OMB 3060-1270

APPENDIX B

Secure and Trusted Communications Networks Reimbursement Program
FCC Form 5640: Reimbursement Claim Request, Section 1.50004(g)
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)
An FRN is a 10-digit number that is assigned by the Commission Registration System (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 will be auto-generated from the information provided in the Application Request for Funding Allocation.
2
Applicant Name

This is the name of the Applicant submitting this request.  This information will be auto-generated from the information provided in the Application Request for Funding Allocation.
3
Applicant Information: 
· Applicant Street Name;
· Applicant City;
· Applicant State;
· Applicant Zip Code;
· Applicant Phone Number;
· Applicant Email.
This information will be auto-generated from the information provided in the Application Request for Funding Allocation.
Contact Information
4
Contact different than Applicant:
· Contact Name;
· Contact Street Name;
· Contact City;
· Contact State;
· Contact Zip Code;
· Contact Phone #;
· 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.  This information will be auto-generated from the information provided in the Application Request for Funding Allocation but filer will have the opportunity to change information to designate a different contact for the filing.
5
Contact same as Applicant:
· Contact Name;
· Contact Street Name;
· Contact City;
· Contact State;
· Contact Zip Code;
· Contact Phone #;
· Contact Email.

These items identify the contact representative.  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. 
This information will be auto-generated from the information provided in the Application Request for Funding Allocation but filer will have the opportunity to change information to designate a different contact for the filing.
Invoice Information
6
For each invoice submitted for reimbursement, provide the following information:
· Description of invoice to be reimbursed;
· Vendor Name;
· Vendor Employer Identification Number (EIN) or Tax Identification Number (TIN);
· Invoice Number;
· Invoice date;
· Invoice due date. 
The applicant must answer these questions for each invoice that is seeking reimbursement on the same reimbursement request. Information will help the FCC evaluate accuracy and reasonableness of reimbursement request. 

7
Does the attached invoice contain costs ineligible for reimbursement? (Yes or No)
The applicant must answer these questions for each invoice that is seeking reimbursement on the same reimbursement request. Information will help the FCC evaluate accuracy and reasonableness of reimbursement request. 
8
Provide copy of invoice for demonstrating cost actually incurred for which you are seeking reimbursement.
Information will help FCC evaluate accuracy and reasonableness of reimbursement request.  If invoice relates to quote issued by vendor that has not been previously submitted and reviewed by Fund Administrator, then filer will need to attach copy of associated quote from vendor.
9
Reimbursement Request Amount.
Recipients must show actual expenses on invoice reasonably incurred for the removal, replacement, and disposal of covered communications equipment or service. Information will help FCC evaluate accuracy and reasonableness of reimbursement request.
10
Description of equipment or services being reimbursed. 
Information will help FCC evaluate accuracy and reasonableness of reimbursement request.
11
Does the invoice contain expense(s) related to a technology upgrade that are not eligible for reimbursement as a comparable replacement? 
Information will help FCC evaluate accuracy and reasonableness of reimbursement request.
12
Identify if cost is associated with a single site, multiple sites, across all sites, or non-site-specific. 
Information will help FCC evaluate accuracy and reasonableness of reimbursement request.
13
Identify locations associated with cost estimate.

Information will help FCC track where money is spent and help to evaluate money spent by location.  For single or multiple sites, filer will need to identify sites by Location ID, i.e., site(s) previously identified by filer in system through Application Request for Funding Allocation or subsequently filed Modification application.
14
Identify percentage of cost allocated to location.
Information required if multiple sites identified and will help FCC evaluate accuracy and reasonableness of reimbursement request and track funding disbursements.
15
Identify Cost Estimate to which this cost is related.

Information will help FCC evaluate accuracy and reasonableness of the reimbursement request.  Filer will need to select a Cost Estimate as previously identified by filer in an earlier filed Application Request for Funding Allocation or subsequently filed Modification application.
16
If cost incurred for which reimbursement sought (combined with other expenses incurred) significantly exceeds original cost estimate, provide explanation for deviation.
Information will help FCC evaluate accuracy of cost estimates for future cost estimation.
Certifications
17
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.
18
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.

19
Certifying Official Name
Name of certifying official.  
20
Certifying Official Title
Job title of certifying official.
21
Certifying Official Phone Number
Phone number of the certifying official.
22
Certifying Official Email Address
Email address of the certifying official.
23
Certifying Date Signed
The date on which the filing is certified will be auto-generated.


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