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Commission Document Attachment

DA-13-1636A7

FCC Form 500
Approval by OMB Control No. 3060-0853
Estimated Average Burden Hours Per Response: 1.5 hours

Universal Service for Schools and Libraries

Funding Commitment Adjustment Request Form

Instructions for Completing the

Universal Service for Schools and Libraries

Funding Commitment Adjustment Request Form

This form is used ONLY to adjust service start dates, contract expiration dates, request service delivery extensions for
non-recurring services, cancel or reduce funding commitments and/or notify the Universal Service Administrative
Company (USAC) about equipment transfers within three (3) years due to permanent or temporary entity closures.. You
are still required to file an FCC Form 486, Receipt of Service Confirmation Form, to notify USAC that your service
provider(s) are permitted to begin submitting invoices to USAC.

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. No authorization can be
granted unless all information requested is provided. 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.

I. INTRODUCTION

The FCC Form 500, Funding Commitment Adjustment Request Form , is used by the Billed Entity who filed an FCC Form
471, Description of Services Ordered and Certification Form, on behalf of an eligible school, library, library consortium, or
consortium of multiple entities, and who received a commitment of funds to inform the fund administrator, the Schools and
Libraries Division (SLD) of the Universal Service Administrative Company (USAC), that it wishes to accomplish one or
more of the following:
-
To adjust the Funding Year Service Start Date reported on a previously filed FCC Form 486 for this Funding
Year
-
To adjust the Contract Expiration Date listed on its FCC Form 471 application for this Funding Year
-
To request an extension of the service delivery and installation deadline for non-recurring services
-
To cancel irrevocably and totally a Funding Request Number (FRN)
-
To reduce irrevocably the amount of a Funding Request Number (FRN)
To notify USAC of an equipment transfer within the three year prohibition on transfer period due to a
temporary or permanent entity closure
Throughout these Instructions, the Billed Entity will be referred to as "applicant" or "Billed Entity" or "you." A Billed Entity
may be a school, school district, library, library consortium, or consortium of multiple entities, or an entity filing on their

OMB Control No. 0360-0853
behalf. The same applicant that filed the FCC Form 471 application should be identified as the applicant for the FCC Form
500.
The applicant must submit the relevant information on an FCC Form 500 for each FRN approved by USAC that is affected
by a change. The FRNs cited on this FCC Form 500 must be based on the Funding Commitment Decision Letter(s)
(FCDL) issued by the fund administrator.
Cancellations or reductions of a funding commitment cannot be made until USAC receives a completed FCC Form 500.
USAC will send a written notification to you and your service provider to acknowledge receipt of an FCC Form 500 for each
FRN for which the service provider's SPIN is listed. You may end up owing the service provider for discounts issued prior
to the service provider's receipt of the FCC Form 500 notification cancelling or reducing such discounts.

II. FILING REQUIREMENTS AND GENERAL INSTRUCTIONS

Who Must File the FCC Form 500?


The Billed Entity representing a school, school district, library, library consortium, or consortium of multiple entities who is
authorized to submit Funding Commitment Adjustment Requests regarding the FCC Form 471 to which this FCC Form
500 relates, must be the entity filing the FCC Form 500 with USAC. Your FCDL from USAC cites your Billed Entity
Number, which you must also record in Block 1, Item 2 of this FCC Form.

How Many FCC Form(s) 500 to File?


1. You may choose to submit one FCC Form 500 setting forth the required information for the type(s) of adjustment
requested for one funding year. Alternatively, you may choose to submit a separate FCC Form 500 for each affected
FRN. When deciding whether to file multiple FCC Form 500 applications or a single FCC Form 500 containing the
information for multiple FRNs, consider that it is possible to submit multiple Block entries each covering one FRN, all
under the same FCC Form 500.
Form 500 Instructions
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OMB Control No. 0360-0853
2. Is all of the information necessary to complete successfully the FCC Form 500 available? If any of the information
required for a particular FRN is missing, the applicant should submit a separate FCC Form 500 for the particular FRN
in question. In order for your FCC Form 500 to be accepted for processing, all components of information should be
completed. If required information is missing or an invalid entry is made, your FCC Form 500 may be rejected and
returned to you without being accepted and processed.

When to File?


You may file an FCC Form 500 no earlier than the receipt of an FCDL from USAC. You should file an FCC Form 500 as
soon as you are aware of new circumstances requiring adjustment of FRNs and as soon as you are able. For service
delivery extension requests for non-recurring services, you MUST submit the request for the deadline extension to USAC
on or before the September 30 following the close of the funding year.

