OMB 3060-1270

APPENDIX A

Secure and Trusted Communications Networks Reimbursement Program
FCC Form 5640: Application Request for Funding Allocation, Section 1.50004(c)
Information Submitted Using Online Portal

Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual representation of what each applicant will see, the order in which they will see information, or the exact wording or directions used to collect the information.

Item Number
Field(s) Description
Purpose/Instructions
Applicant Information
1
Applicant FCC Registration Number (FRN)
A 10-digit number that is assigned by the Commission Registration System (CORES) to a business or individual registering with the FCC, https://apps.fcc.gov/cores/userLogin.do.  This unique FRN is used to identify the registrant’s business dealings with the FCC.
2
Applicant Name
This is the name of the Applicant submitting this request.  This information will be auto-generated by system based on the FRN submitted. 
3
Applicant Contact Information:
· Applicant Street Name;
· Applicant City;
· Applicant State;
· Applicant Zip Code;
· Applicant Phone Number;
· Applicant Email.
This information on the Applicant will be auto-generated based on the FRN submitted.

Applicant Payment Information
4
Commercial and Government Entity (CAGE) Code
The CAGE code is a five-character identifier, which is used by entities doing business with the Federal government to provide banking and other related information.  The System Award Management (SAM) is a government-wide portal that consolidates the capabilities of multiple systems and information sources used by the Federal government in conducting the acquisition and financial assistance (which includes grants and cooperative agreements) processes, https://www.sam.gov/SAM/. The CAGE Code is also referred to as a SAM registration number. 
5
Data Universal Numbering System (DUNS) Number

A Data Universal Numbering System (DUNS) Number is a unique nine-digit number assigned by Dun & Bradstreet that is used to identify organizations, https://www.dnb.com/duns-number.html.  Applicant will need to provide the DUNS number associated with the SAM CAGE coder identified in response to Item 4.
6
DUNS+4

A DUNS+4 is the DUNS number plus a 4-character suffix.  It is created by the SAM registrant to establish additional Electronic Funds Transfer (EFT) accounts for a given DUNS number registration. (DUNS+4 has no affiliation with Dun & Bradstreet), SAM Non-Federal User Guide, https://sam.gov/SAM/SAM_Guide/SAM_Non_Federal_User_Guide/
SAM_Non_Fed_User_Guide.html.
Real Party in Interest Information
7
FCC Registration Number (FRN) for Real Party in Interest
If a party other than the Applicant is the real party in interest (e.g., a parent or other controlling entity), enter that party's 10-digit FCC Registration Number (FRN).  The FRN is assigned by CORES to a business or individual registering with the FCC. This unique FRN is used to identify the registrant's business dealings with the FCC.  This information helps the FCC identify the controlling party and affiliated applicants. 
8
Name of Real Party in Interest
If a party other than the Applicant is the real party in interest (e.g., a parent or other controlling entity), enter that party's name in this item.  If there is more than one real party in interest, attach an exhibit detailing all parties in interest. The name will be auto-generated based on the FRN submitted for Real Party in Interest. 
Contact Information
9
Contact same as Applicant.  
· Contact Name;
· Contact Street Name;
· Contact City;
· Contact State;
· Contact Zip Code;
· Contact Phone Number;
· Contact Email.
This can be selected to auto-populate the Contact Information if the Contact is the same as the Applicant. This information on the Applicant will be auto-generated based on the FRN submitted.

10
Contact different than Applicant.
· Contact Name;
· Contact Street Name;
· Contact City;
· Contact State;
· Contact Zip Code;
· Contact Phone Number;
· Contact Email.
These items identify the contact representative, if different from the Applicant.  This is usually the headquarters offices of a large company, the law firm or other representative of the Applicant, or the person or company that prepared or submitted the application on behalf of the Applicant.  If there is a question about the application, an FCC representative will communicate with the Applicant’s contact representative.

Identifying Applicant Type
11
Please identify the primary U.S. state, District of Columbia, or U.S. territory in which reimbursement support will be applied. 

This is the U.S. State, District of Columbia, or U.S. territory in which you expect a majority of your request for allocation will be utilized.  This information is used to assist the FCC in reporting funding allocation information to Congress as required by applicable statutes.

