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FCC Form 498 & Instructions

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Released: April 29, 2014
FCC FORM 498




OMB 3060-0824


Instructions for Completing the Service Provider

Identification Number and Contact Information Form



The FCC Form 498 is used to collect contact, remittance, and payment information for
service providers that receive support from the federal universal service programs. For
greater flexibility, this form allows service providers to use the same information for all of
the programs, different contact and remittance information for each of the four programs,
or multiple contact and remittance information. Please report any changes to this
information on a revised FCC Form 498 to prevent any delays in notification and the
timeliness of disbursements.

I. Introduction

On May 8, 1997, the Federal Communications Commission (the Commission) released a
Report and Order on Universal Service in CC Docket No. 96-45 that established new
federal universal service fund, consistent with the universal service provisions contained in
section 254 of the Communications Act of 1934, as amended.

The Commission appointed the Universal Service Administrative Company
(USAC) administrator of the federal universal service fund and disburses funds for the
High Cost, Low Income, Rural Health Care, and Schools and Libraries Programs. One of
the functions of USAC is to provide a means for the billing, collection, and disbursement of
funds for all four programs.

Pursuant to 47 C.F.R. §§ 54.202, 54.301, 54.303, 54.307, 54.309, 54.311, 54.407,
54.422, 54.515, 54.679, 54.702, 54.802, and 54.902, USAC must obtain information
relating to service provider name, address, telephone number, Federal Employee
Identification Number (Federal EIN or tax ID number), contact names and telephone
numbers, billing, and collection information.

To that end, the Commission and USAC have developed a Service Provider Identification
Number and Contact Information Form, FCC Form 498, to collect this information from
service providers that receive support from the High Cost, Low Income, Rural Health
Care, and Schools and Libraries Programs.

This document provides instructions for completing the FCC Form 498. Each service
provider that receives federal universal service support under any of the four programs
must complete this form. First time applicants will be assigned a Service Provider
Identification Number (SPIN). This form will be used to collect the following information:
service provider name, address, phone numbers, e-mail addresses, contact names, and
billing and collection information. USAC will use this information to administer the billing,
collection, and disbursement operations of the federal universal service programs.


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FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824



II. FILING REQUIREMENTS AND GENERAL INSTRUCTIONS

A.

Who Should File the FCC Form 498


All service providers that participate in the High Cost, Low Income, Rural Health Care, or
Schools and Libraries Universal Service Programs must file FCC Form 498 to receive
disbursement payments.

Service providers should complete an FCC Form 498 in order to:

 Apply for a new SPIN.
 Revise an existing FCC Form 498.
 Consolidate, merge, or deactivate existing SPINs due to a merger, acquisition, or
consolidation of companies.
 Deactivate a SPIN and end participation in the federal universal service programs.
High Cost and Low Income program recipients must comply with 47 C.F.R. §
54.205 if relinquishing High Cost or Low-Income federal universal service support.

USAC will rely on the data provided in this form to disburse federal universal service
support consistent with the specifications of the service provider. This form allows service
providers to specify which addresses and payment information to use for each of the
programs in which they participate. For example, service providers participating in all four
programs may use a single financial institution and remittance contact for all support
payments. Other service providers may wish to have federal universal service program
payments sent to different financial institutions. Such service providers would follow
directions provided below to specify a separate remittance contact and financial institution
information for each of the programs in which they participate.

Further, the information in this form will enable certain service providers to offset
payments from the Schools and Libraries and/or Rural Health Care Programs against any
federal universal service contribution obligations. Contributors are companies that are
obligated to make payments to federal universal service. Each contributor and each
contributor’s business unit should complete the FCC Form 498. For each contributor or
business unit, USAC will assign a number upon receipt of a complete and correct FCC
Form 498. Copies of the FCC Form 498 may be reproduced and completed for as many
business units as are providing service.

B.

When and Where to File


Service providers must submit the FCC Form 498 before support payments will be
authorized. Original applications must be sent to:

USAC Customer Operations, Forms Processing

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FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

Attn: FCC Form 498
2000 L Street, N.W. Suite 200
Washington, DC 20036


Revisions to the FCC Form 498 can be filed electronically at:

http://www.usac.org/sp/about/498/default.aspx

C.

Where to Get More Information


Please direct any questions about completing this form to USAC via:

Internet at: http://www.usac.org/sp/tools/forms.aspx
E-mail at: CustomerSupport@usac.org
Telephone at: 888-641-8722 or Fax 888-637-6226


III. SPECIFIC INSTRUCTIONS


The following section describes the service provider information that should be provided
on the FCC Form 498.

A.

Form Overview

Indicate, by checking the appropriate box, the action being requested with the submission
of this form. For an original application, all fields must be completed. To initiate revisions,
all lines in Blocks 1-3 and 17-18 must be completed. FCC Form 498 is USAC’s official
record of contact and remittance information. Service providers, therefore, must keep the
information in this form current. Failure to maintain current information may affect the
timeliness of payment.

THE FOLLOWING 4 OPTIONS MUST BE CERTIFIED BY A COMPANY OFFICER:


1. Original Application for SPIN: Please check this box if this is the company’s initial
FCC Form 498.

2. Revision to Existing FCC Form 498 on file with USAC: Please check this box if this
is a revision to an existing FCC Form 498 on file with USAC. If it is a revision, please
include the company’s previously assigned SPIN.

3. Request for SPIN Merger/Consolidation: Please check this box to consolidate the
activity of multiple SPINs into one SPIN, or merge a SPIN into your SPIN due to an
acquisition or merger. Additional documentation is required. Please see Appendix A on
page 19 of the instructions for additional information.

4. Request for SPIN Deactivation: Please check this box to discontinue participation in
all federal universal service programs and deactivate the SPIN in its entirety. High Cost
and Low Income recipients must comply with 47 C.F.R. § 54.205 if relinquishing High Cost
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FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

or Low Income federal universal service support. Additional documentation is required.
Please see Appendix A on page 19 of the instructions for additional information.

Service Provider Identification Number (SPIN):
Leave this field blank if this is the initial
submission of an FCC Form 498. USAC will process the form within seven to 10 business
days of receipt and will assign a SPIN to the company. Within 48 hours after processing
has been completed, USAC will notify the company of the assigned SPIN.

For all subsequent submissions of FCC Form 498 (e.g., revisions to original data), please
include your assigned SPIN. Revisions to previously filed information cannot be processed
without the SPIN.

FCC Form 499 Filer ID:

Companies who are required to file the FCC Form 499 must
provide the FCC Form 499 Filer ID (Telecom Relay Service (TRS) Company Code) as it
appears on the Telecommunications Reporting Worksheet FCC Form 499. This must be
indicated for all companies that are required to file the FCC Form 499.

B.

Block 1: General Company Information


Block 1 requires you to identify the legal name and address of the service provider.

Item (1) Company Name:

Provide the full legal name of the company providing service
as it appears on articles of incorporation, registration, or other legal documents.

Item (2) Name Company Is Doing Business As (DBA) or Formerly Known
As (FKA):

Provide the name currently used by the service provider, or if this form effects
a name change, provide the name formerly used.

