1
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FCC Form 466 Application Number
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Auto-populated by the system: This is a unique identifier for
each Request for Funding (FCC Form 466).
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2
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Funding Request Number (FRN)
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Auto-populated by the system: This is the unique identifier for
each Request for Funding (FCC Form 466) provided in the funding
commitment letter (FCL) issued by the Universal Service
Administrative Company (USAC) to the applicant.
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3
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Funding Year: Funding Start Date
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Auto-populated by the system: This displays the date funding
began for an FRN.
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4
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Funding Year: Funding End Date
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Auto-populated by the system: This displays the date funding will
end/ended for an FRN.
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5
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Health Care Provider (HCP) Number
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Auto-populated by the system: This is the unique USAC-assigned
identifier for the site listed in Site Name. The Site Number was
issued by USAC when the FCC Form 465 was completed.
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6
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HCP Name
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Auto-populated by the system: This is the site name submitted on
the FCC Form 465.
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7
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HCP Contact Information
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Auto-populated by the system: This is the site’s physical
address, county, city, state, zip code, telephone, website,
contact name, contact employer and geolocation. Geolocation only
applies to a site that does not have a street address. This
information was previously submitted on the FCC Form 465.
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8
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Legal Entity Name
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Auto-populated by the system: If applicable. This is the name of
the Legal Entity that owns and/or operates the site. In some
cases, the Legal Entity Name may be different from the Site Name.
This name was previously submitted on the FCC Form 465.
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9
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Legal Entity FCC RN
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Auto-populated by the system: If applicable. This is the unique
FCC identifier for the Legal Entity that owns and/or operates the
site. This unique identifier was previously submitted on the FCC
Form 465.
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10
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Billed Entity Name
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Auto-populated by the system: If applicable. This is the entity
that pays the bills of the service provider for the site. This
may be the site itself, or it may be the “parent”
organization, association, consortium, etc. to which the site
belongs. This information was previously submitted on the FCC
Form 466.
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11
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Billed Entity Contact Information
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Auto-populated by the system: If applicable. This is the Billed
Entity’s physical address, county, city, state, zip code,
telephone, website, contact name, contact employer, email address
and geolocation. This information was previously submitted on the
FCC Form 466.
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12
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Consortium Name
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Auto-populated by the system: If applicable. The user identifies
as being a member of a larger collective group (e.g., consortium,
association, network, etc.) that participates in either the
Telecommunications or HCF Programs. This information was
previously submitted on the FCC Form 465.
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13
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498 ID of Service Provider(s)
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Auto-populated by the system: The selected service provider’s
498 ID (formerly the Service Provider Identification Number
(SPIN) ID). This ID is pulled from the FCC Form 466 for an FRN.
There may be multiple service providers should the circuit have
multiple connections.
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14
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Service Provider Name(s)
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Auto-populated by the system: Based on the 498 ID(s) entered on
the FCC Form 466 for an FRN. There may be multiple service
providers if the circuit has multiple connections.
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15
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Service Provider/Applicant Invoice Number
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Optional. Allows the service provider and/or applicant to track
their FCC Form 466/467 within their billing system.
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16
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Action Taken
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User selects purpose of the FCC Form 467 which can be to: (1)
confirm the accuracy of all information provided on the FCC Form
466; (2) notify USAC of a disconnection of service; or (3) inform
USAC that service was not turned on during the funding year.
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17
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Expense/Service Type
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Auto-populates. This is the expense/service category the health
care provider identified on their submitted Form 466.
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18
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Bandwidth
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Auto-populates. User must confirm the site is receiving the same
bandwidth identified on their submitted FCC Form 466.
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19
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Date Service Started
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The date service began or is expected to begin. If the service
start date is delayed, the actual service start date should be
indicated here.
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20
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Date Service Ended/Disconnected
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The date service is to end or was disconnected. If the actual
end date or disconnection date occurred before the original
reported service end/disconnection date, the actual service end
or disconnection date should be indicated here.
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21
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Contract Status
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Displays the status of the contract (e.g., month-to-month,
evergreen, etc.).
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22
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Billing Account Number (BAN)
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The line item BAN listed on the service provider’s bill.
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23
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Total Actual Undiscounted Cost
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The actual total undiscounted cost (including taxes and fees) for
the billing period.
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24
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Percentage of Expense Eligible
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Auto-populated by the system: The percentage of the item expense
that is eligible for support.
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25
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Percentage of Usage Eligible
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Auto-populated by the system: The percentage of the line item
expense that is used by an eligible site.
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26
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Total Eligible Actual Cost
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Auto-populated by the system: The system will calculate and
display the total amount of the line item expense that is
eligible for universal service support.
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27
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USF Support Committed
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Auto-populated by the system: The system will calculate and
display the total amount of the eligible line item expense that
USAC may pay the service provider for the line item.
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28
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Supporting Documentation
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Optional. Provides the option for the user to upload and submit
supporting documents to their request.
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29
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I certify under penalty of perjury that the service identified
above has been or is being provided to the above-named applicant.
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The Authorized Person is required to provide all required
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 certifications. The applicant must provide this
certification in order to receive universal service fund support.
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30
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I certify under penalty of perjury that the universal service
credit will be applied to the telecommunications service billing
account of the applicant or the billed entity as directed by the
applicant.
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See Item #29 Purpose/Instructions above.
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31
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I certify under penalty of perjury that I am authorized to submit
this request on behalf of the above-named applicant.
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See Item #29 Purpose/Instructions above.
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32
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I certify under penalty of perjury that I have examined the
invoice and supporting documentation and that, to the best of my
knowledge, information and belief, all statements contained
herein are true.
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See Item #29 Purpose/Instructions above.
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33
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I certify under penalty of perjury that the applicant or
consortium that I am representing satisfies all of the
requirements 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. § 254.
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See Item #29 Purpose/Instructions above.
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34
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I understand that any letter from USAC that erroneously states
that funds will be made available for the benefit of the
applicant may be subject to rescission.
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See Item #29 Purpose/Instructions above.
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35
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I understand that all documentation associated with this request
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.
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See Item #29 Purpose/Instructions above.
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36
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Signature
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The Authorized Person is required to provide all required
signatures and certifications. The FCC Form 467 must be certified
electronically.
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37
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Date Submitted
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Auto populated by system.
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38
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Date Signed
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Auto populated by system.
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39
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Authorized Person Name
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This is the name of the Authorized Person certifying the FCC Form
467. This field will be auto-populated if the name of the
Authorized Person is already within the system.
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40
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Authorized Person’s Employer
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This is the name of the employer of the Authorized Person
certifying the FCC Form 467. This field will be auto-populated if
already within the system.
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41
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Authorized Person’s Employer FCC RN
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This is the FCC RN of the Authorized Person certifying the FCC
Form 467. This field will be auto-populated if already within the
system.
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42
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Authorized Person’s Title/Position
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This is the title of the Authorized Person signing the FCC Form
467. This field will be auto-populated if already within the
system.
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43
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Authorized Person’s Mailing Address
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This is the address (can be physical address or mailing address)
of the Authorized Person certifying the FCC Form 467. This field
will be auto-populated if already within the system.
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44
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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 467. This field will be auto-populated if already
within the system.
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45
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Authorized Person Email Address
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This is the email address of the Authorized Person certifying the
FCC Form 467. This field will be auto-populated if already within
the system.
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