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Commission Document Attachment

DA-13-1636A4

FCC Form 486
Do Not Write in this Area Approval by OMB
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3060-0853
Estimated time
per response: 1.5 hours

Schools and Libraries Universal Service

Receipt of Service Confirmation and Children's Internet Protection Act and Technology Plan Certification

Form

To be completed by the Billed Entity
Please read instructions before completing. (You can also file online.)
Applicant's Form Identifier
FCC Form 486 Application#: ______________
(Create your own code to identify THIS FCC Form 486)
(To be assigned by administrator)

Block 1: Billed Entity Information
1. Name of Billed Entity

2.aBilled Entity Number
3. Funding Year July 1, ________ through June 30, __________
4. Complete Mailing Address of Billed Entity
Street Address, P.O. Box, or Route Number
City
State Zip Code
Telephone Number Extension
Fax Number
5. Contact Person Information
Contact Person Name
Street Address, P.O. Box or Route Number
City
State Zip Code

Check the box next to the preferred mode of contact. (At least one box MUST be checked.)

Telephone Number Extension Fax Number
Email Address
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Entity Number

__________________

Applicant's Form Identifier

___________________________

Contact Person

__________________________________

Phone Number

_________________________

Block 2: Early Filing Information and CIPA Waiver Requests

6a.

Early Filing

CHECK THE BOX BELOW IF THE FRNS ON THIS FCC FORM 486 ARE FOR SERVICES STARTING ON OR
BEFORE
JULY 31 OF THE FUNDING YEAR.
The Funding Requests listed in Block 3 have been approved by USAC as shown in my Funding Commitment
Decision Letter (FCDL). I have confirmed with the service provider(s) featured in those Funding Requests that
these services will start on or before July 31 of the Funding Year.

Remember: Early filing using Item 6a is an option if and ONLY if services will start within the month of
July of the relevant Funding Year, all relevant certifications in Block 4 can be accurately made, and the
FCC Form 486 is postmarked on or before July 31 of the Funding Year.

6b.

CIPA Waiver

CHECK THE BOX BELOW IF YOU ARE REQUESTING A WAIVER OF CIPA REQUIREMENTS FOR THE
SECOND FUNDING YEAR IN WHICH YOU HAVE APPLIED FOR DISCOUNTS IF YOU AS THE BILLED
ENTITY ARE THE ADMINISTRATIVE AUTHORITY.
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 schools or libraries represented in the
Funding Request Number(s) on this FCC Form 486 will be brought into compliance with the CIPA
requirements before the start of the Third Funding Year in which they apply for discounts.
(For Libraries for Funding Year 2004: You may also request this waiver for FY2004 if you as the Billed Entity
are the Administrative Authority for the library(ies) represented on this FCC Form 486. By checking this box,
you are certifying that the libraries represented in the Funding Request Number(s) on this FCC Form 486 will
be brought into compliance with the CIPA requirements before the start of Funding Year 2005.)
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Entity Number __________________ Applicant's Form Identifier ___________________________
Contact Person __________________________________ Phone Number _________________________

Block 3: Service Information
7.

Please provide the following information for each FCC Form 471 Block 5 (Discount Funding Request) item for which the Billed Entity is indicating that

the named service provider may begin submitting invoices to USAC. You will need your FCDL for some of the information required below.
Remember: The FRNs listed below must be from the same Funding Year as is listed in Block 1, Item 3.

If you need additional pages, please label them 3A, 3B, 3C, etc. and indicate the number in the space provided here: Page 3_____

(A)
(B)
(C)
(D)
(E)

FCC Form

Funding

Service Provider

Service Provider

Funding Year Service Start

471

Request

Identification Number

Name From FCDL

Date (Earliest Date that Discounted

Application

Number

(SPIN)

Services Will Begin)

Number

(FRN)

From FCDL

From FCDL

From FCDL

1
2
3
4
5
6
7
8
9
10
11
12
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Entity Number

________________________

Applicant's Form Identifier

________________ ________________

Contact Person

__________________________________

Phone Number

_________________________

Block 4:Certifications and Signature
8.