Item (3) Affiliated Entities: Check this box if this SPIN has or maintains affiliated
entities as defined in Section III.E


Items (4, 5, 6, 7, & 8) Service Provider’s Address:

Provide the service provider’s full
mailing address, street address or route number, city, state, and zip code. Do not include
a post office box. USAC will reject any FCC Form 498 that uses a post office box.

C. Block 2: General Contact Information


Block 2 requires the contact information for the individual preparing this form. The General
Contact is the point of contact for questions regarding billing, collection, and disbursement
related matters. The General contact is also designated as the service provider’s main
point of contact for the e-file system, and in addition to the officer on file, may access the
additional forms for the universal service support programs, and acts as the service
provider’s main point of contact for the organization’s authorized e-file users. The General
Contact can change remittance information for any of the four programs.

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FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

Items (9, 10, 11, & 12) General Contact Information:

Provide the name, title, phone
number, and fax number for the person that should be contacted with questions regarding
the billing, collection, and disbursement of funds for the service provider. Only the
General Contact or an Officer of the company is permitted to make revisions to the FCC
Form 498, but the Officer listed in Block 18 must certify any revisions.

Items (13, 14, 15 16, 17, & 18) Address and E-Mail Address of General Contact:


Provide the General Contact’s full mailing address, street address or route number, city,
state, zip code, and e-mail address. Please do not use a post office box. USAC will reject
any FCC Form 498 that uses a post office box. A confirmation notice will be sent to the e-
mail address listed in Block 2. The e-mail address must be specific to the General
Contact. Generic e-mail addresses are not accepted in this block. USAC will reject all
forms with a generic e-mail address.

D. Block 3: Federal EIN, DUNS and FCC Registration Number


Block 3 requires the service provider’s Federal Employer Identification Number (Federal
EIN or tax ID number), business structure, Dunn and Bradstreet Identification Number
(DUNS), and FCC Registration Number (CORES ID).

Item (19) Federal EIN:

Enter the service provider’s Federal EIN. Please do not use
individual social security numbers for the Federal EIN. For companies required to indicate
their 499 Filer ID, the Federal EIN listed on the FCC Form 498 must match the Federal
EIN listed on the FCC Form 499.

Item (20) Business Structure:

Check one of the three boxes indicating whether the
service provider is a corporation, partnership or other.

Item (21) DUNS:

Enter the service provider’s nine digit DUNS number.

Item (22) FCC Registration Number:

Enter the service provider’s nine digit FCC
Registration number (CORES ID)..


Supplemental Page for Companies with Affiliate Relationships


E. Block 4: Affiliate Company Information


Please complete this section if you checked the box on item (3) on page 1 indicating that
your company maintains affiliate relationships as defined in section 3(1) of the
Communications Act.

“The term "affiliate" means a person that (directly or indirectly) owns or controls, is owned
or controlled by, or is under common ownership or control with, another person. For
purposes of this paragraph, the term "own" means to own an equity interest (or the
equivalent thereof) of more than 10 percent.”
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FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824


Please list the SPIN number as well as the name of affiliated companies as defined
above.

If your organization has more than twenty two (22) affiliates, please submit an additional
sheet(s) to USAC.



High Cost Program


F. Block 5: High Cost Financial Institution and Remittance Information


Please complete this section only if your company receives support from the High Cost
Program, including the Connect America Fund and Mobility Fund component of the
Connect America Fund. Block 5 requires financial institution and remittance information
that will be used to direct any High Cost payments and remittance information. Financial
institution information is required. Electronic payment of universal service support
payments is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-
134, 110 Stat. 1321-358. If the remittance contact is the same as the General Contact in
Block 2, please check the box to indicate this in Block 5 and continue with lines 33 to 35.

Check the box at the top of the page to maintain the SPIN (Service Provider
Identification Number) but cease participation in the High Cost Program. High Cost
recipients must comply with 47 C.F.R. § 54.205 if relinquishing High Cost universal
service support for this program.

Item (23) High Cost Remittance Company Name:

Provide the name of the company
that will receive payment for High Cost payments if different than the company indicated in
item 1.

Items (24 & 25) High Cost Remittance Contact Name and Title:

Provide the name and
title of the High Cost remittance contact person who will answer questions regarding the
remittance of High Cost Support payments to the service provider. All High Cost
remittance statements will be sent to the High Cost remittance contact’s attention.

Items (26, 27, 28, 29 & 30) Address of High Cost Remittance Contact:

Provide the full
mailing address, street address or route number, city, state, and zip code of the High Cost
remittance contact. Please do not use a post office box. USAC will reject any FCC Form
498 that uses a post office box. This is the address to which High Cost program
remittance statements will be sent.

Item (31 & 32) Telephone and Fax Number of High Cost Remittance Contact:

Provide
the telephone, extension and fax number of the High Cost remittance contact.

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FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

Item (33) Name of High Cost Remittance Financial Institution:

High Cost Program
payments are made via Automatic Clearing House (ACH), and financial institution
information is required to process such payments. If you do not provide this information,
you will not receive payment.

Items (34 & 35) High Cost Remittance Financial Institution Account Number and
Transit Number for ACH Payments:

Provide the ACH financial institution account
number and financial institution transit number. Please be sure that the transit number is
nine digits. If you do not provide this information, you will not receive payment.

Item (36) E-mail Address of High Cost Remittance Contact

: Provide the e-mail
address of the High Cost Program remittance contact. This e-mail address will be used for
your electronic remittance statements and outreach.

G. Block 6: Company Contact for High Cost Program


Please complete Block 6 only if a service provider receives support from the High Cost
Program. Block 6 requires the service provider’s High Cost contact information. If the
High Cost Program contact information is the same as that presented in Block 2, please
check the box to indicate this in Block 6 and continue onto the next block. Otherwise,
please complete the contact information in Block 5. The General Contact or an Officer of
the company is permitted to make revisions to the FCC Form 498, but the Officer listed in
Block 18 must certify any revisions.

Items (37, 38, 38, 40, 41, 42 & 43) Name and Address of High Cost Program Contact:


Provide the High Cost Program company contact person’s name, title, mailing address,
street address or route number, city, state, and zip code. Please do not use a post office
box. USAC will reject any FCC Form 498 that uses a post office box. USAC will send all
High Cost Program correspondence to this address. The High Cost Program contact
should be an employee of the service provider. This High Cost Program contact is
authorized to request additional High Cost Program information related to this SPIN.

Items (44, 45, & 46) Phone Number, Fax, and E-Mail Address of High Cost Program
Contact

: Provide the phone number, fax number, and e-mail address of the High Cost
Program contact person who will receive correspondence and answer questions regarding
the High Cost Program.

Low Income Program


H. Block 7: Low Income Financial Institution and Remittance Information


Please complete this section only if your company receives support from the Low Income
Program, also known as the Lifeline Program. Block 7 requires financial institution and
remittance information that will be used to direct any Lifeline Program payments and
remittance information. Financial institution information is required. Electronic payment of
universal service support payments is mandated by the Debt Collection Improvement Act
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FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

of 1996, Pub. Law 104-134, 110 Stat. 1321-358. If the remittance contact is the same as
the General Contact in Block 2, please check the box to indicate this in Block 7. Continue
in Block 7 with lines 57 to 59.

