Fcc Form 498 – Fill Out and Use This PDF

Instructions for Completing the Service Provider and Billed Entity

Identification Number and Contact Information Form

The FCC Form 498 is used to collect contact, remittance, and payment information for service providers and billed entities 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 contacts 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 a 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 USAC disburses funds for the High Cost, Lifeline, 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 the service provider name or billed entity, 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 and Billed Entity Identification Number and Contact Information Form, FCC Form 498, to collect this information from service providers and billed entities that receive support from the High Cost, Lifeline, 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 FCC Form 498 filers will be assigned a Form 498 Identification Number (FCC Form 498 ID). This form will be used to collect the following information: service provider or billed entity 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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II. FILING REQUIREMENTS AND GENERAL INSTRUCTIONS

A.Who Should File the FCC Form 498

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

In addition all Schools and Libraries Applicants (billed entities) receiving payments via the Billed Entity Applicant Reimbursement process must file FCC Form 498 to receive disbursement payments.

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

Apply for a new FCC Form 498 ID.

Revise an existing FCC Form 498.

Consolidate, merge, or deactivate existing FCC Form 498 IDs due to a merger, acquisition, or consolidation of companies/entities.

Deactivate an FCC Form 498 ID and end participation in the federal universal service programs. High Cost and Lifeline program recipients must comply with 47 C.F.R. § 54.205 if relinquishing High Cost or Lifeline 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 or billed entity. This form allows service providers and billed entities to specify which address(es) 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 should 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 High Cost, Lifeline, 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 the federal universal service fund. 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.

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B.When and Where to File

Service providers and billed entities must submit the FCC Form 498 online via the online filing tool.

To access the online filing tool Visit the USAC E-File site at

http://www.usac.org/about/tools/e-file.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/about/getting-started/default.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 or billed entity 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 20-21 must be completed. FCC Form 498 is USAC’s official record of contact and remittance information. Service providers and billed entities, therefore, must keep the information in this form current. Failure to maintain current information may affect the timeliness of payment.

Payee Type

When beginning the form, select the box that most appropriately describes you:

Service Provider: An entity or company that provides service to customers, health care providers, or schools and libraries in the four federal universal service programs. By selecting this box, you will need to complete all pages of the FCC Form 498 that apply to your company and the programs your company participates in.

School/Library or other billed entity: An entity paying for eligible services and/or goods from a Service Provider in the Schools and Libraries Program that has chosen to receive discount reimbursement under the Billed Entity Applicant Reimbursement process (BEAR). By selecting this box, you will need to complete pages 1, 2, 7, 8, and 10 of the FCC Form 498.

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

1.Original Application for FCC Form 498 ID: Please check this box if this is the company’s or billed entity’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 or billed entity’s previously assigned FCC Form 498 ID.

3.Request for FCC Form 498 ID Merger/Consolidation: Please check this box to consolidate the activity of multiple FCC Form 498 IDs into one FCC Form 498 ID, or merge a FCC Form 498 ID into your FCC Form 498 ID 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 FCC Form 498 ID Deactivation: Please check this box to discontinue participation in all federal universal service programs and deactivate the FCC Form 498 ID in its entirety. High Cost and Lifeline recipients must comply with 47 C.F.R. § 54.205 if relinquishing High Cost or Lifeline federal universal service support. Additional documentation is required. Please see Appendix A on page 19 of the instructions for additional information.

Service Provider and Billed Entity Identification Number (FCC Form 498 ID): 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 FCC Form 498 ID to the company. Within 48 hours after processing has been completed, USAC will notify the company or billed entity of the assigned FCC Form 498 ID.

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

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 or Billed Entity Information

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

Item (1) Company or Billed Entity Name: Provide the full legal name of the company providing service or the billed entity as it appears on articles of incorporation, registration, or other legal documents.

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

As (FKA): Provide the name currently used by the service provider or billed entity; or if this form effects a name change, provide the name formerly used.

Item (3) Name of Holding Company: This is typically the name of the company’s or organization’s holding company or controlling entity, if any applies.

