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DA-13-1590A3

FCC Form 471
Do not write in this area.
Approval by OMB
3060-0806

Schools and Libraries Universal Service


Description of Services Ordered and Certification Form 471


Estimated Average Burden Hours per Response: 4 hours

This form is designed to help schools and libraries to list the eligible services they have ordered and estimate the annual
charges for them so that the Fund Administrator can set aside sufficient support to reimburse providers for services.

Please read instructions before beginning this application. (You can also file online at http://www.usac.org/sl" title="www.usac.org/sl">www.usac.org/sl.)

The instructions include information on the deadlines for filing this application.

Applicant's Form Identifier (Create an identifier for your own reference)
Form 471 Application #:

X

(To be assigned by administrator)

Block 1: Billed Entity Address and Information

1 Name of Billed Entity

X XX X


2 Funding Year
(Funding years run from July 1 through the following June 30)
3a Entity Number
3b FCC Registration Number
4a Street Address, P.O. Box, or Route Number

City State
Zip Code
4b Telephone Number

Ext
4c Fax Number
5a Type of Application (check only one)
Individual School (individual public or non-public school)
School District (LEA; public or non-public [e.g. diocesan] local district representing multiple schools)
Library (including library system, library outlet/branch or library consortium as defined under LSTA)
Consortium (intermediate service agencies, consortia of schools and/or libraries)

Statewide application for (enter 2-letter state code)
representing (check all that apply)
All public schools/districts in the state

All non-public schools in the state
All libraries in the state
5b Recipient(s) of Services:
Private Public Charter
Federal Entity
Tribal Head Start State Agency
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FCC Form 471 [Month] 2013

OMB 3060-0806

Entity Number

__________________________________

Applicant's Form Identifier

__________________________________

Contact Person

__________________________________

Contact Telephone Number

__________________________________

Block 1: Billed Entity Address and Information (continued)

6a Contact Person's Name
If the Contact Person's Street Address is the same as

Item 4

above, check here. If not, complete Item 6b.
6b Street Address, P.O. Box, or Route Number NOTE: USAC will use THIS address to mail correspondence about this
form.
City
State
Zip Code
Check the box next to your preferred mode of contact and provide your contact information. One box MUST be checked and an
entry provided.
6c Telephone Number
Ext.
6d Fax Number
6e E-mail Address
Re-enter E-mail Address
6f Holiday/vacation/summer contact information: please include name of alternate contact (if applicable) and
alternate phone, fax or E-mail address

If a consultant is assisting you with your application process, please complete Item 6g below:

6g Consultant Name
Name of Consultant's Employer
Consultant's Street Address
City
State Zip Code
Consultant's Telephone Number
Ext.
Consultant's Fax Number
Consultant's E-mail Address
Re-enter E-mail Address
Consultant Registration Number

Blocks 2 and 3 [Reserved]

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FCC Form 471 [Month] 2013

OMB 3060-0806
OMB 3060-0806

Entity Number

__________________________________

Applicant's Form Identifier

__________________________________

Contact Person

__________________________________

Contact Telephone Number

__________________________________

Block 4: Discount Calculation Worksheet

Worksheet _______

Page ______ of _______

The Block 4 worksheet is used to calculate your discount for services. You will complete one or more worksheets depending on the type of application
you are filing. If you file more than one worksheet, please number the completed worksheets to assure that they are all processed correctly. Please
refer to the instructions for information specific to the Type of Application you indicated in Block 1, Item 5.
Check here if this worksheet contains all eligible entities in the school district or library system.
9a List entities and calculate discount(s):
(For Administrator's Use)

School District or Library System Name:

School District or Library System Entity Number:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Name of Eligible Entity

Entity Number AND

Urban

Total

Number of

Percent of

Disc.