Check the box at the top of the page to maintain the SPIN (Service Provider
Identification Number) but cease participation in the Lifeline Program. Lifeline
recipients must comply with 47 C.F.R. § 54.205 if relinquishing Lifeline federal
universal service support

.


Item (47) Low Income Remittance Company Name:

Provide the name of the company
that will receive payment for Lifeline Program payments if different than the company
indicated in item 1.


Items (48 & 49) Low Income Remittance Contact Name and Title:

Provide the name
and title of the Lifeline Program remittance contact person that will answer questions
regarding the remittance of Lifeline Program payment to the service provider. All Lifeline
Program remittance statements will be sent to the remittance contact person’s attention.

Items (50, 51, 52, 53, & 54) Address of Low Income Remittance Contact:

Provide the full mailing address, street address or route number, city, state, and zip code
of the Lifeline Program remittance contact for the service provider. Please do not use a
post office box. USAC will reject any FCC Form 498 that uses a post office box. This is the
address to which Lifeline Program remittance statements will be sent.

Item (55 & 56) Telephone and Fax Number of Low Income Remittance Contact:


Provide the telephone number, extension and fax number of the Lifeline Program
remittance contact.

Item (57) Name of Low Income Remittance Financial Institution:

Lifeline Program
payments are made via electronic Automatic Clearing House (ACH), and financial
institution information is required to process such payments. If you do not provide this
information, you will not receive payment.

Items (58 & 59) Low Income Remittance Financial Institution Account Number and
Transit Number for ACH Payments:

Provide the ACH financial institution account
number and financial institution transit number. Please be sure that the transit number is
nine digits. If you do not provide this information, you will not receive payment.

Item (60) E-mail Address of Low Income Remittance Contact

: Provide the e-mail
address of the Lifeline Program remittance contact. This e-mail address will be used for
your electronic remittance statements and outreach.

I. Block 8: Company Contact for Low Income Program


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FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

Please complete this block only if your company participates in the Lifeline Program.
Block 8 requires completion of the Lifeline Program contact information. If the Lifeline
Program contact information is the same as that presented in Block 2, please check the
box in Block 8 and continue onto the next block. Otherwise, please complete the Lifeline
Program contact information in Block 8. The General Contact or an Officer of the
company is permitted to make revisions to the FCC Form 498, but the Officer listed in
Block 18 must certify any revisions.

Items (61, 62, 63, 64, 65, 66 & 67) Name, Title, and Address of Service Provider’s
Low Income Program Contact:

Provide the Lifeline Program contact person’s name,
title, mailing address, street address or route number, city, state, and zip code. Please do
not use a post office box. USAC will reject any FCC Form 498 that uses a post office box.
USAC will send all Lifeline Program correspondence to this address. The Lifeline Program
contact should be an employee of the service provider. This Lifeline Program contact is
authorized to request additional Lifeline Program information related to this SPIN.

Items (68, 69, & 70) Phone Number, Fax, and E-mail Address of Low Income
Program Contact:

Provide the phone number, fax number, and e-mail address of the
Lifeline Program contact person who will receive Lifeline Program correspondence and
answer questions regarding the Lifeline Program.





J. Block 9: High Cost and Low Income Study Area Code (SAC)/SPIN

Association


Companies that do not receive support from the High Cost and Low Income
Programs and do not have SAC assignments may proceed to Block 10.


For providers that receive support from the High Cost and Low Income Programs, please
list the Study Area Codes (SACs) you wish to have associated with the Service Provider
Identification Number (SPIN) data.

Box One (1):

Check this box if you are not changing the existing SAC data currently on
file with USAC.

If you check this box, you may proceed to Block 10.



Box Two (2):

Check this box if you wish to update the SAC data currently on file with
USAC. Be sure to include all of the SACs you wish to associate with the SPIN.

SAC:

Please indicate the six (6) digit SAC.

SAC Company Name:

Please enter the name of the Company associated to the SAC.

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FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

Incumbent:

Check this box if the SPIN associated with this SAC is listed with USAC as
an Incumbent Carrier for that area.

Competitive

: Check this box if the SPIN associated with this SAC is listed with USAC as
a Competitive Carrier for that area.

If your organization has more than twenty two (22) SAC codes, please submit an
additional sheet with those codes to USAC.

Rural Health Care Program


K. Block 10: Rural Health Care Financial Institution and Remittance

Information





Please complete this section only if your company receives support from the Rural Health
Care Program. Block 10 requires financial institution and remittance information that will
be used to direct any Rural Health Care Program payments and remittance information.
Financial institution information is required. Electronic payment of universal service
support payments is mandated by the Debt Collection Improvement Act of 1996, Pub. Law
104-134, 110 Stat. 1321-358. If the remittance contact is the same as the General
Contact in Block 2, please check the box to indicate this in Block 10 and continue with
lines 81 to 83.

Check the box at the top of the page if to maintain your SPIN (Service Provider
Identification Number) but cease participation in the Rural Health Care Program.



Items (71) Rural Health Care Remittance Company Name:

Provide the name of the
company that will receive payment for Rural Health Care Program payments if different
than the company indicated in item 1.

Items (72 & 73) Rural Health Care Remittance Contact Name and Title:
Provide the name and title of the remittance contact person who will answer questions
regarding the remittance of Rural Health Care Program payments to the service provider.
All Rural Health Care Program remittance statements will be sent to the remittance
contact person’s attention.

Items (74, 75, 76,77 & 78) Address of Rural Health Care Remittance
Contact:

Provide the full mailing address, street address or route number, city, state, and
zip code of the Rural Health Care Program remittance contact. Please do not use a post
office box. USAC will reject any FCC Form 498 that uses a post office box. This is the
address to which Rural Health Care Program remittance statements will be sent.

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FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

Item (79 & 80) Telephone and Fax Number of Rural Health Care Remittance Contact:

Provide the telephone number, extension and fax number of the Rural Health Care
Program remittance contact.

Item (81) Name of Rural Health Care Remittance Financial Institution:

Rural Health
Care Program payments are made via electronic Automatic Clearing House (ACH), and
financial institution information is required to process such payments. If you do not
provide this information, you will not receive payment.

Items (82 & 83) Rural Health Care Remittance Financial Institution Account Number
and Transit Number for ACH Payments:

Provide the ACH financial institution account
number and transit number. Please be sure that the transit number is nine digits. If you do
not provide this information, you will not receive payment.

Item (84) E-mail Address of Rural Health Care Remittance Contact:

Provide the e-mail
address of the Rural Health Care Program remittance contact. This e-mail address will be
used for your electronic remittance statements and outreach.

L. Block 11: Company Contact for Rural Health Care Program


Please complete this section only if your company receives support from the Rural Health
Care Program. Block 11 requires completion of the Rural Health Care Program contact
information. If the Rural Health Care Program contact information is the same as that
presented in Block 2, please check the box to indicate this in Block 11 and continue onto
the next block. Otherwise, please complete the Rural Health Care Program contact
information in Block 11. The General Contact or an Officer of the company is permitted to
make revisions to the FCC Form 498, but the Officer listed in Block 18 must certify any
revisions.