Item (4) TAX ID or Federal EIN of Holding Company: Enter the federal TAX ID or EIN of the company’s or organization’s Holding Company.

Item (5) Affiliated Entities: Check this box if this FCC Form 498 ID has or maintains affiliated entities as defined in Section III.E

Items (6, 7, 8, 9, & 10) Service Provider’s Address: Provide the service provider’s or billed entity’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 organization’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 or billed entity’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.

Items (11, 12, & 13) 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 organization. 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 (14, 15, 16, 17, 18, & 19) 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.

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

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

Item (20) 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 (21) Business Structure: Check one of the three boxes indicating whether the organization is a corporation, partnership or other.

Item (22) DUNS (Dun and Bradstreet): Enter the organization’s nine digit DUNS number.

Item (23) FCC Registration Number: Enter the organization’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.”

Please list the FCC Form 498 ID number as well as the name of affiliated companies as defined above.

If your organization has more than twenty two (22) affiliates, please submit 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

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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 FCC Form 498 ID (Service Provider and Billed Entity Identification Number) but cease participation in the High Cost Program. High Cost recipients must comply with 47 C.F.R. § 54.205 if relinquishing federal High Cost universal service support.

Item (24) 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 (25 & 26) 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.

Item (27 & 28) Telephone and email address of remittance contact: Provide the telephone, extension and email address of the High Cost Remittance contact.

Item (29) 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 (30 & 31) 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.

In order to protect recipients of Universal Service Funds, USAC may request additional documentation to validate the banking information submitted by filers of the FCC Form 498. Do not provide additional documentation with your submission. You will be contacted by USAC with instructions on how to securely provide this data to validate banking information. Please see Appendix B on page 23 of the instructions for additional information.

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

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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 (32, 33 34, 35, 35, 37 & 38) 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. USAC will send all non-financial 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 FCC Form 498 ID.

Items (39 & 40) Phone Number and E-Mail Address of High Cost Program Contact: Provide the phone number, and e-mail address of the High Cost Program contact person who will receive correspondence and answer questions regarding the High Cost Program

Lifeline Program

H. Block 7: Lifeline Financial Institution and Remittance Information

Please complete this section only if your company receives support from 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 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 FCC Form 498 ID (Service Provider and Billed Entity Identification Number) but cease participation in the Lifeline Program. Lifeline recipients must comply with 47 C.F.R. § 54.205 if relinquishing federal Lifeline universal service support.

Item (41) Lifeline 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 (42 & 43) Lifeline 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.

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Lifeline

Item (44& 45) Telephone and email address of remittance contact of Lifeline Remittance Contact: Provide the telephone number, extension, email address of the Life Line Remittance contact

Item (46) Name of Lifeline 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 (47& 48) Lifeline 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.

In order to protect recipients of Universal Service Funds, USAC may request additional documentation to validate the banking information submitted by filers of the FCC Form 498. Do not provide additional documentation with your submission. You will be contacted by USAC with instructions on how to securely provide this data to validate banking information. Please see Appendix B on page 23 of the instructions for additional information.

I. Block 8: Company Contact for Lifeline Program

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 (49, 50, 51, 52, 53, 54 & 55) Name, Title, and Address of Service Provider’s Lifeline Program Contact: Provide the Lifeline Program contact person’s name, title, mailing address, street address or route number, city, state, and zip code.

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 FCC Form 498 ID.

Items (56, & 57) Phone Number and E-mail Address of Lifeline 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.

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J.Block 9: High Cost and Lifeline Study Area Code (SAC)/FCC Form 498 ID Association

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

For providers that receive support from the High Cost and Lifeline Programs, please list the Study Area Codes (SACs) you wish to have associated with the Service Provider Identification Number (FCC Form 498 ID) 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 FCC Form 498 ID.

SAC: Please indicate the six (6) digit SAC.

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

Incumbent: Check this box if the FCC Form 498 ID associated with this SAC is listed with USAC as an Incumbent Carrier for that area.

