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Commission Document Attachment

DA-13-1636A2

FCC Form 479
Approval by OMB 3060-0853
Estimated time per response: 1 hour

DO NOT SEND THIS FORM TO THE UNIVERSAL SERVICE ADMINSTRATIVE COMPANY

OR TO THE FEDERAL COMMUNICATIONS COMMISSION

Schools and Libraries Universal Service

Certification by Administrative Authority to Billed Entity of

Compliance with the Children's Internet Protection Act

Please read instructions before completing.
(To be completed by the Administrative Authority and provided to your Billed Entity)
Administrative Authority's Form Identifier: __________________________________________
Create your own code to identify THIS FCC Form 479.

Block 1: Administrative Authority Information

1. Name of Administrative Authority
2. Funding Year
3. Mailing Address and Contact Information for Administrative Authority
Street Address, P. O. Box or Route Number
City
State Zip Code
Name of Contact Person
Telephone Number Fax Number Email Address

Persons willfully making false statements on this form can be punished by fine or forfeiture, under the

Communications Act, 47 U.S.C. Secs. 502, 503(b), or fine or imprisonment under Title 18 of the United States

Code, 18 U.S.C. Sec. 1001.

Block 2: Certifications and Signature

4. I am the Administrative Authority for one or more schools or libraries for which Universal Service Support Mechanism
discounts have been requested or approved for eligible services. The Administrative Authority must make the
required certification(s) for the purposes of the Children's Internet Protection Act (CIPA) in order to receive
discounted services.
5. I recognize that I may be audited pursuant to this form and will retain for at least five years (or whatever retention
period is required by the rules in effect at the time of this certification) any and all records that I rely upon to complete
this form.

OMB Control No. 0360-0853

Name of Administrative Authority _________________________________________________________________
Administrative Authority's Form Identifier __________________________________________________________
Contact Person _________________________________________________________________________
Telephone Number______________________________________________________________________________
Block 2: Certifications and Signature (Continued)

6. I certify that as of the date of the start of discounted services:
a
the recipient(s) of service under my administrative authority and represented in the Funding Request Number(s)
for which you have requested or received Funding Commitments has (have) complied with the requirements of
the Children's Internet Protection Act, as codified at 47 U.S.C. 254(h) and (l).
b
pursuant to the Children's Internet Protection Act, as codified at 47 U.S.C. 254(h) and (l), the recipient(s) of
service under my administrative authority and represented in the Funding Request Number(s) for which you
have requested or received Funding Commitments:
(FOR SCHOOLS and FOR LIBRARIES IN THE FIRST FUNDING YEAR FOR PURPOSES OF CIPA) is
(are) undertaking such actions, including any necessary procurement procedures, to comply with the
requirements of CIPA for the next funding year, but has (have) not completed all requirements of CIPA for
this funding year.
(FOR FUNDING YEAR 2003 ONLY: FOR LIBRARIES IN THE SECOND OR THIRD FUNDING YEAR FOR
PURPOSES OF CIPA) is (are) in compliance with the requirements of CIPA under at 47 U.S.C. 254(l) and
undertaking such actions, including any necessary procurement procedures, to comply with the
requirements of CIPA under 47 U.S.C. 254(h) for the next funding year.
c
the Children's Internet Protection Act, as codified at 47 U.S.C. 254(h) and (l), does not apply because the
recipient(s) of service under my administrative authority and represented in the Funding Request Number(s) for
which you have requested or received Funding Commitments is (are) receiving discount services only for
telecommunications services.
CIPA Waiver. Check the box below if you are requesting a waiver of CIPA requirements for the Second Funding Year
after the recipients of service under your administrative authority have applied for discounts:
d
I am providing notification that, as of the date of the start of discounted services, I am unable to make the
certifications required by the Children's Internet Protection Act, as codified at 47 U.S.C. 254(h) and (l),
because my state or local procurement rules or regulations or competitive bidding requirements prevent the
making of the certification(s) otherwise required. I certify that the recipient(s) of service under my administrative
authority and represented in the Funding Request Number(s) for which you have requested or received Funding
Commitments will be brought into compliance with the CIPA requirements before the start of the Third Funding
Year in which they apply for discounts.
(CIPA WAIVER FOR LIBRARIES FOR FUNDING YEAR 2004. Check the box above if you are requesting this waiver
of CIPA requirements for Funding Year 2004 for the library(ies) under your administrative authority that have applied
for discounts for Funding Year 2004. By checking this box, you are certifying that the libraries represented in the
Funding Request Number(s) on this FCC Form 479 will be brought into compliance with the CIPA requirements before
the start of the Funding Year 2005).

The certification language above is not intended to fully set forth or explain all the requirements of the statute.

7. Signature of authorized person
8. Date
9. Printed name of authorized person
10. Title or position of authorized person
11. Telephone number of authorized person
Page 2 of 3
FCC Form 479
Month 2013

OMB Control No. 0360-0853

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 54 of the Commission's Rules authorizes the FCC to collect the information on this form. Failure to provide all
requested information will delay the processing of the application or result in the application being returned without
action. Information requested by this form will be available for public inspection. Your response is required to obtain the
requested authorization.
The public reporting for this collection of information is estimated to be 1 hour per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the required data, and completing and
reviewing the collection of information. If you have any comments on this burden estimate, or how we can improve the
collection and reduce the burden it causes you, please write to the Federal Communications Commission, AMD-PERM,
Paperwork Reduction Act Project (3060-0853), Washington, DC 20554. We will also accept your comments regarding
the Paperwork Reduction Act aspects of this collection via the Internet if you send them to PRA@fcc.gov. PLEASE DO
NOT SEND YOUR RESPONSE TO THIS FORM TO THIS ADDRESS.
Remember - 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 OMB control number or if
we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-0853.

THE FOREGOING NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31,
1974, 5 U.S.C. 552a(e)(3) AND THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1,
1995, 44 U.S.C. SECTION 3507.

A paper copy of this form, with a signature in Block 2, Item 7, must be mailed or delivered to your Billed Entity.

Page 3 of 3
FCC Form 479
Month 2013

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