Items (85, 86, 87, 88, 89, 90 & 91) Name, Title, and Address of Rural Health Care
Program Contact:

Provide the Rural Health Care Program contact person’s name, title,
mailing address, street address or route number, city, state, and zip code. Please do not
use a post office box. USAC will reject any FCC Form 498 that uses a post office box.
USAC will send all Rural Health Care Program correspondence to this address. The Rural
Health Care Program contact should be an employee of the service provider. This contact
is authorized to request additional Rural Health Care Program information related to this
SPIN.

Items (92, 93 & 94) Phone, Fax, and E-mail Address of Service Provider’s
Rural Health Care Program Contact

: Provide the phone number, fax number, and e-mail
address of the Rural Health Care Program contact person who will receive
correspondence and answer questions regarding the Rural Health Care Program.

Schools and Libraries Program Payments


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M. Block 12: Schools and Libraries Financial Institution and Remittance

Information


Please complete this section only if your company receives support from the Schools and
Libraries Program. Block 12 requires financial institution and remittance information that
will be used to direct any Schools and Libraries Program payments and remittance
information. Financial institution information is required. Electronic payment of universal
service support payments is mandated by the Debt Collection Improvement Act of 1996,
Pub. Law 104-134, 110 Stat. 1321-358. If the remittance contact is the same as the
General Contact in Block 2, please check the box to indicate this in Block 12 and continue
with lines 105 to 107.

Check the box at the top of the page to maintain your SPIN (Service Provider
Identification Number) but cease participation in the Schools and Libraries
Program.



Item (95) Schools and Libraries Remittance Company Name:

Provide the name of the
company that will receive payment for Schools and Libraries Program payments if
different than the company indicated in item 1.


Items (96 & 97) Schools and Libraries Remittance Contact Name and Title:


Provide the name and title of the Schools and Libraries Program remittance contact
person who will answer questions regarding the remittance of Schools and Libraries
Program payments to the service provider. All Schools and Libraries Program remittance
statements will be sent to the remittance contact person’s attention.

Items (98, 98, 100, 101 & 102) Address of Schools and Libraries Remittance
Contact:

Provide the full mailing address, street address or route number and city, state,
and zip code of the Schools and Libraries Program remittance contact. Please do not use
a post office box. USAC will reject any FCC Form 498 that uses a post office box. This is
the address to which Schools and Libraries Program remittance statements will be sent.

Item (103 & 104) Telephone and Fax Number of Schools and Libraries Remittance
Contact:

Provide the telephone number, extension and fax of the Schools and Libraries
Program remittance contact.

Item (105) Name of Schools and Libraries Remittance Financial Institution:

Schools
and Libraries Program payments are made via electronic Automatic Clearing House
(ACH), and financial institution information is required to process such payments. If you
do not provide this information, you will not receive payment.

Items (106 & 107) Schools and Libraries Remittance Financial Institution Account
Number and Transit Number for ACH Payments:

Provide the ACH financial institution
account number and transit number. Please be sure that the transit number is nine digits.
If you do not provide this information, you will not receive payment.
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FCC Form 498 – AUGUST 2013

FCC FORM 498




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Alternative Financial and Banking Information for BEAR (Billed Entity Applicant

Reimbursements)


Complete Lines 108-110, if you wish your Schools and Libraries Program payments for
applicant reimbursements be paid to a separate banking account.

Check the box to utilize the same banking information as listed in lines 105-107.


Item (108) Name of Alternative Schools and Libraries Remittance Financial
Institution:

Schools and Libraries Program payments are made via electronic Automatic
Clearing House (ACH), and financial institution information is required to process such
payments. If you do not provide this information, USAC will default to the banking
information listed in lines 105-107.

Items (109 & 110) Alternative Schools and Libraries Remittance Financial Institution
Account Number and Transit Number for ACH Payments:

Provide the ACH financial
institution account number and transit number. Please be sure that the transit number is
nine digits. If you do not provide this information, USAC will default to the banking
information listed in lines 105-107.


Item (111) E-mail Address of Schools and Libraries Remittance Contact:


Provide the e-mail address of the Schools and Libraries Program remittance contact. This
e-mail address will be used for your electronic remittance statements and outreach.

N. Block 13: Company Contact for Schools and Libraries Program


Please complete this block only if your company receives support from the Schools and
Libraries Program. Block 13 requires completion of the Schools and Libraries Program
contact information. If the Schools and Libraries Program contact information is the same
as that presented in Block 2, please check the box in Block 13 and continue onto the next
block. Otherwise, please complete the contact information in Block 13. The General
Contact or an Officer of the company is permitted to make revisions to the FCC Form 498,
but the Officer listed in Block 18 must certify any revisions.


Items (112,113,114,115, 116, 117 & 118) Name, Title, and Address of Service
Provider Schools and Libraries Program Contact:

Provide the Schools and Libraries
Program contact person’s name, title, mailing address, street address or route number,
city, state, and zip code. Please do not use a post office box. USAC will reject any FCC
Form 498 that uses a post office box. USAC will send all Schools and Libraries Program
correspondence to this address. This contact should be an employee of the service
provider. This contact is authorized to request additional Schools and Libraries Program
information related to this SPIN.

Page 13 of 20





FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

Items (119, 120 &121) Phone, Fax, and E-Mail Address of Service Provider
Schools and Libraries Program Contact

: Provide the phone number, fax number, and
e-mail address of the Schools and Libraries Program contact person who will receive
correspondence and answer questions regarding the Schools and Libraries Program.

O. Block 14: Offsetting Disbursement Payments against Federal Universal

Service Contribution Obligations For Rural Health Care Participants


This block only relates to telecommunications carriers participating in the Rural Health
Care Program. In accordance with section 54.679 of the Commission’s rules regarding
Rural Health Care Program support, a telecommunications carrier may choose to offset
the amount eligible for support under the Rural Health Care Program against its federal
universal service contribution obligation. A telecommunications carrier must have an FCC
Form 499 Filer ID number to offset its Rural Health Care Program disbursement payments
against its federal universal service contribution obligation. To obtain an FCC Form 499
Filer ID number, visit www.usac.org/sp/tools/forms.aspx and select FCC Form 499. You
do not need an FCC Form 499 Filer ID number to be issued a SPIN.

Item (122) Offset Indicator:

The service provider must indicate (by checking
the box or leaving it blank) whether or not it is requesting to have its Rural Health Care
invoice payments offset against the service provider’s federal universal service
contribution obligations.


P. Block 15: Certification to Assist Health Care Providers


This block only relates to service providers participating in the Healthcare Connect Fund.
In accordance with section 54.640(b) of the Commission’s rules, service providers
participating in the Healthcare Connect Fund must certify, as a condition of receiving
support, that they will provide to health care providers, on a timely basis, all information
and documents regarding supported equipment, facilities, or services that are necessary
for the health care provider to submit required forms or respond to Commission or USAC
inquiries. USAC may withhold disbursements for the service provider if the service
provider, after written notice from USAC, fails to comply with this requirement.