New

Admin

Alt

Weighted Product

Insert appropriate code(s):

Entity Number of School

Discount

Shared

NCES Code (for Schools) or

or

Number of

Students

Students

from

Cons

Entity

Disc

for Calculating

P = pre-K, H = Head Start,

District in which Library

of

Discount

FSCS Code (for Libraries)

Rural

Students

Eligible for

Eligible for

Disc.

tructi
or NIF

Mech

Shared Discount

A = Adult Education,

Outlet/Branch is Located

Member

U or R

NSLP

NSLP

Matrix

on
(Col. 4 x Col. 7)

J = Juvenile Justice,

Entity

(Col. 5 / Col 4)

E = ESA, D = Dormitory

Schools with

Schools

Library Outlet/Branch

Consortia

ALL ENTITIES

SCHOOLS AND LIBRARIES

shared services

9b Shared Services
SCHOOL DISTRICTS: (Including groups of schools within
school districts.) Calculate the totals of Columns 4 and 11.
Divide the total of Column 11 by the total of Column 4. Enter
the result in Column 15.
LIBRARY SYSTEMS: Calculate the total of Column 7.
Divide this total by the number of outlets/branches. Enter the
result in Column 15.
CONSORTIA: Calculate the total of Column 14. Divide this
total by the number of member entities. Enter the result in
Column 15.
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FCC Form 471 [Month] 2013

OMB 3060-0806

Entity Number

__________________________________

Applicant's Form Identifier

_________________________________

Contact Person

__________________________________

Phone Number

_________________________________

Block 5: Discount Funding Request(s)
Instructions:

Use one Block 5 page for EACH service (Funding Request Number)

Block 5, page of

for which you are requesting discounts. Make as many copies of this page as
needed, and number the completed pages to assure that they are all processed correctly.
FRN ______________________

(to be assigned by administrator)
If this is a duplicate Funding Request (e.g., of an FRN that is not yet approved, under appeal,
10
etc.), check this box and enter the original FRN in the space provided:

Category of Service

( only ONE category should be checked)
23 Calculations
11

A.

Monthly charges (total amount per month for service)

PRIORITY 1

PRIORITY 2

Telecommunications
Internal Connections Other than Basic
Service
Maintenance
Internet Access
Basic Maintenance of Internal
Connections
12

Form 470 Application Number

B.

How much of the amount in A is ineligible?
13

SPIN Service Provider Identification Number

C.

Eligible monthly pre-discount amount (A minus B)

Recurring Charges

14

Service Provider Name

D.

Number of months service provided in funding year

E.

Annual pre-discount amount for eligible recurring charges
(C x D)
15a
Check this box if this Funding Request is for non-contracted tariffed or
month-to-month services.

F.

Annual non-recurring charges

Contract Number

15b
15c
Check this box if this Funding Request is covered under a master contract (a

G.

How much of the amount in F is ineligible?
contract negotiated by a third party, the terms and conditions of which are then made
available to an eligible entity that purchases directly from the service provider).
-
Recurring Charges

15d
Check this box if this Funding Request is a
continuation of an FRN from a previous

Non

funding year based on a multi-year contract.
If so, provide that FRN here:
16a

Billing Account Number

(e.g., billed telephone number)

H.

Annual eligible pre-discount amount for non-recurring charges
16b
Check this box if there are multiple Billing Account Numbers and attach a
complete list of those numbers to this page.
(F minus G)

Allowable Vendor Selection/Contract Date

(mm/dd/yyyy)
17

Contract Award Date (mm/dd/yyyy)

18

I.

Total funding year pre-discount amount (E + H)

Service Start Date

(mm/dd/yyyy)
19
20a

Service End Date

(mm/dd/yyyy)

J.

Discount from Block 4 Worksheet

Contract Expiration Date

Total Charges

K.

Funding Commitment Request (I x J)
20b
(mm/dd/yyyy)
21

Description of This Service: NOTE: All Item 21 Attachments must be filed before the close of the filing window.

