Rural Health Care

Forms

The forms may be revised each funding year. Applicants must use the correct funding year form to participate. Applicants are encouraged, if possible, to e-cert and submit their forms electronically. For more information about these forms, review the Guide to Forms.

Funding Year 2015 & 2016

FCC Form 465

File Online

Description of Services Requested and Certification Form

FCC Form 465 and Instructions

Community Mental Health Center Checklist

FCC Form 466

File Online

Funding Request and Certification Form

FCC Form 466 and Instructions

FCC Form 467

File Online

Connection Certification Form

FCC Form 467 and Instructions

Click here for Prior Year Forms.

Click here for Service Provider and Contributor forms (FCC Forms 498, 499-A/Q)