Item (123) Healthcare Connect Fund Certification:

The service provider must certify (by
checking the box) that it will provide to health care providers, on a timely basis, all
information and documents regarding supported equipment, facilities, or services that are
necessary for the health care provider to submit required forms or respond to FCC or
USAC inquiries.

Q. Block 16: Offsetting Disbursement Payments against Federal Universal

Service Contribution Obligations for Schools and Libraries Participants


This block only relates to telecommunications carriers participating in the Schools and
Page 14 of 20





FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

Libraries Program. In accordance with section 54.515 of the Commission’s rules regarding
Schools and Libraries Program support, a telecommunications carrier may choose to
offset the amount eligible for support under the Schools and Libraries Program against its
federal universal service contribution obligation. A telecommunications carrier must have
an FCC Form 499 Filer ID number to offset its Schools and Libraries Program
disbursement payments against its federal universal service contribution obligation. To
obtain an FCC Form 499 Filer ID number, visit www.usac.org/sp/tools/forms.aspx and
select FCC Form 499. You do not need an FCC Form 499 Filer ID number to be issued a
SPIN.


Item (124) Offset Indicator:

The service provider must indicate (by checking
the box or leaving it blank) whether or not it is requesting to have its Schools and Libraries
Program invoice payments offset against the service provider’s federal universal service
contribution obligations.


R. Block 17: Principal Communications Business Types

Block 15 requires the selection of a Principal Communications Business Code.

Principal Communications Business: Mark the boxes that describe the
telecommunications activity or activities of the organization. If more than one is
appropriate, please label the activities in order of importance to the company’s business,
e.g., enter a “1” in the box for the type of entity that represents the most important part of
the organization’s business, enter a “2” in the box that represents the next most important
part, etc. Select no more than 5 of the following categories:

Code


Description


Audio Bridging
Allows end users to transmit a call (using telephone lines), to a
Provider
point specified by the user (the conference bridge), without
change in the form or content of the information as sent and
received (voice transmission).

Coaxial Cable
Uses coaxial cable (cable TV) facilities to provide local exchange
services or telecommunications services that link customers with
interexchange facilities, local exchange networks, or other
customers.

Non-Interconnected
Provides non-interconnected VoIP service, which is a service
VoIP
that (i) enables real-time voice communications that originate
from or terminate to the user’s location using Internet protocol or
any successor protocol and (ii) requires Internet protocol
compatible customer premises equipment, but (iii) is not an
interconnected VoIP service.

Page 15 of 20





FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

Private Service
Offers telecommunications to others for a fee on a non-common
Provider
carrier basis. This would include a company that offers excess
capacity on a private system that it uses primarily for internal
purposes. This category does not include SMR or Satellite
Service Providers.

Toll Reseller
Provides long distance telecommunications services primarily by
reselling the long distance telecommunications services of other
carriers.

Incumbent LEC
(Incumbent Local Exchange Carrier) Provides local exchange
service. An incumbent LEC generally is a carrier that was at one
time franchised as a monopoly service provider or has since
been found to be an incumbent LEC. See 47 U.S.C. § 251(h).

Operator Service
Serves customers needing the assistance of an operator to
Provider
complete calls, or needing alternate billing arrangements, such
as collect calling.

Satellite Service
Provides satellite space segment or earth stations that are used
Provider
for telecommunications service.

Wireless Data
Provides mobile or fixed wireless data services using wireless
technology. This category includes the provision of wireless data
services by resale.

CAP/CLEC (Competitive
Access Provider/Competitive Local Exchange
Carrier) Competes with incumbent local exchange carriers
(LECs) to provide local exchange services, or
telecommunications services that link customers with
interexchange facilities, local exchange networks, or other
customers, other than Coaxial Cable providers.

Interconnected VoIP Provides “interconnected VoIP service,” which is a service that
(1) enables real-time, two-way voice communications; (2)
requires a broadband connection from the user’s location; (3)
requires Internet protocol compatible customer premises
equipment (CPE); and (4) permits users generally to receive
calls that originate on the public switched telephone network and
to terminate calls to the public switched telephone network.

Paging and
Provides wireless paging or wireless messaging services. This
Messaging
category includes the provision of paging and messaging

services by resale.

SMR (Dispatch)
Primarily provides dispatch services and mobile services other
Page 16 of 20





FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

than wireless telephony. While dispatch services may include
interconnection with the public switched network, this category
does not include carriers that primarily offer wireless telephony.
This category includes LTR dispatch or community repeater
systems.

Shared-Tenant
Manages or owns a multi-tenant location that provides
Service Provider /
telecommunications services or facilities to the tenants for a fee.
Building LEC


Cellular/PCS/SMR
(Cellular, Personal Communications Service, or Specialized
Mobile Radio Service Provider) Primarily provides wireless
telecommunications services (wireless telephony). This category
includes all providers of real-time two-way switched voice
services that interconnect with the public switched network,
including providers of prepaid phones and public coast stations
interconnected with the public switched network.

Interexchange
Provides long distance telecommunications services
Carrier
substantially through switches or circuits that it owns or leases.

Payphone Service
Provides access to telephone networks through pay telephone
Provider
equipment, special teleconference rooms, etc. Payphone
service providers are also referred to as pay telephone
aggregators.

Local Reseller
Provides local exchange or fixed telecommunications services by
reselling services of other carriers.

Internet Service
Provides access to the Internet.
Provider


Non-Traditional
Company that does not provide telecommunications services.
Provider (NTP)


S. Block 18: Authorized Contact Signature



Block 16 requires the signature of the Company Officer authorized to certify that the data
set forth in the FCC Form 498 is true, accurate, and complete. Incomplete information or
incorrect filling of this form will result in it being rejected to the company and the form will
not be processed. Persons willfully making false statements on this form can be punished
by fine or forfeiture, under the Communications Act, as amended, 47 U.S.C. secs. 220(e),
502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C.
Sec. 1001. In addition, Block 16 requires the date, printed name, title, and e-mail address
of the Company Officer certifying the form. The e-mail address will be used for return
Page 17 of 20





FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

confirmation and related correspondence only. Generic e-mail addresses are not
accepted in this block. USAC will reject all forms with a generic e-mail address.

Companies may provide a General Contact in Block 2 separate from the Company Officer.
This individual will be able to retrieve the FCC Form 498 information on file with USAC as
well as be given access to USAC’s on-line filing system. This person will also be able to
input new SPIN data for Officer certification.

Incomplete information or incorrect filing of the form will result in it being rejected
to the company and the form will not be processed.

Notice on e-certification:

Authorized Officers and General Contacts may be granted
access to the on-line FCC Form 498 system. This will allow service providers to manage
their FCC Form 498 data on-line. For certification, access requirements and additional
information, please visit http://www.usac.org/sp/tools/forms.aspx or contact USAC via
telephone at 888-641-8722. Save time, avoid problems. File electronically at
https://forms.usac.org

Notice:

The Federal Communications Commission (the Commission) has designated the
Universal Service Administrative Company (USAC) as administrator of federal universal
service. One of the functions of USAC is to provide a means for billing, collection, and
disbursement of funds for the various federal universal service programs. In an effort to
implement these requirements and obligations, the Commission has adopted this
collection of information. Pursuant to the Commission’s rules, 47 C.F.R. §§ 54.202,
54.301, 54.303, 54.307, 54.309, 54.311, 54.407, 54.422, 54.515, 54.611, 54.702, 54.802,
and
54.902, USAC must obtain information relating to service provider name and address,
telephone number, Federal EIN, contact names and telephone numbers, billing, collection,
and disbursement information. Each service provider receiving federal universal service
support from the High-Cost, Low-Income, Rural Health Care, or Schools and Libraries
programs, should complete the FCC Form 498. USAC will use this information in
administering the billing, collection, and disbursement operations of federal universal
service.