Attachment

You MUST attach a description of the service, including a breakdown of components, costs, manufacturer name, make and model number. You
must include any additional account or telephone numbers if the billed account has multiple numbers. Label the description with an Attachment
Number, and note number in space provided.
a. If the service is site-specific (provided to one site
22

Entity/Entities Receiving This Service:

and not shared by others), list the Entity Number of
the entity from Block 4 receiving this service:
b. If the service is shared by all entities on a Block 4
worksheet, list the worksheet number (e.g., 1):
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FCC Form 471 [Month] 2013

OMB 3060-0806
Do not write in this area

Entity Number

__________________________________

Applicant's Form Identifier

_________________________________

Contact Person

__________________________________

Phone Number

_________________________________

Block 5 (Continued):

Description of Broadband and other Connectivity Services Ordered for Schools and Libraries from this

24 funding request
Complete the information below for this funding request only if requesting

Telecommunications Services

or

Internet Access

for the purpose
of providing broadband and other types of connectivity to school and/or library facilities.
Check this box if this request is for services or equipment that do not providing broadband or connectivity and skip to Item 25. For instance,
check the box if this funding request is for internal connections, basic maintenance, or requests for services like e-mail or phone service.
a Which technology(ies) and speed(s) are being provided in this Funding Request? Please list the number of lines and average download speed
for the lines included in this funding request. If there are multiple download speeds for the lines within one type of broadband connection, this
form provides two additional lines per broadband connection category. If you need additional space, please makes copies of this page and
number the completed pages to assure that they are all processed correctly. A response to this Item is not a substitute for a complete response
to Item 21 but should be consistent with the description of services in the response to Item 21. Please ask your service provider if you need
assistance.
For example, if an applicant was requesting three DSL connections, two averaging 2 Mbps download speed and a third averaging 3 Mbps
download speed, the entries would look like this:

Type of connection

Number of lines

Download speed per

included in this FRN
line in Mbps
DSL
2
2 Mbps
DSL
1
3 Mbps

Number of lines

Download speed per

Type of connection

included in this FRN
line in Mbps
Dial-up
.056 Mbps
T1/DS-1
1.5 Mbps
T3/DS-3
45 Mbps
Fiber optic/OC-x
Fiber optic/OC-x
Fiber optic/OC-x
Cable
Cable
Cable
DSL
DSL
DSL
Satellite
Satellite
Cellular Wireless
Cellular Wireless
Non-Cellular Wireless (e.g. microwave)
Non-Cellular Wireless (e.g. microwave)
b If the Internet service is available to students or patrons in more than just a single location or office, please indicate:
1. If the access is provided by wired connections, approximately what percentage of the school classroom or public library spaces
included in the Block 4 worksheet for this FRN will have access to wired drops? _____%
2. If the access is provided by Wi-FI connections, approximately what percentage of the school classroom or public library spaces
included in the Block 4 worksheet for this FRN will have access to a Wi-Fi signal? _____%
c For consortia and statewide applications, do the connections in this FRN include the last mile connection to the school or library? Yes No
If no above, are these connections only for backbone connections? Yes No
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FCC Form 471 [Month] 2013

OMB 3060-0806
Do not write in this area

Entity Number

__________________________________

Applicant's Form Identifier

_________________________________

Contact Person

__________________________________

Phone Number

_________________________________

Block 6: Certifications and Signature

25
I certify that the entities listed in Block 4 of this application are eligible for support because they are: (Check one or both.)
a
schools under the statutory definitions of elementary and secondary schools found in the

No Child Left Behind Act of 2001, 20 U.S.C.
7801(18) and (38)

