File electronically at http://usac.org/about/tools/e-file.aspx/ FCC Form 498 OMB 3060-0824 Service Provider And Billed Entity 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 and applicants 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. Provider Type Please check one box below Service Provider School/Library or other Billed Entity Submission Type Please check one box below Original Application for FCC Form 498 ID Revision to existing FCC Form 498 on file with USAC Request for FCC Form 498 ID Merger/Consolidation Request for FCC Form 498 ID Deactivation Service Provider Identification Number (FCC Form 498 ID) (To be inserted by USAC for first time applications. Required for subsequent revisions.) 499 Filer ID (Required if your company is required to file the FCC Form 499) Block 1: Organization Information [All Fields REQUIRED] 1 Company Name or Billed Entity 2 Name Entity or 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] 9 First: Middle Initial: Last: 10 General Contact (Company Preparer Name) Title 11 ( ) Phone Number Ext. 12 Street Address 13 Address Line 2 14 15 16 City State Zip Code + 4 17 E-mail Address Block 3: Federal EIN, DUNS and FCC Registration Number [All Fields REQUIRED] 18 19 Corporation Partnership Other Enter Federal Employer Identification Number (Check applicable corporate structure.) (Federal EIN or Tax ID Number) 20 21 Enter Dun and Bradstreet Number (DUNS) FCC Registration Number (CORES ID) Page 1 of 11 FCC Form 498-July 2019 This is a Supplemental Page for Companies with Affiliate Relationships Block 4: Affiliate Company Information Please list all companies with which this FCC Form 498 ID 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 FCC Form 498 ID Number Affiliate Company Name (Attach additional copies of this page if necessary) Page 2 of 11 FCC Form 498-July 2019 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] Check this box to discontinue use of this FCC Form 498 ID 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. 22 Remittance Company Name, if different from Company Name 23 First: Middle Initial: Last: 24 Remittance Contact Name - Statements will be sent to Remittance Contact's attention Title 25 ( ) 26 Phone Number Ext E-mail Address for receipt of remittance advice 27 Remittance Financial Institution for ACH or locked box transfer of funds (required) 28 29 Financial Institution Account Number for ACH (required) ACH Financial Institution Transit Number - must be nine digits (required) Block 6: Company Contact for High Cost Support Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 7. 30 First: Middle Initial: Last: 31 Contact Name for High Cost Program Title (Must be a company employee or designated representative) 32 Contact Address or PO Box for High Cost Program 33 Address Line 2 34 35 36 City State Zip Code + 4 37 ( ) 38 Phone Number Ext E-mail Address of High Cost Program Contact Page 3 of 11 FCC Form 498-July 2019 This page is for Lifeline Program participants only. For more information about Lifeline Support, please refer to: http://www.usac.org/li/ Block 7: Lifeline Support Financial Institution and Remittance Information [All Fields REQUIRED] Check this box to discontinue use of this FCC Form 498 ID for LifelineSupport. 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. 39 Remittance Company Name, if different from Company Name 40 First: Middle Initial: Last: 41 Remittance Contact Name - Statements will be sent to Remittance Contact's attention Title 42 ( ) 43 Phone Number Ext E-mail Address for receipt of remittance advice 44 Remittance Financial Institution for ACH or locked box transfer of funds (required) 45 46 Financial Institution Account Number for ACH (required) ACH Financial Institution transit Number - must be nine digits (required) Block 8: Company Contact for Lifeline Support Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 9. 47 First: Middle Initial: Last: 48 Contact address for Lifeline Program Title (Must be a company employee or designated representative) 49 Contact Address for Lifeline Program 50 Address Line 2 51 52 53 City State Zip Code + 4 54 ( ) 55 Phone Number Ext E-mail Address of Lifeline Program Contact Page 4 of 11 FCC Form 498-July 2019 This is a Supplemental Page for Participants in the High Cost and Lifeline Programs. Block 9: High Cost and Lifeline Study Area/FCC Form 498 ID Association This information will be used to associate the Study Area Codes (SAC) to this FCC Form 498 ID for the purposes of High Cost and Lifeline 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 11 FCC Form 498-July 2019 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] Check this box to discontinue use of this FCC Form 498 ID 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. 56 Remittance Company Name, if different from Company Name 57 First: Middle Initial: Last: 58 Remittance Contact Name - Statements will be sent to Remittance Contact's attention Title 59 ( ) 60 Phone Number Ext E-mail Address for receipt of remittance advice 61 Remittance Financial Institution for ACH or locked box transfer of funds (required) 62 63 Financial Institution Account Number for ACH (required) ACH Financial Institution transit Number - must be nine digits (required) Block 11: Company Contact for Rural Health Care Support Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 12. 64 First: Middle Initial: Last: 86 Contact Name for Rural Health Care Program Title (Must be a company employee or designated representative) 65 Contact Address for Rural Health Care Program 66 Address Line 2 67 68 69 City State Zip Code + 4 70 ( ) 71 Phone Number Ext E-mail Address of Rural Health Care Program Contact Page 6 of 11 FCC Form 498-July 2019 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] Check this box discontinue use of this FCC Form 498 ID 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. 