I certify that, if required by program rules, the entity(ies) receiving discounted services as indicated on this FCC
Form 486 are covered by technology plan(s), that have been approved by a state or other authorized body (i.e., a
USAC-certified technology plan approver) prior to the commencement of service and that cover all 12 months of the
funding year. Provide the name(s) of the organization(s) that approved a technology plan for any eligible entity that is
receiving services covered under this FCC Form 486 or, if EVERY FRN listed in this FCC Form 486 is for services that
do not require a technology plan, enter "NONE" here.
9. I certify that the services listed on this FCC Form 486 have been, are planned to be, or are being provided to all or
some of the eligible entities identified in the FCC Form 471 application(s) cited above. I certify that there are signed
contracts covering all of the services listed on this FCC Form 486 except for those services provided under tariff or on a
month-to-month basis. I certify that I am authorized to submit this receipt of service confirmation on behalf of the above-
named Billed Entity; that I have examined this request; and that, to the best of my knowledge, information, and belief, all
statements of fact contained herein are true.
10. I understand 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 services receive an appropriate share
of benefits from those services. I recognize that I may be audited pursuant to this application and will retain for five
years (or whatever retention period is required by the rules in effect at the time of your certification) any and all records,
including FCC Forms 479 where required, that I rely upon to complete this form and, if audited, will make available to
the Administrator such records.

NOTES FOR COMPLETING THE CERTIFICATIONS IN ITEM 11: A Billed Entity who is the Administrative Authority
must check Item 11a or 11b or 11c. Check only ONE item. If the Billed Entity is not the Administrative Authority,
skip to Item 11d. A Billed Entity who represents one or more Administrative Authorities must check Item 11d or
11e. A Billed Entity who represents one or more Administrative Authorities in Funding Years after Funding Year
2001 and who checks Item 11d must check Item 11f or 11g. See the FCC Form 486 Instructions for Item 11,
"Special Notes for Billed Entities Who Represent One or More Administrative Authorities."

IF THIS FORM PERTAINS TO A FUNDING YEAR PRIOR TO FUNDING YEAR 2001 (THE FUNDING YEAR
BEGINNING JULY 1, 2001), SKIP TO ITEM 12.

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Entity Number

___________________

Applicant's Form Identifier

______________________________________

Contact Person

__________________________________

Phone Number

________________________________
11. FOR A BILLED ENTITY WHO IS THE ADMINISTRATIVE AUTHORITY:
I certify that as of the date of the start of discounted services:
a.
the recipient(s) of service represented in the Funding Request Number(s) on this Form 486 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 represented in the Funding Request Number(s) on this Form 486:
(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 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 represented in the Funding Request Number(s) on this Form 486 is (are) receiving discount
services only for telecommunications services.

FOR A BILLED ENTITY WHO REPRESENTS ONE OR MORE ADMINISTRATIVE AUTHORITIES:

d. I certify as the Billed Entity for the consortium that I have collected duly completed and signed FCC Forms 479
from all eligible members of the consortium.
e. I certify as the Billed Entity for the consortium that the only services that have been approved for discounts under
the universal service support mechanism on behalf of eligible members of the consortium are telecommunications
services, and therefore the requirements of the Children's Internet Protection Act, as codified at 47 U.S.C. 254(h)
and (l), do not apply.

For Funding Years after Funding Year 2001: If you checked Item 11d above, check ONE of the boxes below:

f. I certify that some or all of the eligible consortium members checked FCC Form 479 Item 6d to seek a CIPA
Waiver, and upon request from the Administrator I can provide this information; OR
g. I certify that no eligible consortium members checked FCC Form 479 Item 6d to seek a CIPA Waiver.
The certification language above is not intended to fully set forth or explain all the requirements of the statute.
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FCC Form 486
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Entity Number

__________________

Applicant's Form Identifier

_______________________________________

Contact Person

__________________________________

Phone Number

_________________________________

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.

12. Signature of authorized person
13. Date
______________________________________________________________
14. Printed name of authorized person
15. Title or position of authorized person
16a. Street Address, P.O. Box, or Route Number

City

State Zip Code

16b. Telephone number of authorized person Extension 16c. Fax number of authorized person
16d. Email address of authorized person
16e. Name of authorized person's employer
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Entity Number _____________________ Applicant's Form Identifier _______________________________

Contact Person __________________________________ Phone Number _______________________________

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 range from 1 to 1.5 hours 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.

Please submit this form to:

SLD Form 486
PO Box 7026
Lawrence, KS 66044-7026

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

SLD Forms
ATTN: SLD Form 486
3833 Greenway Dr
Lawrence, KS 66046
888-203-8100

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FCC Form 486
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