Competitive: Check this box if the FCC Form498 ID 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.

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Check the box at the top of the page to maintain your FCC Form 498 ID (Service Provider and Billed Entity Identification Number) but cease participation in the federal universal service Rural Health Care Program.

Items (58) 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 (59 & 60) 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.

Item (61 & 62) Telephone and email address of remittance contact of Rural Health Care Remittance Contact: Provide the telephone number, extension, and e-mail address of the Rural Health Care Remittance contact.

Item (63) 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 (64 & 65) 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.

In order to protect recipients of Universal Service Funds, USAC may request additional documentation to validate the banking information submitted by filers of the FCC Form 498. Do not provide additional documentation with your submission. You will be contacted by USAC with instructions on how to securely provide this data to validate banking information. Please see Appendix B on page 23 of the instructions for additional information.

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.

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Items (66, 67, 68, 69, 70, 71 & 72) 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. 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 FCC Form498 ID.

Items (73 & 74) Phone 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

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

Please complete this section only if your company or billed entity 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 FCC Form 498 ID (Service

Provider and Billed Entity Identification Number) but cease participation in the federal universal service Schools and Libraries Program. (This box applies to service providers only)

Item (75) Schools and Libraries Remittance Company Name: Provide the name of the company or billed entity that will receive payment for Schools and Libraries Program payments if different than the company indicated in Block 1.

Items (76 & 77) 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.

Item (78 & 79) Telephone and email address of remittance contact for Schools and Libraries Remittance Contact: Provide the telephone number, extension, and e-mail address of the Schools and Libraries Remittance contact.

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Item (80) 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 (81&82) Schools and Libraries Remittance Financial Institution Account Number and Transit Number for ACH Payments: Provide the ACH financial institution account number and transit number. This cannot be a consultant’s account. Please be sure that the transit number is nine digits. If you do not provide this information, you will not receive payment.

In order to protect recipients of Universal Service Funds, USAC may request additional documentation to validate the banking information submitted by filers of the FCC Form 498. Do not provide additional documentation with your submission. You will be contacted by USAC with instructions on how to securely provide this data to validate banking information. Please see Appendix B on page 23 of the instructions for additional information.

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

Please complete this block only if your company or billed entity 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 (83, 84 85, 86, 87, 88 & 89) 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. USAC will send all Schools and Libraries Program correspondence to this address. This contact should be an employee of the organization. This contact is authorized to request additional Schools and Libraries Program information related to this FCC Form 498 ID.

Items (90 &91) Phone and E-Mail Address of Service Provider

Schools and Libraries Program Contact: Provide the phone 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.

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O.Block 14: Billed Entity/FCC Form 498 Association (For BEAR Recipients only)

If you are a billed entity that has chosen to receive your schools and libraries (E-rate) payments from the universal service fund in the form of BEAR (Billed Entity Applicant Reimbursement) payments, please enter the Billed Entity Numbers that are to be associated with the FCC Form 498 ID on this form.

P.Block 15: Offsetting Disbursement Payments against Federal Universal Service Contribution Obligations For High Cost Program Participants

This block only relates to telecommunications carriers participating in the High Cost Program. A telecommunications carrier may choose to offset the amount eligible for support under the High Cost Program against its federal universal service contribution obligation. A telecommunications carrier must have an FCC Form 499 Filer ID number to offset its High Cost 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 FCC Form498 ID.

Item (92) Offset Indicator: The service provider must indicate (by checking

the box or leaving it blank) whether or not it is requesting to have its High Cost invoice payments offset against the service provider’s federal universal service contribution obligations.

Q.Block 16: Offsetting Disbursement Payments against Federal Universal Service Contribution Obligations For Lifeline Program Participants

This block only relates to telecommunications carriers participating in the Lifeline Program. A telecommunications carrier may choose to offset the amount eligible for support under the Lifeline Program against its federal universal service contribution obligation. A telecommunications carrier must have an FCC Form 499 Filer ID number to offset its Lifeline 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 FCC Form498 ID.