12
Identify your Applicant type. Select up to 3. 
A - State Government;
B - County Government;
C - City or Township Government;
D - Special District Government;
E - Regional Organization;
F - U.S. Territory or Possession;
G - Independent School District;
H - Public/State Controlled Institution of Higher Education;
I - Indian/Native American Tribal Government (Federally -Recognized);
J - Indian/Native American Tribal Government (Other than Federally-Recognized);
K - Indian/Native American Tribal Designated Organization;
L - Public/Indian Housing Authority;
M - Nonprofit with section 501(c)(3) IRS Status (Other than an Institution of Higher Education);
N - Nonprofit without section 501(c)(3) IRS Status (Other than an Institution of Higher Education);
O - Private Institution of Higher Education;
P – Individual;
Q - For-Profit Organization (Other than Small Business);
R - Small Business;
S - Hispanic-serving Institution;
T - Historically Black College or University (HBCU);
U - Tribally Controlled College or University (TCCU);
V - Alaska Native and Native Hawaiian Serving Institutions;
W - Non-domestic (non-U.S.) Entity;
X – Other.

This information is used to assist the FCC in reporting funding allocation information to Congress as required by applicable statutes.  If Applicant selects “Other,” Applicant will be able to utilize an information field to elaborate on the Applicant’s description that was not adequately captured by the listed options.  


13
Is the Applicant a commercial broadband provider? 

Information will help the FCC identify applicant type and track and analyze funding allocations.  The FCC can also use this information to assist with the prioritization of funding among different categories of applicants should funding demand exceed funding available.
14
Is the Applicant an Eligible Telecommunications Carrier (ETC)?
Eligible telecommunications carriers (ETCs) as defined in 47 CFR § 54.201 receiving universal service fund support. Information will help the FCC identify applicant type and track and analyze funding allocations. 
15
If Applicant is an ETC, then identify your ETC Status (ILEC or Non-ILEC).
Information used to identify if the filer as an ETC.  ILEC refers to the term Incumbent Local Exchange Carrier.
16
If Applicant is an ETC, please enter a list of Service Provider Identification Numbers (SPINs) that your company uses to conduct transactions with the Universal Service Administrative Company (USAC).
A Service Provider Identification Number (SPIN) (also known as a 498 ID) is a unique nine-digit number assigned to service providers that conduct business with the Universal Service Administrative Company (USAC).  A SPIN is assigned when an FCC Form 498 is filed with USAC.
17
If Applicant is an ETC, then identify the Study Area Code(s), where you are designated as an ETC.
Information used to identify geographic areas where filer is designated as an ETC.
18
Applicant FCC Form 499 Filer ID Number(s) (if applicable).
An FCC Form 499 Filer ID Number is a 6-digit identifier assigned to telecommunications providers that report quarterly and annual revenue to the FCC. This information is used to cross-check filer information with other FCC records. 
19
Is Applicant subject to the Commission’s Part 32 - Uniform System of Accounts for Telecommunications Companies regulations, 47 CFR §§ 32.01 et seq.? (Yes or No)