Reminder: 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 Office of Management and Budget (OMB) control
number. This collection has been assigned an OMB control number of 3060-0824.

The Commission is authorized under the Communications Act of 1934, as
amended, to collect the information we request in this form. We will use the information
that you provide for federal universal service billing, collection, and disbursement
purposes. If we believe there may be a violation or potential violation of a state or federal
statute, or of a Commission regulation, rule, or order, your form may be referred to the
federal, state, or local agency responsible for investigating, prosecuting, enforcing, or
implementing the statute, rule, regulation, or order. In certain cases, the information in
Page 18 of 20





FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824

your form may be disclosed to the Department of Justice, a court, or other governmental
or adjudicative bodies when (a) the Commission; or (b) any employee of the
Commission; or (c) the United States government, is a party to a proceeding before the
body or has an interest in the proceeding. In addition, consistent with the Communications
Act of 1934, the Commission regulations and orders, the Freedom of Information Act, 5
U.S.C. § 552, or other applicable law, information provided in or submitted with this form
or in response to subsequent inquiries may be disclosed to the public.

If you owe a past due debt to the federal government, the information you provide also
may be disclosed to the Department of the Treasury Financial Management Service, other
federal agencies, and/or your employer to offset your salary, IRS tax refund, or other
payments to collect that debt. The Commission also may provide this information to these
agencies through the matching of computer records where authorized.

If you do not provide the information we request on the form, the Commission may delay
processing you application, or may return your application without action.

This Notice is required by the Paperwork Reduction Act of 1995, P.L. 104-13, 44 U.S.C.
Section 3501 et seq. We have estimated that each response to this collection of
information will take, on average, 1.5 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 how we can improve the collection and reduce the burden it causes you,
please write to the Federal Communications Commission, AMD-PERM, Washington, D.C.
20554, Paperwork Reduction Project (3060-0824). We also will accept your comments via
Internet if you send them to PRA@fcc.gov. Please DO NOT SEND COMPLETED FORMS
TO THIS ADDRESS.


Page 19 of 20





FCC Form 498 – AUGUST 2013

FCC FORM 498




OMB 3060-0824


Appendix A:


SPIN Merger/Consolidation Requirements.


To successfully process a Merger/Consolidation request, USAC requires the following
information:

 Copies of sale, acquisition or merger documentation indicating the date of sale,
clearly demonstrating the surviving organization’s unfettered right to all SPIN data
and activity.

 Only the first and last page (signature page) of the FCC Form 498 is required for
SPINS that will be impacted by a merger/consolidation request.

 A complete FCC Form 498 for the SPIN that will be the replacement/surviving
SPIN.

 A federal W-9 form indicating the Federal EIN (or Tax ID number).

 Updated FCC Form 499 Filer ID information (where applicable).


SPIN Deactivation Requirements.


To successfully process a SPIN Deactivation, USAC requires the following information:

 A brief cover letter explaining the deactivation, and any supporting documents.

 Only the first and last page (signature page) of the FCC Form 498 is for a SPIN
being deactivated.

 Updated FCC Form 499 Filer ID information (where applicable).



Page 20 of 20





FCC Form 498 – AUGUST 2013

Save time, avoid problems. File electronically at http://www.usac.org/sp/about/498/default.aspx


FCC Form 498
OMB 3060-0824

Service Provider Identification Number and General Contact Information Form


Estimated Average Burden Hours Per Response: 1.5 hours

FCC Form 498 is used to collect contact and remittance information for service providers that receive support from the Federal universal service support programs. For greater flexibility, this form
allows service providers to use the same general contact information for all their contacts and the same remittance data collected for each of the four programs or multiple contact and remittance
information. Please report any changes to this information on a revised FCC Form 498 to prevent any delays in notification and the timeliness of disbursements. 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.

Please read instructions, located at: http://usac.org/sp/tools/forms.aspx, before beginning this application.

Please check one box below

See Instruction Section III.A


Original Application for SPIN
Revision to existing FCC Form 498 on file with USAC
Request for SPIN Merger/Consolidation
Request for SPIN Deactivation

See Instruction Section III.A


Service Provider Identification Number (SPIN)

(To be inserted by USAC for first time applicants. Required for subsequent revisions.)
499 Filer ID
(Required if your company is required to file the FCC Form 499)

Block 1: General Company Information [All Fields REQUIRED]

See Instruction Section III.B
1
Company Name
2
Name Company is Doing Business As (DBA) or Formerly Known As (FKA)
3
Check this Box if the Company is part of or maintains affiliate companies and complete page 2.
4
Street Address
5
Address Line 2
6
7
8
City
State
Zip Code + 4

Block 2: General Contact Information [All Fields REQUIRED]

See Instruction Section III.C


9 First:
Middle Initial:
Last:
10
General Contact (Company Preparer Name)
Title
11 (
)
12 (
)
Phone Number
Ext.
Fax Number
13
Street Address
14
Address Line 2
15
16
17
City
State
Zip Code + 4
18
E-mail Address

Block 3: Federal EIN, DUNS and FCC Registration Number [All Fields REQUIRED]

See Instruction Section III.D


19
20
Corporation
Partnership
Other
Enter Federal Employer Identification Number
(Check applicable corporate structure.)
(Federal EIN or Tax ID Number)
21
22
Enter Dunn and Bradstreet Number (DUNS)
FCC Registration Number (CORES ID)
Page 1 of 9
FCC Form 498-August 2013

This is a Supplemental Page for Companies with Affiliate Relationships

Block 4: Affiliate Company Information

See Instruction Section III.E


Please list all companies with which this SPIN is affiliated. The term "affiliate" means a person that (directly or indirectly) owns
or controls, is owned or controlled by, or is under common ownership or control with, another person. For purposes of this paragraph,
the term "own" means to own an equity interest (or the equivalent thereof) of more than 10 percent.


Affiliate SPIN Number

Affiliate Company Name

(Attach additional copies of this page if necessary)
Page 2 of 9
FCC Form 498-August 2013

This page is for High Cost Program participants only.

For more information about the High Cost Program, please refer to: http://www.usac.org/hc/

Block 5: High Cost Support Financial Institution and Remittance
Information [ALL Fields REQUIRED]

See Instruction Section III.F


Check this box to discontinue use of this SPIN for High Cost Support.


