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FCC Form 463

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Released: August 5, 2014
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FCC Form 463

OMB Approved 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 1: RHC Invoice Number

Line 6: Vendor/Applicant Invoice

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 Two: Eligible Expenses

Block Three: Dates, Quantities, and Costs

Block Four: Calculation of

Support

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

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OMB Approved 3060-0804

Estimated time per response: 1 hour

Block Five: Supporting Documentation

Line 10: Applicants and/or vendor may, if they so choose, 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 supporting documentation, the applicant and vendor will ensure that USAC

has such documentation 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 understand that the vendor must apply the amount submitted, approved, and paid by USAC (Column P - USF support amount

to be Paid) to the billing account of the health care provider(s) and FRN/FRN IDs listed on this invoice.

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

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OMB Approved 3060-0804

Estimated time per response: 1 hour

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.

Note: We are currently transitioning our documents into web compatible formats for easier reading. We have done our best to supply this content to you in a presentable form, but there may be some formatting issues while we improve the technology. The original version of the document is available as a PDF, Word Document, or as plain text.

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