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About Rural Health CareRural Health Care Tools

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. Applicants may also complete a form online (see below) and then download the completed form, sign it and submit the paper copy by mail. Forms may also be downloaded and filled out by hand. The paper copy of the forms must be signed and dated by the applicant, and mailed to:

Rural Health Care Division
30 Lanidex Plaza West
P.O. Box 685
Parsippany, NJ 07054-0685

Forms are available in three formats:

  • Adobe Acrobat
  • MS Excel
  • MS Word
FY 2005 Form 465
Description of Services Requested and Certification

Apply Online  or

Download:   Download FY5 Form 465 (Excel) 57kb  |   Download FY5 Form 465 (PDF) 29kb

View Instructions

Download:   View fy4&5 Form 465 instructions (word) 88kb  |  View FY4 & 5 Form 465 instructions (pdf) 38kb

FY 2005 Form 467
Description of Services Requested and Certification

Apply Online  or

Download:   Download FY5 Form 465 (Excel) 55kb  |   Download FY5 Form 465 (PDF) 38kb

View Instructions

Download:   View fy4&5 Form 465 instructions (word) 68kb  |  View FY4 & 5 Form 465 instructions (pdf) 37kb

FY 2005 Form 466
Description of Services Requested and Certification

Apply Online  or

Download:   Download FY5 Form 465 (Excel) 194kb  |   Download FY5 Form 465 (PDF) 56kb

View Instructions

Download:   View fy4&5 Form 465 instructions (word) 109kb  |  View FY4 & 5 Form 465 instructions (pdf) 57kb

FY 2005 Form 466A
Description of Services Requested and Certification

Apply Online  or

Download:   Download FY5 Form 465 (Excel) 61kb  |   Download FY5 Form 465 (PDF) 27kb

View Instructions

Download:   View fy4&5 Form 465 instructions (word) 79kb  |  View FY4 & 5 Form 465 instructions (pdf) 29kb


FY 2004 Form 467
Receipt of Service Confirmation

Apply Online  or

Download only:   Download FY5 Form 467 (Excel) 52kb  |   Download FY5 Form 467 (PDF)  26kb

View instructions  or

Download:  View FY4 & 5 Form 467 instructions(Word) 93kb  |   View FY4 & 5 Form 467 instructions (PDF) 23kb

 

FY 2003 Form 465
Description of Services Requested and Certification

The FY2003 Form 465 is no longer being accepted.

FY 2003 Form 467
Receipt of Service Confirmation

Download only:   Download FY5 Form 467 (Excel) 53kb  |   Download FY5 Form 467 (PDF)  31kb

View instructions  or

Download:  View FY4 & 5 Form 467 instructions(Word) 54kb  |   View FY4 & 5 Form 467 instructions (PDF) 54kb


FY 2002 Form 467
Receipt of Service Confirmation

Download only:   Download FY5 Form 467 (Excel) 53kb  |   Download FY5 Form 467 (PDF)  31kb

View instructions  or

Download:  View FY4 & 5 Form 467 instructions(Word) 54kb  |   View FY4 & 5 Form 467 instructions (PDF) 54kb

Service Provider Forms

Please download the instructions and read carefully for guidance on filling out the Service Provider forms.

Service Provider Forms

Form 499-Q
Quarterly Telecommunications Reporting Worksheet

Complete 499-Q Online or

Download Form and Instructions:     91kb

Additional Resources:
- Contributor Companies Helpful Hints
- FCC Methodology Calculation Example

Form 499-A
Annual Telecommunications Reporting Worksheet

Due Date: April 1, 2005

Complete 499-A Online or

Download Form:      241kb
Download Instructions:  172kb

Additional Resources:
- Reporting Requirements
- General Helpful Hints
- FCC Methodology Calculation Example
- How to File Form 499A Online

Content Last Modified: November 22, 2005