, that do not operate as for-profit businesses and do not have endowments exceeding $50 million; and/or
b
libraries or library consortia eligible for assistance from a State library administrative agency under the Library Services and Technology
Act of 1996 that do not operate as for-profit businesses and whose budgets are completely separate from any schools, including, but not
limited to, elementary, secondary schools, colleges, or universities.
26
I certify that the entity I represent or the entities listed on this application have secured access, separately or through this program, to all of the
resources, including computers, training, software, internal connections, maintenance, and electrical capacity, necessary to use the services
purchased effectively. I recognize that some of the aforementioned resources are not eligible for support. I certify that the entities I represent or
the entities listed on this application have secured access to all of the resources to pay the discounted charges for eligible services from funds to
which access has been secured in the current funding year. I certify that the Billed Entity will pay the non-discount portion of the cost of the goods
and services to the service provider(s).
a
Total funding year pre-discount amount on this Form 471
(Add the entries from Items 23I on all Block 5 Discount Funding Requests.)
b
Total funding commitment request amount on this Form 471
(Add the entries from Items 23K on all Block 5 Discount Funding Requests.)
c
Total applicant non-discount share
(Subtract Item 25b from Item 25a.)
d
Total budgeted amount allocated to resources not eligible for E-rate support
Total amount necessary for the applicant to pay the non-discount share of the
e
services requested on this application AND to secure access to the resources
necessary to make effective use of the discounts. (Add Items 25c and 25d.)
Check this box if you are receiving any of the funds in Item 25e directly from a service provider listed on any of the Forms 471 filed by this
f
Billed Entity for this funding year, or if a service provider listed on any of the Forms 471 filed by this Billed Entity for this funding year assisted
you in locating funds in Item 25e.
27
I certify that, if required by Commission rules, all of the individual schools and libraries receiving services under this form are
covered by technology plans that do or will cover all 12 months of the funding year, and that have been or will be approved
by a state or other authorized body or an SLD-certified technology plan approver prior to the commencement of service.
Or
I certify that no technology plan is required by Commission rules.
28
I certify that (if applicable) I posted my Form 470 and (if applicable) made any related RFP available for at least 28 days before considering all bids
received and selecting a service provider. I certify that all bids submitted were carefully considered and the most cost-effective service offering was
selected, with price being the primary factor considered, and is the most cost-effective means of meeting educational needs and technology plan
goals.
29 I certify that the entity responsible for selecting the service provider(s) has reviewed all applicable FCC, state, and local procurement/competitive
bidding requirements and that the entity or entities listed on this application have complied with them.
30
I certify that the services the applicant purchases at discounts provided by 47 U.S.C. 254 will be used primarily for educational purposes and will
not be sold, resold or transferred in consideration for money or any other thing of value, except as permitted by the Commission's rules at 47 C.F.R.
54.500, 54.513. Additionally, I certify that the entity or entities listed on this application have not received anything of value or a promise of
anything of value, other than services and equipment sought by means of this form, from the service provider, or any representative or agent
thereof or any consultant in connection with this request for services.
31
I certify that I and the entity(ies) I represent have complied with all program rules, including recordkeeping requirements, and I acknowledge that
failure to do so may result in denial of discount funding and/or cancellation of funding commitments. There are signed contracts covering all of
the services listed on this Form 471 except for those services provided under non-contracted tariffed or month-to-month arrangements. I
acknowledge that failure to comply with program rules could result in civil or criminal prosecution by the appropriate law enforcement authorities.
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FCC Form 471 [Month] 2013

OMB 3060-0806
Do not write in this area

Entity Number

__________________________________

Applicant's Form Identifier

__________________________________

Contact Person

__________________________________

Phone Number

__________________________________

Block 6: Certification and Signature (Continued)