Financial institution information is required. Electronic payment of universal service support payments


is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.
Check this box if this information is the same as the General Contact information (Block 2) and complete lines 33-35.
23
Remittance Company Name, if different from Company Name
24 First:
Middle Initial:
Last:
25
Remittance Contact Name - Statements will be sent to Remittance Contact's attention
Title
26


Remittance Contact Address



27
Address Line 2
28
29
30

City
State
Zip Code + 4
31 (
)
32 (
)
Phone Number
Ext
Fax Number
33
Remittance Financial Institution for ACH or locked box transfer of funds (required)
34
35
Financial Institution Account Number for ACH (required)
ACH Financial Institution Transit Number - must be nine digits (required)
36
E-mail Address of Remittance Contact (Required if participating in the High Cost Program)

Block 6: Company Contact for High Cost Support

See Instruction Section III.G


Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 7.
37 First:
Middle Initial:
Last:
38
Contact Name for High Cost Program
Title
(Must be a company employee or designated representative)
39


Contact Address for High Cost Program




40
Address Line 2
41
42
43

City
State
Zip Code + 4
44 (
)
45 (
)
Phone Number
Ext
Fax Number
46
E-mail Address of High Cost Program Contact
Page 3 of 9
FCC Form 498-August 2013

This page is for Low Income Program participants only.

For more information about Low Income Support, please refer to: http://www.usac.org/li/

Block 7: Low Income Support Financial Institution and Remittance
Information [All Fields REQUIRED]

See Instruction Section III.H


Check this box to discontinue use of this SPIN for Low Income Support.


Financial institution information is required. Electronic payment of universal service support payments
is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.


Check this box if this information is the same as the General Contact information (Block 2) and complete lines 57-59.
47
Remittance Company Name, if different from Company Name
48 First:
Middle Initial:
Last:
49
Remittance Contact Name - Statements will be sent to Remittance Contact's attention
Title
50


Remittance Address



51
Address Line 2
52
53
54

City
State
Zip Code + 4
55 (
)
56 (
)
Phone Number
Ext
Fax Number
57
Remittance Financial Institution for ACH or locked box transfer of funds (required)
58
59
Financial Institution Account Number for ACH (required)
ACH Financial Institution transit Number - must be nine digits (required)
60
E-mail Address of Remittance Contact (Required if participating in the Low Income Program)

Block 8: Company Contact for Low Income Support

See Instruction Section III.I


Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 9.
61 First:
Middle Initial:
Last:
62
Contact address for Low Income Program
Title
(Must be a company employee or designated representative)
63


Contact Address for Low Income Program




64
Address Line 2
65
66
67

City
State
Zip Code + 4
68 (
)
69 (
)
Phone Number
Ext
Fax Number
70
E-mail Address of Low Income Program Contact
Page 4 of 9
FCC Form 498-August 2013

This is a Supplemental Page for Participants in the High Cost and Low Income Programs.

Block 9: High Cost and Low Income Study Area/SPIN Association

See Instruction Section III.J


This information will be used to associate the Study Area Codes (SAC) to this SPIN for the purposes of
High Cost and Low Income Support.


Check this box if there is no change to the SAC data on file.
Check this box if you are changing your organization's
SAC data currently on file with USAC.

Study Area Code (SAC)

SAC Company Name

Study Area Type

Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
Incumbent
Competitive
(Attach additional copies of this page if necessary)
Page 5 of 9
FCC Form 498-August 2013

This page is for Rural Health Care Support participants only.

For more information about Rural Health Care Support, please refer to: http://www.usac.org/rhc/

Block 10: Rural Health Care Support Financial Institution and Remittance
Information [ALL Fields REQUIRED]

See Instruction Section III.K


Check this box to discontinue use of this SPIN for Rural Health Care Support.


Financial institution information is required. Electronic payment of universal service support payments
is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.


Check this box if this information is the same as the General Contact information (Block 2) and complete lines 81-83.
71
Remittance Company Name, if different from Company Name
72 First:
Middle Initial:
Last:
73
Remittance Contact Name - Statements will be sent to Remittance Contact's attention
Title
74


Remittance Address



75
Address Line 2
76
77
78

City
State
Zip Code + 4
79 (
)
80 (
)
Phone Number
Ext
Fax Number
81
Remittance Financial Institution for ACH or locked box transfer of funds (required)
82
83
Financial Institution Account Number for ACH (required)
ACH Financial Institution transit Number - must be nine digits (required)
84
E-mail Address of Remittance Contact (Required if participating in the Rural Health Care Program)

Block 11: Company Contact for Rural Health Care Support

See Instruction Section III.L


Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 12.
85 First:
Middle Initial:
Last:
86
Contact Name for Rural Health Care Program
Title
(Must be a company employee or designated representative)
87


Contact Address for Rural Health Care Program




88
Address Line 2
89
90
91

City
State
Zip Code + 4
92 (
)
93 (
)
Phone Number
Ext
Fax Number
94
E-mail Address of Rural Health Care Program Contact
Page 6 of 9
FCC Form 498-August 2013

This page is for Schools and Libraries Program participants only.

For more information about the Schools and Libraries Program, please refer to: http://www.usac.org/sl/

Block 12: Schools and Libraries Support Financial Institution and
Remittance Information [ALL Fields REQUIRED]

See Instruction Section III.M


Check this box discontinue use of this SPIN for Schools and Libraries Support.


Financial institution information is required. Electronic payment of universal service support payments
is mandated by the Debt Collection Improvement Act of 1996, Pub. Law 104-134, 110 Stat. 1321-358.


Check this box if this information is the same as the General Contact information (Block 2) and complete lines 105-107.
95
Remittance Company Name, if different from Company Name
96 First:
Middle Initial:
Last:
97
Remittance Contact Name - Statements will be sent to Remittance Contact's attention
Title
98


Remittance Address



99
Address Line 2
100
101
102

City
State
Zip Code + 4
103 (
)
104 (
)
Phone Number
Ext
Fax Number
105
Remittance Financial Institution for ACH or locked box transfer of funds (required)
106
107
Financial Institution Account Number for ACH (required)
ACH Financial Institution Transit Number - must be nine digits (required)

Alternative Banking Information for the payment of Billed Entity Applicant Reimbursements

Check this box if you wish to use the same banking information as listed in lines 105-107.
108
Remittance Financial Institution for ACH or locked box transfer of funds (required)
109
110
Financial Institution Account Number for ACH (required)
ACH Financial Institution Transit Number - must be nine digits (required)
111
E-mail Address of Remittance Contact (Required if participating in the Schools and Libraries Program)

Block 13: Company Contact for Schools and Libraries Support

See Instruction Section III.N


Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 14.
112 First:
Middle Initial:
Last:
113
Contact Name for Schools and Libraries Program
Title
(Must be a company employee or designated representative)
114


Contact Address for Schools and Libraries Program


115
Address Line 2
116
117
118
City
State
Zip Code + 4
119
(
)
120
(
)
Phone Number
Ext
Fax Number
121
E-mail Address of Schools and Libraries Program Contact
Page 7 of 9
FCC Form 498-August 2013

Disbursement Offsets and Healthcare Connect Certification

Block 14: Offsetting Disbursement Payments Against Federal Universal Service
Contribution Obligations For Rural Healthcare Participants

See Instruction Section III.O


The following information pertains only to telecommunications companies participating in the Rural Health Care Program. In accordance with FCC rule section 54.679
regarding Rural Health Care payments, a telecommunications company may choose to offset its payment against its Federal universal service contribution. A
telecommunications company must have an FCC Form 499 Filer ID number in order to offset its Rural Health Care Program payments against its Federal universal
service contribution. In order to obtain an FCC Form 499 Filer ID number, visit http://www.usac.org/cont/tools/forms/default.aspx and select FCC Form 499. You do not
need an FCC Form 499 Filer ID in order to be issued a SPIN.
122
Yes, I want my Rural Health Care Program disbursement payments to be offset against my Federal
universal service contribution obligations. This box must be checked in order to receive offsets. The Default is "No."