Question aimed at identifying Applicants that may raise duplicate recovery concerns.  The Commission’s Part 32 – Uniform System of Accounts for Telecommunications Companies applies to “every incumbent local exchange carrier, as defined in section 251(h) of the Communications Act, and any other carrier that the Commission designates by order.  This part refers to such carriers as ‘companies’ or ‘Class B companies.’  Incumbent local exchange carriers’ successor or assign companies, as defined in section 251(h)(1)(B)(ii) of the Communications Act, that are found to be non-dominant by the Commission, will not be subject to this Uniform System of Accounts.”  47 CFR § 32.11.
Program Eligibility
20
Is the Applicant a health care provider? (Yes or No)
Information will help the FCC identify applicant type and track and analyze funding allocations.  
21
Is the Applicant a school? (Yes or No)
Information will help the FCC identify applicant type and track and analyze funding allocations.  
22
Is the Applicant a library? (Yes or No)
Information will help the FCC identify applicant type and track and analyze funding allocations.  
23
Is Applicant a provider of advanced communications service with 10 million or fewer customers? (Yes or No)
The term “advanced communications service” means high-speed, switched, broadband telecommunications capability that enables users to originate and receive high-quality voice, data, graphics, and video telecommunications using any technology with connection speeds of at least 200 kbps in either direction.”  47 CFR § 1.50001(a).  For additional information on the meaning of a provider of advanced communications please refer to the Second Report and Order, WC Docket No. 18-89, 35 FCC Rcd 14284, paras. 110-116 (2020).  “Customers” is interpreted to include customers of the Applicant and customers of any affiliate taking advanced communications service from the provider and its affiliates as of the date the application is filed.  Id. at paras. 114-115.
Note:  If Applicant answers “yes” and there is no record of the applicant filing the Form 477 “Local Telephone Competition and Broadband Reporting” to report broadband deployment in the most recent reporting period, then Applicant will need to provide additional information supporting attestation.
24
Is Applicant a provider of advanced communications service with 2 million or fewer customers? (Yes or No)
Information will assist the FCC in determining whether applicant is eligible for prioritization in funding per statutory scheme.  “Customers” includes customers of the Applicant and customers of any affiliate taking advanced communications service from the provider and its affiliates as of the date the application is filed.  Second Report and Order, WC Docket No. 18-89, 35 FCC Rcd 14284, paras. 114-115.
25
Have you previously purchased, leased, or otherwise obtained communications equipment or services on the Covered List that was produced or provided by Huawei Technologies Company or ZTE Corporation, including their affiliates and subsidiaries, on or before June 30, 2020?  (Yes or No)
Information needed to determine whether applicant is eligible to participate in the Reimbursement Program.  By statute, program is limited to the permanent removal, replacement, and disposal of certain communications equipment or service deemed “covered” and that was obtained by the eligible provider of advanced communications service by a certain date. Consistent with amendments to the Secure Networks Act by the Consolidated Appropriations Act, 2021, the Commission limited reimbursement eligibility to covered communications equipment or services produced or provided by Huawei Technologies Company or ZTE Corporation that was obtained on or before June 30, 2020.

Locations
26
Location ID
A number auto-generated by system, starting with 00001, that uniquely identifies the location that is subject to the removal, replacement, and disposal of covered communications equipment and service.  
27
Location Name
Name commonly used by Applicant to refer to site location.
28
Latitude of Location
Latitude of the location to which service the provider has made service available.  
29
Longitude of Location
Longitude of the location to which service the provider has made service available.  
30
Location Address – Number & Street
Number and street address of the location.
31
Location Address – City
City associated with the street address of the location.
32
Location Address – State
2 letter postal abbreviation of the state associated with the street address of the location.
33
Location Address – Zip Code
5-digit ZIP code associated with the street address of the location.
34
Location Address – No Postal Address Available
In those cases where postal address is not available, alternate address information.
35
What type of site location is this (cell site, mobile switching center, central office, network operations center, headquarters, or other?  If “other,” briefly describe. 
Information assists in identifying the type of site location to help the FCC determine the type of costs most likely incurred at the location for the removal, replacement, and disposal of equipment and services on the Covered List.
Cost Estimates
36
Identify if the cost estimate is associated with a single site, multiple sites, across all sites, or non site-specific (select one). 
Reimbursement Program is designed to provide eligible applicants with support available for draw down based on cost estimates for the removal, replacement, and disposal of covered communications equipment or service.  This information will assist with the FCC’s cost estimate assessment and award of a funding allocation.
Applicant will need to provide detailed information by site Location ID on (1) the covered equipment or services being replaced, removed, and disposed; (2) the replacement equipment and services; and (3) costs related to the overall removal, replacement, and disposal process.
37
Identify the Location ID associated with the cost estimate. 
This information will help the FCC link up cost estimates to the location that is subject to the removal, replacement, and disposal of covered communications equipment and service. 
38
Indicate whether cost estimated is associated with a technology upgrade that exceeds a comparable replacement?
Question will help identify participants seeking a technology upgrade solution so that the Fund Administrator and the Bureau can review the applications accordingly.  Participants may obtain Reimbursement Program support for an amount equivalent to the cost estimate of a comparable replacement.   If a participant upgrades to a higher quality, more advanced, non-comparable replacement, then the participant bears the difference in cost between the comparable replacement and the technology upgrade solution chosen.
39
Indicate whether cost estimate is related to the following categories (select all that apply): 
· Access layer;
· Distribution layer; 
· Core layer; 
· Software; and/or 
· Services. 
This information will assist with the FCC’s cost estimate assessment and award of a funding allocation.
40
Indicate if the cost estimate average is not identified in the Cost Catalog (Yes or No). 
Applicants can reference the Catalog of Eligible Expenses and Estimated Costs (Cost Catalog) prepared by the Wireline Competition Bureau for pre-determined average cost estimates for typically anticipated categories of costs associated with the removal, replacement, and disposal of covered communications equipment and service.  Applicants that submit their own cost estimates must submit supporting documentation and certify that the estimate is made in good faith.
41
Identify a cost by referencing the Catalog of Eligible Expenses prepared by the Wireline Competition Bureau for pre-determined cost estimate ranges for typically anticipated categories of cost associated with the removal, replacement, and disposal of covered communications equipment and service. (Cost Catalog) 
This will auto-populate with the average cost of the item selected in the Cost Catalog. The cost estimate will be based on the average of the low-end and high-end range of cost estimates identified in the Cost Catalog. 

