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New FCC Form 463
Subject To Approval by OMB 3060-0804
Rural Health Care (RHC) Universal Service
Estimated time per response: 1 hour
Healthcare Connect Fund
Invoice and Request for Disbursement Form

Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.

Block One: General Information

Line 6: Vendor/Applicant Invoice

Line 1: RHC Invoice Number

Number

Line 2: FRN

Line 7: SPIN

Line 3: HCP Number

Line 8: Vendor Name

Line 4: Site/Consortium Name

Line 9: Total Invoice Amount

Line 5: Funding Year:

Block Four: Calculation of

Block Two: Eligible Expenses

Block Three: Dates, Quantities, and Costs

Support

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DRAFT

Block Five: Supporting Documentation

Line 10: Applicants and/or vendors may attach supporting documentation, including, but not limited to, a copy of the bill(s) for the line item(s) being
submitted on this Form 463. By providing copies of the bills and/or support documentation, the applicant and vendor will ensure such documentation is
available for any future audit. See 47 C.F.R. § 54.648

Block Six: Vendor Certifications and Signatures

Line 11: I certify that I am authorized to submit this Form 463 on behalf of the vendor.
Line 12: I certify that the vendor has credited health care provider(s) and FRN/FRN IDs listed on the USAC invoice with the amount shown
under Column P (USF support amount to be Paid).
Line 13: I declare under penalty of perjury that I have examined this form and attachments to the best of my knowledge, information, and
belief, the dates, quantities, and costs provided under Block three of this Form 463 are true and correct.
Line 14: Signature
Line 15: Date
Line 16: Printed Name of Authorized Person
Line 17: Title/Position of Authorized Person
Line 18: Phone Ext.
Line 19: Email
Line 20: Employer
Line 21: Employer's FCC RN

Block Seven: Applicant Certifications and Signatures

Line 22: I certify that I am authorized to submit this Form 463 on behalf of the healthcare provider or consortium.
Line 23: I delcare 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 on this Form 463 is true and correct.
Line 24: I declare under penalty of perjury that the HCP or consortium members have received the related services, network equipment,
and/or facilities itemized on this Form 463.
Line 25: I declare under penalty of perjury that the required 35 percent minimum contribution for each item on the Form 463 was funded
by eligible sources as defined in the FCC rules and that the required contribution was remitted to the vendor.
Line 26: Signature
Line 27: Date
Line 28: Printed Name of Authorized Person
Line 29: Title/Position of Authorized Person
Line 30: Phone Ext.
Line 31: Email
Line 32: Employer
Line 33: Employer's FCC RN
DRAFT

Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act, 47 U.S.C. Secs. 502, 503(b),
or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.
FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT
Part 3 of the Commission’s Rules authorize the FCC to request the information on this form. The purpose of the information is to determine your
eligibility for certification as a health care provider. The information will be used by the Universal Service Administrative Company and/or the staff of
the Federal Communications Commission, to evaluate this form, to provide information for enforcement and rulemaking proceedings and to maintain a
current inventory of applicants, health care providers, billed entities, and service providers. No authorization can be granted unless all information
requested is provided. Failure to provide all requested information will delay the processing of the application or result in the application being returned
without action. Information requested by this form will be available for public inspection. Your response is required to obtain the requested
authorization.
The public reporting for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you have
any comments on this burden estimate, or how we can improve the collection and reduce the burden it causes you, please write to the Federal
Communications Commission, AMD-PERM, Paperwork Reduction Act Project (3060-0804), Washington, DC 20554. We will also accept your comments
regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to pra@fcc.gov. PLEASE DO NOT SEND YOUR
RESPONSE 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 if we fail to provide you with this notice. This collection
has been assigned an OMB control number of 3060-0804.
THE FOREGOING NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. 552a(e)(3) AND THE PAPEWORK
REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.
DRAFT

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