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New FCC Form 462
Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Funding Request Form
Subject to Approval by OMB  3060-0804
Estimated time per response: 2 hours
Read instructions thoroughly before completing this form. Failure to comply may cause delayed or denied funding.
Block 1: General Information
 1   Funding Year ___________ 2   Funding Request Number (FRN):
 3   HCP Number: 4   Site Name/Consortium Name:
Block 2: Competitive Bidding Information
 5  FCC Form 461 Application Number:
 6  Allowable Contract Selection Date (ACSD):
 7  Number of vendors who bid:
 8  Request for competitive bidding exemption (Only complete if claiming a competitive bidding exemption). 
Annual Undiscounted Cost of $10,000 or less
Government Master Services Agreement Contract ID: Friendly Name:
Pre-Approved Master Services Agreement Contract ID: Friendly Name:
Evergreen Contract Contract ID: Friendly Name:
E-Rate Approved Contract Contract ID: Friendly Name:
Block 3: Vendor Information
 9   Service provider identification number (SPIN):
10  Vendor name:
Block 4: Type of Funding Request
11          Individual HCP, single eligible expense
              Individual HCP, multiple eligible expenses
              Consortium Application
Block 5: Single Eligible Expense Request for Funding
12  Category of Expense 13  Expense Type
14  Bandwidth                         14a  Is this service symmetrical?        Yes              No
If no, what is the upload bandwidth ___________.  
What is the download bandwidth ___________.   15  Circuit ID (optional)
16  Percentage of expense eligible
17  Does the Service Type include both eligible and ineligible components?               Yes              No
      If yes, percentage of usage eligible ___________________
18  Billing Account Number (BAN)
19  Contract ID 19a  Date contract signed
19b  Expected service start date 19c  Length of initial contract term
19d  Number of contract extensions 19e  Length of optional extension(s) combined
20  Circuit start location 21  Circuit end location
22  Is this a multi-year funding request?       Yes         No Multi-year commitments cannot exceed 3 funding years and may not extend beyond the expiration date of an Evergreen Contract.
23  Expense frequency 24  Quantity of expense periods
25  Undiscounted cost per expense period 26  Source of HCP contribution
27  One-time installation charges
FCC Form 462
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FCC Form 462
Block 8: Request for Confidentiality
32  Is applicant requesting confidential treatment and non-disclosure of commercial and financial information? (See 
instructions for specific information covered by this request.)           Yes         No
Block 9: Certifications
33 I certify that I am authorized to submit this request on behalf of the health care provider or consortium.
34
I declare 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 in this form and in any attachments is true and 
correct.
35
I certify under penalty of perjury that the health care provider or consortium has considered all bids 
received and selected the most cost-effective method of providing the requested services. The “most cost-
effective service” is defined as the “method that costs the least after consideration of the features, quality of 
transmission, reliability, and other factors that the health care provider deems relevant to choosing a method 
of providing the required health care services.” 47 C.F.R. Sec. 54.642(c).
36 I certify under penalty of perjury that all Healthcare Connect Fund support will be used only for the eligible program purposes for which support is intended.  
37 I certify that the health care provider or consortium is not requesting support for the same service from both the Telecommunications Program and the Healthcare Connect Fund.  
38
I certify that the health care provider or consortium satisfies all of the requirements under Section 254 of the 
Telecommunications Act of 1996, as amended, and applicable Commission rules, and understand that any 
letter from the Administrator that erroneously commits funds for the benefit of the applicant may be subject to 
recission. 
39 I certify that I have reviewed all applicable requirements for the program and will comply with those requirements. 
40
I understand that all documentation associated with this application, including all bids, contracts, scoring 
matrices, and other information associated with the competitive bidding process, and all billing records for 
services received, must be retained for a period of at least five years pursuant to 47 C.F.R. § 54.648, or as 
otherwise prescribed by the Commission’s rules.
41  Signature 42  Date
43  Printed Name of Authorized Person
44  Title/Position of Authorized Person
45  Phone              Ext. 46  Email
47  Employer 48  Employer’s FCC RN
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 
Block 7: Additional Documentation
31  List all supporting documentation (Competitive bids, Contract, etc.) that is required to be submitted with this form.
        Type of Documentation
         a. 
         b.
         c.
Block 1: General Information
28  This contract contains a Service Level Agreement.                 Yes         No    
If yes, provide the following information 
concerning the SLA in the contract:
a. Latency: b. Jitter:
d. Packet Loss: d. Reliability:
Block 6: Multiple Eligible Expenses and Consortium Requests for Funding (attach Network Cost Worksheet)
29  Total undiscounted cost for eligible recurring expenses
30  Total undiscounted cost for eligible non-recurring expenses
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FCC Form 462
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 2 hours 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.
Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Network Cost Worksheet (attach, if required, to Form 462)
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Rural Health Care (RHC) Universal Service
Healthcare Connect Fund
Network Cost Worksheet (attach, if required, to Form 462)
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