42
For individualized cost estimates not based on the Cost Catalog, provide a cost estimate reasonably incurred for the permanent removal, replacement, and disposal of covered communications equipment or service.
If an applicant finds a Cost Catalog cost estimate average does not fully account for its costs or a cost category is not identified in the Cost Catalog, the applicant can instead provide its own individualized cost estimate. Applicants providing individualized cost estimates must submit additional supporting documentation (e.g., quotes issued by vendor) and certify the cost estimate is made in good faith, as required by the Commission’s rules.
43
Provide justification as to why Applicant is submitting individualized cost estimate including additional documentation. 
Applicants providing individualized cost estimates must submit additional supporting documentation (e.g., quotes issued by vendor).
Timeline and Plan Information
44
Provide a specific timeline for the permanent removal, replacement, and disposal of the covered communications equipment or service.
Timeline required by statute.  Applicant will need to upload timeline detailing all relevant steps in the removal, replacement, and disposal process.  Applicant will separately complete field in system identifying anticipated completion date for completing the process. 
45
Does the applicant request that some or all of the contents of the timeline be kept confidential? (Yes or No).
Applicants will be able to submit confidential and public/redacted versions of their timeline. Applicants must upload a request for confidentiality.
46
Provide description of Applicant’s plan for the permanent removal, replacement and disposal of covered communications equipment or service.
Applicant will need to upload attachment describing all relevant steps in its plan for the permanent removal, replacement, and disposal of covered communications equipment and service.  
47
Do you expect major service disruptions to subscribers in the process of removing and replacing covered equipment and services? (Yes or No)
Applicant will need to provide a description of the services and equipment if “Yes.”
Equipment or Service
48
Is the equipment or service an existing equipment or service or a replacement equipment or service?
This will help the FCC track existing equipment or services and replacement equipment or services.
49
Is the Equipment or Service a Covered Equipment or Service? (Yes or No)
This will ensure that providers are not seeking reimbursement for removal, replacement, and disposal of covered communications equipment or services with other covered communications equipment or services provided by Huawei or ZTE that is prohibited from reimbursement. 
50
For Covered Equipment or Service that is being removed, replaced, and/or disposed identify: 
· Location ID of equipment or service;
· Equipment or service make;
· Equipment or service model;
· Equipment or service type;
· Description of equipment or service capabilities;
· Number of units at site;
· Date obtained;
· Whether equipment or service is functional.
Provide make, model, description of equipment type, description of equipment capabilities, location ID of existing equipment, number of units of existing equipment at site, and whether equipment is functional.  This information will help the FCC link cost estimates to the location that is subject to the removal, replacement, and disposal of covered communications equipment and service.  Applicant will need to provide supporting documentation demonstrating acquisition and/or possession of covered equipment, e.g., pictures of equipment at site, purchase orders, etc. 
51
For Replacement Equipment or Service, identify:
· Location ID of equipment or service;
· Equipment ID or Service ID;
· Equipment or service make;
· Equipment or service model;
· Equipment manufacturer’s or service provider’s country of origin;
· Description of equipment or service type;
· Description of equipment or service capabilities;
· Number of units at site.
Provide make, model, description of equipment type, description of equipment capabilities, location ID of new equipment replacing existing equipment, number of units of new equipment at site. This information will help the FCC link cost estimates to the location that is subject to the removal, replacement, and disposal of covered communications equipment and service. The “country of origin” question will help the Commission track and analyze technology trends. The Equipment ID or Service ID will be auto-generated. 
52
Supporting Documentation