Block 15: Certification to Assist Health Care Providers

See Instruction Section III.P


In accordance with FCC rule section 54.640(b), service providers participating in the Healthcare Connect Fund must certify, as a condition of receiving support, that they
will provide to health care providers, on a timely basis, all information and documents regarding supported equipment, facilities, or services that are necessary for the
health care provider to submit required forms or respond to FCC or USAC inquiries. USAC may withhold disbursements to the service provider if the service provider,
after written notice from USAC, fails to comply with this requirement.
123
I certify, as a condition of receiving support under the Healthcare Connect Fund, that the above-named service provider will provide to
health care providers, on a timely basis, all information and documents regarding the supported equipment, facility(ies), or service(s)
that are necessary for the health care provider to submit required forms or respond to FCC or USAC inquiries.

Block 16: Offsetting Disbursement Payments Against Federal Universal Service
Contribution Obligations For Schools and Libraries Participants

See Instruction Section III.Q


The following information pertains only to telecommunications companies participating in the Schools and Libraries Program. In accordance with FCC rule section
54.515 regarding Schools and Libraries Program payments, a telecommunications company may choose to offset its Schools and Libraries Program payment against its
Federal universal service contribution. A telecommunications company must have an FCC Form 499 Filer ID number in order to offset its Schools and Libraries
payments against its Federal universal service contribution. In order to obtain an FCC Form 499 Filer ID number, visit http://www.usac.org/cont/tools/forms/default.aspx
and select FCC Form 499. You do not need an FCC Form 499 Filer ID in order to be issued a SPIN.
124
Yes, I want my Schools and Libraries Program disbursement payments to be offset against my Federal
universal service contribution obligations. This box must be checked in order to receive offsets. The Default is "No."

Service Identification

Block 17: Principal Communications Types [REQUIRED Field]

See Instruction Section III.R


Select up to 5 boxes that best describe the reporting entity. Enter numbers starting with "1" to show the order of importance -- see instructions.

Audio Bridging Provider

Interconnected VoIP

Coaxial Cable

Paging and Messaging

Non-Interconnected VoIP

SMR (Dispatch)

Private Service Provider

Shared-Tenant Service Provider

Toll Reseller

Cellular/PCS/SMR

Incumbent LEC

Interexchange Carrier

Operator Service Provider

Payphone Service Provider

Satellite Service Provider

Local Reseller

Wireless Data

Internet Service Provider

CAP/CLEC

Non-Traditional Provider (NTP)


Page 8 of 9
FCC Form 498-August 2013

Officer Certification

Block 18: Authorized Contact Signature [All Fields REQUIRED]

See Instruction Section III.S

I certify that I am an officer of the above-named service provider, that I am authorized to submit this FCC Form 498 on behalf of the above named service


provider, and that to the best of my knowledge, the data set forth in this form is true, accurate, and complete.
Persons willfully making false statements on this form can be punished by fine or forfeiture, under the Communications Act, as amended, 47 U.S.C. Secs. 220(e), 502,
503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.

Company Officer Information

Check this box if this information is the same as the General Contact information (Block 2)
Signature of the

Company Officer

Date
First:
Middle Initial:
Last:
Printed Name
Title
E-mail address

Notice:

The Federal Communications Commission (the Commission) has designated the Universal Service Administrative Company (USAC) as administrator of Federal universal service. One of
the functions of USAC is to provide a mechanism for the billing, collection, and disbursement of funds for the various Federal universal service programs. In an effort to implement these
requirements and obligations, the Commission has adopted this collection of information. Pursuant to the Commission rules, 47 C.F.R. §§ 54.301, 54.303, 54.307, 54.309, 54.311, 54.407, 54.413,
54.515, 54.611, 54.702, 54.802, and 54.902, USAC must obtain information relating to service provider name and address, telephone number, Federal employee identification number, contact
names and telephone numbers, and billing and collection information. Each service provider receiving Federal universal service support from the High Cost, Low Income, Rural Health Care, or
Schools and Libraries Programs, should complete the FCC Form 498. USAC will use this information in administering the billing, collections, and disbursement operations of the Federal universal
service programs.

Reminder:

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 Office of Management and Budget (OMB) control number. This collection has been assigned an OMB control number of 3060-0824.
The Commission is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. We will use the information you provide for the Federal
universal service billing, collections, and disbursement purposes. If we believe there may be a violation or a potential violation of a state or Federal statute, or of a Commission regulation, rule, or
order, your form may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation, or order. In certain cases,
the information in your application may be disclosed to the Department of Justice, a court, or adjudicative body when (a) the Commission; or (b) any employee of the Commission; or (c) the United
States Government is a party of a proceeding before the body or has an interest in the proceeding. In addition, consistent with the Communications Act of 1934, FCC regulations and orders, the
Freedom of Information Act, 5 U.S.C. § 552, or other applicable law, information provided in or submitted with this form or in response to subsequent inquiries may be disclosed to the public.
If you owe a past due debt to the Federal government, the information you provide may also be disclosed to the Department of the Treasury Financial Management Service, other Federal agencies,
and/or your employer to offset your salary, IRS tax refund, or other payments to collect that debt. The Commission may also provide the information to these agencies through the matching of
computer records where authorized.
If you do not provide the information we request on the form, the Commission may delay processing of your application, or may return your application without action.
This Notice is required by the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. 3501 et seq. We have estimated that each response to this collection of information will take, on
average, 1.5 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 for
response. If you have any comments on this estimate, or how we can improve the collections and reduce the burden it causes you, please write to the Federal Communications Commission, AMD-
PERM, Washington D.C. 20554, Paperwork Reduction Project (3060-0824). We will also accept your comments via Internet if you send them to PRA@fcc.gov. Please DO NOT SEND
COMPLETED DATA COLLECTION FORMS TO THIS ADDRESS.
Mail this signed form to:

USAC Customer Operations, Forms Processing
2000 L Street, N.W., Suite 200
Attn: FCC Form 498
Washington, DC 20036

Questions?

See the FCC Form 498 Instructions found at http://usac.org/sp/tools/forms.aspx

Use this form for:

New application for a Service Provider Identification Number
Revision to existing Service Provider data currently on file with USAC
Merger or Consolidation of Existing Service Provider Identification Number (Additional documentation is required, please see page 2 of the instructions)
Deactivation of a Service Provider Identification Number (Please see page 2 of the instructions)
Page 9 of 9
FCC Form 498-August 2013

Document Outline

  • 3060-0824_Inst_08_2013
  • 3060-0824_08-2013

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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