more voluntary options to extend the term of the
contract, then the user enters the combined length of all the voluntary options.
The user selects the expense category of a line item.
The user selects the expense type of a line item.
The user indicates the frequency of the expense (e.g., monthly, yearly, quarterly) for
which support is sought.
The user indicates the number of expense periods (e.g., 12 months, 36 months, etc.)
that are included within this request.
Optional. The line item BAN listed on the service provider’s bill.
Optional. The user enters a service provider-specific identifier assigned to the
connection between two locations for the line item. The Circuit ID is located on the
service provider invoice.
The physical location and/or Site Number where the circuit originates for the line item.
The physical location and/or Site Number where the circuit terminates for the line item.
The user indicates if the circuit is newly installed.
The user indicates if upload and download speeds are equal for the service.
The user enters upload speed for the service.
If service is not symmetrical (different upload and download speeds,) then the user
enters the download speed for the service.
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Item #
43
44

Field Description
Expected Service Start Date
Service Level Agreement (SLA)

45
46
47
48
49

Latency
Jitter
Packet Loss
Reliability
Total Number of Fiber Strands

50
51
52

Number of Fiber Strands Eligible
Quantity of Expenses
Processing: Type of Funding Request

53

Multi-Year Contracts

54

Percentage of Expense Eligible

55
56

Percentage of Usage Eligible
Total Undiscounted Cost Per Expense
Period
Total Undiscounted Cost For Eligible
(Recurring) Expenses
Total Undiscounted Cost For Eligible
(Non-Recurring) Expenses
Total Discounted Cost Per Expense
Period
Total Discounted Cost For Eligible
(Recurring) Expenses
Total Discounted Cost For Eligible (NonRecurring) Expenses
One-Time Installation Charges
Taxes & Fees Per Expense Period

57
58
59
60
61
62
63

Purpose/Instructions
The date service is expected to start for the line item expense.
Optional. The user indicates whether the applicant’s contract with the service provider
includes an SLA.
The latency requirement per the contract SLA.
The jitter requirement per the contract SLA.
The packet loss rate requirement per the contract SLA.
The reliability requirements per the contract SLA.
The total number of fiber strands that are part of the fiber lease or similar agreement
for this line item.
The number of fiber strands that are eligible for support for this line item.
The number of expenses the applicant is seeking under this line item.
The user indicates the type of funding an applicant is requesting (e.g., multi-year
contract, month-to-month services, etc.).
If applicable. The user indicates the amount requested by funding year for each expense
type.
The percentage of the line item expense that is eligible for support.
The percentage of the line item expense that is used by an eligible site.
The total undiscounted cost per expense period (excluding taxes and fees).
The system will calculate and display the total undiscounted cost for recurring eligible
expenses.
The system will calculate and display the total undiscounted cost for non-recurring
eligible expenses.
The total discounted cost per expense period (excluding taxes and fees).
The system will calculate and display the total discounted cost for recurring eligible
expenses.
The system will calculate and display the total discounted cost for non-recurring eligible
expenses.
The user indicates any one-time installation charges.
The taxes and fees for the line item.

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Item #
64
65

Field Description
Source of Health Care Provider
Contribution
Supporting Documentation

66

I certify under penalty of perjury that I
am authorized to submit this request
on behalf of the applicant or
consortium.

67

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 of fact contained therein
are true.

Purpose/Instructions
The sources from which the Site or Consortium will fund its 35% contribution for this
line item.
There is additional documentation required to be submitted (where applicable) with the
FCC Form 462 to support the request for funding. Specifically, consortium and
individual applicants must submit: contracts, terms of service agreements (if applicable),
competitive bidding documents (including documentation to support its certification
that it has selected the most cost-effective option), and written descriptions of cost
allocation (if applicable). Consortium applicants must also submit: revisions to financial
agreements (if submitted with the FCC Form 460), revisions to the Network Plan
(submitted with the FCC Form 461), a narrative description of how the network will be
managed (if not previously provided), a network cost worksheet listing all participating
health care providers, evidence of a viable source for the 35% contribution,
sustainability plans (if applicable), revisions to sustainability plans (if previously
submitted) and letters of agency (if not previously submitted).
Applicants are required to provide this certification in order to receive Healthcare
Connect Fund support. For individual Health Care Provider applicants, certifications
must be signed by an officer or director of the Healthcare Provider or other authorized
employee of the Health Care Provider. For consortia applicants, an officer, director, or
other authorized employee of the Consortium Leader must sign the required
certification.
See Item #66 Purpose/Instructions above.