Provide documentation of the equipment or service such as a purchase order or a photograph.
53
Does the proposed replacement of covered equipment and service involve reasonable costs incurred for the replacement of older mobile wireless networks with fourth generation LTE equipment or services that are 5G ready? (Yes or No)
Applicant will need to provide a description of the services and equipment if “Yes.”
54
Does the proposed replacement of covered equipment and services involve Open RAN or virtualized network solutions? (Yes/No)

Applicant will need to provide a description of the services and equipment if “Yes.”
55
Is the equipment or service replacing the covered equipment compatible with or does it include standardized open and interoperable interfaces in the fronthaul Radio Access Network and Core Network? (Yes or No)

Information collected to help analyze technology trends.
56
If the answer to Item 55 is “Yes,” is this equipment or service compliant with O-RAN Alliance 7.2 fronthaul standards? (Yes or No)
Information collected to help analyze technology trends and technology choices by providers, which does not suggest or otherwise encourage an applicant to select a particular technology solution.
57
If the answer to Item 55 is “No,” can it be upgraded to be O-RAN Alliance 7.2 fronthaul standards, and is there a commitment to do so? (Yes or No)
Information collected to help analyze technology trends and technology choices by providers, which does not suggest or otherwise encourage an applicant to select a particular technology solution.
58
Is the equipment or service compliant with the 3GPP X2 standard and other 3GPP open interfaces? 
Information collected to help analyze technology trends and technology choices by providers, which does not suggest or otherwise encourage an applicant to select a particular technology solution.
59
If the answer to Item 59 is “Yes,” then is there an associated fee to make this equipment interoperable or open? 
Information collected to help analyze technology trends and technology choices by providers, which does not suggest or otherwise encourage an applicant to select a particular technology solution.
60
Provide documentation of the equipment such as a purchase order or a photograph.
Information will help verify answers. 
Certifications
61
Applicant must certify under penalty of perjury in (via electronic signature of authorized representative) the following that as of the date of submission of this application following that Applicant has developed a specific plan and timeline for the permanent removal, replacement, and disposal of covered communications equipment or service.  
Certifications required by statute.  
62
Applicant must certify under penalty of perjury in (via electronic signature of authorized representative) the following that beginning on the date of the approval of the application, the Applicant: (1) will not purchase, rent, lease or otherwise obtain covered communications equipment or service, using reimbursement funds (including funds derived from private sources) and (2) in developing risk management practices, will consult and consider the standards, guidelines, and best practices set forth in the cybersecurity framework developed by the National Institute of Standards and Technology.
Certifications required by statute.  
63
Applicant must certify in good faith under penalty of perjury (via electronic signature of authorized representative) the following:  
(1) Applicant will reasonably incur the estimated costs claimed as eligible for reimbursement; 
(2) Applicant will use all money received from the Reimbursement Program only for expenses eligible for reimbursement; 
(3) Applicant will comply with all policies and procedures relating to allocations, draw downs, payments, obligations, and expenditures of money from the Reimbursement Program; 
(4) Applicant will maintain detailed records, including receipts, of all costs eligible for reimbursement actually incurred for a period of 10 years; and 
(5) Applicant will file all required documentation for its expenses.
Certifications necessary to protect Reimbursement Program against waste, fraud, and abuse.
64
Applicant certifies that all information provided in this filing is true and correct to the best of Applicant’s knowledge.
Certification necessary to ensure accuracy of information provided.

65
Certifying Official Name
Name of certifying official.  
66
Certifying Official Title
Job title of certifying official.
67
Certifying Official Phone Number
Phone number of the certifying official.
68
Certifying Official Email Address
Email address of the certifying official.
69
Certifying Date Signed
The date on which the filing is certified will be auto-generated.


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