32
I acknowledge that the discount level used for shared services is conditional, for future years, upon ensuring that the most disadvantaged schools
and libraries that are treated as sharing in the service, receive an appropriate share of benefits from those services.
33
I certify that I will retain required documents for a period of at least five years (or whatever retention period is required by the rules in effect at the
time of this certification), after the last day of service delivered. I certify that I will retain all documents necessary to demonstrate compliance with
the statute and Commission rules regarding the application for, receipt of, and delivery of services receiving schools and libraries discounts, and
that if audited, I will make such records available to the Administrator. I acknowledge that I may be audited pursuant to participation in the schools
and libraries program.
34
I certify that I am authorized to order telecommunications and other supported services for the eligible entity(ies) listed on this application. I certify
that I am authorized to submit this request on behalf of the eligible entity(ies) listed on this application, that I have examined this request, that all of
the information on this form is true and correct to the best of my knowledge, that the entities that are receiving discounts pursuant to this application
have complied with the terms, conditions and purposes of the program, that no kickbacks were paid to anyone and that false statements on this
form can be punished by fine or forfeiture under the Communications Act, 47 U.S.C. 502, 503(b), or fine or imprisonment under Title 18 of the
United States Code, 18 U.S.C. 1001 and civil violations of the False Claims Act.
35
I acknowledge that FCC rules provide that persons who have been convicted of criminal violations or held civilly liable for certain acts arising from
their participation in the schools and libraries support mechanism are subject to suspension and debarment from the program. I will institute
reasonable measures to be informed, and will notify USAC should I be informed or become aware that I or any of the entities listed on this
application, or any person associated in any way with my entity and/or the entities listed on this application, is convicted of a criminal violation or
held civilly liable for acts arising from their participation in the schools and libraries support mechanism.
36
I certify that if any of the Funding Requests on this Form 471 are for discounts for products or services that contain both eligible and ineligible
components, that I have allocated the eligible and ineligible components as required by the Commission's rules at 47 C.F.R. 54.504(g)(1), (2).
37
I certify that this funding request does not constitute a request for internal connections services, except basic maintenance services, in violation of
the Commission requirement that eligible entities are not eligible for such support more than twice every five funding years, as required by the
Commission's rules at 47 C.F.R. 54.506(c).
38
I certify that the non-discount portion of the costs for eligible services will not be paid by the service provider. The pre-discount costs of eligible
services featured on this Form 471 are net of any rebates or discounts offered by the service provider. I acknowledge that, for the purpose of this
rule, the provision, by the provider of a supported service, of free services or products unrelated to the supported service or product constitutes a
rebate of some or all of the cost of the supported services.
39
Signature of
40
Date
authorized
person
Printed name
41
of authorized
person
42
Title or position
of authorized
person
Check here if the consultant in Item 6g is the Authorized Person.

43a
Street Street Address, P.O. Box, or Route Number
City
State Zip Code
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FCC Form 471 [Month] 2013

OMB 3060-0806

Entity Number

__________________________________

Applicant's Form Identifier

__________________________________

Contact Person

__________________________________

Contact Telephone Number

__________________________________
.
43b
Telephone Number
Ext.
of Authorized

Person

43c
Fax Number of Authorized Person
E-mail Address
43d
of Authorized
Person
Re-enter E-mail Address
43e
Name of Authorized
Person's Employer

NOTICE:

Section 54.504 of the Federal Communications Commission's rules requires all schools and libraries ordering services that are eligible for and seeking
universal service discounts to file this Services Ordered and Certification Form (FCC Form 471) with the Universal Service Administrator. 47 C.F.R. 54.504(c).
The collection of information stems from the Commission's authority under Section 254 of the Communications Act of 1934, as amended. 47 U.S.C. 254. The
data in the report will be used to ensure that schools and libraries comply with the competitive bidding requirement contained in 47C.F.R. 54.504. All schools
and libraries planning to order services eligible for universal service discounts must file this form themselves or as part of a consortium.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number.
The FCC 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 to determine whether approving this application is in the public interest. If we believe there may be a violation or a potential violation of any applicable
statute, regulation, rule or order, your application 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 or a court
or adjudicative body when (a) the FCC; or (b) any employee of the FCC; 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 FCC may
also provide the information to these agencies through the matching of computer records when authorized.
If you do not provide the information we request on the form, the FCC may delay processing of your application or may return your application without action.
The foregoing Notice is required by the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. 3501, et seq.
Public reporting burden for this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, completing, and reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing the reporting burden to the Federal Communications
Commission, Performance Evaluation and Records Management, Washington, DC 20554.

Please submit this form to:

SLD-Form 471
P.O. Box 7026
Lawrence, Kansas 66044-7026

For express delivery services or U.S. Postal Service, Return Receipt Requested, mail this form to:

SLD Forms
ATTN: SLD Form 471
3833 Greenway Drive
Lawrence, Kansas 66046
(888) 203-8100

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FCC Form 471 [Month] 2013

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