72 Remittance Company Name, if different from Company or Billed Entity Name 73 First: Middle Initial: Last: 74 Remittance Contact Name - Statements will be sent to Remittance Contact's attention Title 75 ( ) 76 Phone Number Ext E-mail Address for receipt of remittance advice 77 Remittance Financial Institution for ACH or locked box transfer of funds (required) 78 79 Financial Institution Account Number for ACH (required) ACH Financial Institution Transit Number - must be nine digits (required) Block 13: Company Contact for Schools and Libraries Support Check this box if this information is the same as the General Contact information (Block 2) and continue on to Block 14. 80 First: Middle Initial: Last: 81 Contact Name for Schools and Libraries Program Title (Must be a company, or entity employee or designated representative) 82 Contact Address for Schools and Libraries Program 83 Address Line 2 84 85 86 City State Zip Code + 4 87 ( ) 88 Phone Number Ext E-mail Address of Schools and Libraries Program Contact Page 7 of 11 FCC Form 498-July 2019 This is a Supplemental Page for Schools, Libraries and Other Applicant Payment Recipients Block 14: Billed Entity Number/FCC Form 498 Association Please list all Billed Entity Numbers with which this FCC Form 498 ID affiliated. Billed Entity Number Billed Entity Name (Attach additional copies of this page if necessary) Page 8 of 11 FCC Form 498-July 2019 Disbursement Offsets and Healthcare Connect Certification Block 15: Offsetting Disbursement Payments Against Federal Universal Service Contribution Obligations For High Cost Participants The following information pertains only to telecommunications companies participating in the High Cost Program. 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 High Cost 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 FCC Form 498 ID. 89 Yes, I want my High Cost 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 16: Offsetting Disbursement Payments Against Federal Universal Service Contribution Obligations For Lifeline/Lifeline Participants The following information pertains only to telecommunications companies participating in the Lifeline Program. 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 Lifeline 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 FCC Form 498 ID. 90 Yes, I want my High Cost 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 17: Offsetting Disbursement Payments Against Federal Universal Service Contribution Obligations For Rural Healthcare Participants 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 FCC Form 498 ID. 91 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 18: Certification to Assist Health Care Providers In accordance with FCC rule section 54.640(b), service providers participating in the Healthcare Connect Fund Program 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. 92 I certify, as a condition of receiving support under the Healthcare Connect Fund Program, 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 19: Offsetting Disbursement Payments Against Federal Universal Service Contribution Obligations For Schools and Libraries Participants 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 93 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." Page 9 of 11 FCC Form 498-July 2019 Service Identification Block 20: Principal Communications Types [REQUIRED Field] 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 School/Library or other Billed Entity Recipient DATA Act Business Types Block 21: DATA Act Business Type (REQUIRED Field] Select up to 3 boxes that best describe the reporting entity. Enter check marks. For additional description -- see instructions. State Government Nonprofit with 501C3 IRS Status (Other than an Institution of Higher Education) County Government Nonprofit without 501C3 IRS Status (Other than an Institution of Higher Education) City or Township Government Private Institution of Higher Education Special District Government Individual Regional Organization For-profit Organization (Other than Small Business) U.S. Territory or Possession Small Business Independent School District Hispanic-serving Institution Public/State Controlled Institution of Higher Education Historically Black College or University (HBCU) Indian/Native American Tribal Government(Federally-Recognized) Tribally Controlled College or University (TCCU) Indian/Native American Tribal Government (Other than Federally-Recognized) Alaska Native and Native Hawaiian Serving Institution Indian /Native American Tribal Designated Organization Non-domestic (non-U.S.) Entity Public/Indian Housing Authority Other Officer Certification Block 22: Officer Certification [All Fields REQUIRED] 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 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. Officer Information Check this box if this information is the same as the General Contact information (Block 2) Signature of the Officer Date First: Middle Initial: Last: Title Printed Name Page 10 of 11 FCC Form 498-July 2019 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, Lifeline, 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. In addition, the Name, Address, DUNNS Number and Business Type will be disclosed in accordance with FFATA/DATA Act reporting requirements. 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 700 12th Street NW, Suite 900 Washington, DC 20005 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 11 of 11 FCC Form 498-July 2019