Item (93) Offset Indicator: The service provider must indicate (by checking

the box or leaving it blank) whether or not it is requesting to have its High Cost invoice payments offset against the service provider’s federal universal service contribution obligations.

R.Block 17: Offsetting Disbursement Payments against Federal Universal Service Contribution Obligations For Rural HealthCare Program Participants

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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.

Item (94) 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.

S. Block 18: Certification to Assist Health Care Providers

This block only relates to service providers participating in the Healthcare Connect Fund Program. In accordance with section 54.640(b) of the Commission’s rules, 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 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 (95) Healthcare Connect Fund Program 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.

T.Block 19: 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 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 FCC Form498 ID.

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Item (96) 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.

U. Block 20: Principal Communications Business Types Block 20 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. Certain categories that reflect revenue subject to FCC Form 499 reporting will require the company to have an FCC Form 499 Filer ID.

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V. Block 21: DATA Act Business Types

Block 21 requires the selection of up to three Business Types that best describe the organization. These selections will be reported as part of the Data Accountability and Transparency (DATA) Act.

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C. Block 22: Officer Certification

Block 22 requires the signature of the Company/Organization 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.

For Service Providers:

An officer is a person who occupies a position specified in the corporate by-laws (or partnership agreement), and would typically be president, vice president for operations, vice president for finance, comptroller, treasurer, or a comparable position. If the filer is a sole proprietorship, the owner must sign the certification.

For Billed Entities:

An officer is a person who occupies a position authorized by the school, district or country, and consortium applicants, and would typically be a Superintendent, Assistant Superintendent, Principal or Assistant Principal, County or District Administrator, or state education department leads.

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/Organization Officer certifying the form. The e-mail address will be used for return 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/Organization 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 FCC Form 498 ID 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.

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Notice on e-filing and e-certification:

Filers are required to enter data, and to verify, submit, and certify the FCC Form 498 data online via a web-based data entry system. An electronic signature by the officer will be considered the equivalent to a handwritten signature certifying the accuracy of the data. The officer, therefore, acknowledges that such electronic signature certifies his or her identity and attests under penalty of perjury as to the truth and accuracy of the information contained in each electronically signed submission.

Visit http://www.usac.org/cont/tools/forms for more information and access to the online filing system. If you need additional assistance you can contact USAC Customer Support at (888) 641-8722, or CustomerSupport@usac.org for assistance in filing your FCC Form 498.

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 or billed entity receiving federal universal service support from the High-Cost, Life Line, 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. In addition, the Name, Address, DUNS Number and Business Type will be disclosed in accordance with FFATA/DATA Act reporting requirements. 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 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

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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.

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Appendix A:

FCC Forms 498 ID 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 FCC Form498 ID data and activity.

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

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

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

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

FCC Form 498 ID Deactivation Requirements.

To successfully process a FCC Form 498 ID Deactivation, USAC requires the following information to be submitted to USAC. This information can be submitted via the USAC E- File System:

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 FCC Form 498 ID being deactivated.

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

When Filing your FCC Form 498 online you will be prompted to upload the required documents to complete these types of requests.

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Appendix B:

Validation of Banking Information.

USAC may request additional documentation to validate and confirm the banking information provided on a new or revised FCC Form 498 submission.

Information that may be requested to validate the banking information will consist of:

The first page of a banking statement that clearly indicates the name of the entity, bank name, routing number and account number; and/or

A voided check that indicates the name of the entity, bank name, routing number and account numbers.

Do not submit this additional documentation with your FCC Form 498 submission.

Not all FCC Form 498 submissions may require this validation. For example, if you have an existing FCC Form 498 and file a revision that does not modify the banking information, you will not be asked to validate the banking data included on the revised form.

If USAC is required to validate the banking information, you will be contacted with instructions on how to securely provide this documentation through our electronic filing system for review. Once the documentation is received, USAC will review the documents and approve the FCC Form 498 banking information. USAC will maintain your documentation only as needed to validate your banking information or as required by the Commission’s records requirements. These documents will otherwise be destroyed.

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