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Item #
68

69

70
71

Field Description
I certify under penalty of perjury that
the applicant or consortium has
considered all bids received and
selected the most cost-effective
method of providing the requested
services. “Cost-effective” is defined as
the “method that costs the least after
consideration of the features, quality of
transmission, reliability, and other
factors that the applicant deems
relevant to choosing a method of
providing the required health care
services.” 47 CFR § 54.622(c).
I certify under penalty of perjury that
the applicant or consortium is not
requesting support for the same service
from both the Telecommunications
Program and the Healthcare Connect
Fund Program.
I certify under penalty of perjury that all
RHC Program support will be used only
for eligible health care purposes.
I certify under penalty of perjury that
the applicant or consortium and/or its
consultant, if applicable, has not
solicited or accepted a gift or any other
thing of value from a service provider
participating in or seeking to participate
in the RHC Program.

Purpose/Instructions
See Item #66, Purpose/Instructions above.

See Item #66, Purpose/Instructions above.

See Item #66, Purpose/Instructions above.
See Item #66, Purpose/Instructions above.

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Item #
72

73

74

Field Description
I certify under penalty of perjury that
the applicant or consortium satisfies all
of the requirements under Section 254
of the Act and applicable Commission
rules, and understand that any letter
from the Administrator that
erroneously commits funds for the
benefit of the applicant may be subject
to rescission.
I certify under penalty of perjury that I
have reviewed all applicable rules and
requirements for the RHC Program and
complied with those rules and
requirements.
I understand that all documentation
associated with this application,
including all bids, contracts, scoring
matrices, and other information
associated with the competitive bidding
process, all billing records for services
received and any other documentation
demonstrating compliance with the
rules 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 or as
otherwise prescribed by the
Commission’s rules.

Purpose/Instructions
See Item #66, Purpose/Instructions above.

See Item #66, Purpose/Instructions above.

See Item #66, Purpose/Instructions above.

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Item #
75

76

Field Description
I certify under penalty of perjury that
any consultants or third parties
associated with this request or RFP do
not have an ownership interest, sales
commission arrangement, or other
financial stake in the vendor 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.
Signature

77

Date Submitted

78

Date Signed

79

Authorized Person Name

80

Authorized Person’s Employer

81
82

Authorized Person’s Employer FCC
Registration Number
Authorized Person’s Title/Position

83

Authorized Person’s Mailing Address

84

Authorized Person Telephone Number

85

Authorized Person Email Address

Purpose/Instructions
See Item #66, Purpose/Instructions above.

The Authorized Person is required to provide all required certifications and signatures.
The FCC Form 462 must be certified electronically.
Auto generated by system. This date is assigned based on the date the user submits the
FCC Form 462.
Auto generated by system. This date is assigned based on the date the user certifies the
FCC Form 462.
This is the name of the Authorized Person certifying the FCC Form 462. This field will be
auto-populated if already within the system.
This is the name of the employer of the Authorized Person certifying the FCC Form 462.
This field will be auto-populated if already within the system.
This is the FCC registration number of the Authorized Person certifying the FCC Form
462. This field will be auto-populated if already within the system.
This is the title of the Authorized Person certifying the FCC Form 462. This field will be
auto-populated if already within the system.
This is the address (can be physical address or mailing address) of the Authorized Person
certifying the FCC Form 462. This field will be auto-populated if already within the
system.
This is the telephone number of the Authorized Person certifying the FCC Form 462. This
field will be auto-populated if already within the system.
This is the email address of the Authorized Person certifying the FCC Form 462. This field
will be auto-populated if already within the system.
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