Rural Health Care

Forms

Please note that the RHC Program application forms, which expired on December 31, 2016, were replaced with new OMB-approved forms in My Portal on January 1, 2017. Applicants should refer to My Portal for the most up-to-date application forms.

Beginning January 1, 2017, applicants may only submit form data through My Portal and may not submit paper or PDF versions of paper forms. Telecom Program applicants requiring additional assistance with the transition to submission online can contact us via email.

For an overview these forms, review the Guide to Forms.

Funding Year 2015 & 2016

FCC Form 465

File Online

Description of Services Requested and Certification Form

Community Mental Health Center Checklist

FCC Form 466

File Online

Funding Request and Certification Form

FCC Form 467

File Online

Connection Certification Form

Click here for Prior Year Forms.

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