Where to File?


The FCC Form 500 must be filed manually by completing and mailing an originally signed form to:

SLD Form 500, P.O.
Box 7026, Lawrence, KS 66044-7026.

Alternatively, for those applicants using express delivery services or U.S. Postal
Service Return Receipt, applicants should use the following address:

SLD Forms, ATTN: Form 500, 3833 Greenway
Drive, Lawrence, KS 66046, 888-203-8100.

Note: DO

NOT

FILE THIS OR ANY OTHER UNIVERSAL SERVICE FORM WITH THE FEDERAL COMMUNICATIONS
COMMISSION.

Compliance.


Anyone filing false information is subject to penalties for false statements, including 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.
All of the information required to successfully process your request(s) in the FCC Form 500 must be completed, in order
for this form to be accepted by the fund administrator for processing. A valid entry must be submitted on the FCC Form
500 for each component of information being provided to USAC. These Instructions set forth the requirements for a valid
entry. If you have any questions about completing this form, please visit the USAC website and if you have remaining
questions, please contact the SLD Client Service Bureau toll-free at 1-888-203-8100, before submitting the form. If the
form is not properly completed, it may be rejected and returned to you.
Form 500 Instructions
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OMB Control No. 0360-0853

Where to Get More Information?


You may call the SLD Client Service Bureau toll-free at 1-888-203-8100, send an email using the "Submit a Question
feature on the Administrator's website or a fax toll-free to 1-888-276-8736 for more information on how to complete this or
other universal service forms. Information and detailed guidance is also available on the Administrator's website .

III. SPECIFIC INSTRUCTIONS

Type or clearly print in the spaces provided. Applicants may attach additional pages if necessary. It is not necessary to
include all changed FRNs from one FCC Form 471 on one FCC Form 500; nor is it necessary to limit the FCC Form 500
to one FRN.
Note also that only one funding year can be featured on an FCC Form 500.

Top of Form

The data at the top of FCC Form 500 will help both you and USAC identify each particular FCC Form 500 you file.

Do Not Staple

Please do not staple the pages of any program forms. This will delay processing of your request.
"Do Not Write In This Area" - USAC uses this space to apply a bar code to your form upon receipt, so that we can
properly track and archive your form.

Applicant's Form Identifier:

If you are filing more than one FCC Form 500, please use this space to assign a unique
number or letter of your own devising to facilitate communication with us about THIS particular FCC Form 500. This
Applicant's Form Identifier can be very simple; for example, if you are filing three FCC Forms 500, you might label them
"A," "B," and "C." The Applicant's Form Identifier can also be descriptive, such as "Internet." Choose identifiers that suit
your own record keeping needs.

FCC Form 500 Application Number:

USAC will assign and record your FCC Form 500 Application Number. Leave this
item blank.

Top of each page after page 1:

If you are filing this form on paper, please provide the Billed Entity Name (from Item 1),
Billed Entity Number (from Item 2, below), and name and phone number of the contact person (from Item 5, below) at the
top of each page of the form in the space provided. This will help alleviate problems caused if the pages become
separated.

A.

Block 1: Applicant Information

Block 1 of FCC Form 500 asks you for your address and basic identification information. "You" refers to the applicant a
school, school district, library, library consortium, or consortium of multiple entities, or entity filing on their behalf.

Item (1)

- Provide your name as indicated on the corresponding FCDL. You may be an individual school, school district,
library, library consortium, or a consortium of multiple entities, including a school district, a county, a city, a state, or an
entity created solely as an agent for eligible entities to participate in this universal service discount mechanism.

Item (2)

- Provide the Billed Entity Number as it appears on your FCDL for the corresponding FCC Form 471.

Please be
sure to obtain this information from your FCDL or RFCDL, as the information may have been reported differently
in your FCC Form 471 application.

Item (3)

- Provide the funding year for which your funds were approved, e.g., "07/01/2013 06/30/2014." The funding year
you supply here must be the same as the funding year contained in your FCDL for the corresponding FCC Form 471. For
example, Funding Year (FY) 2013 runs from July 1, 2013 through June 30, 2014. Each subsequent funding year is expected
to begin on July 1 of that year. Cite only one funding year in this item.

Item (4)

- Provide your organization's full mailing address, whether a street address, Post Office Box number, or route
number; 10-digit phone number including the area code; fax number; and email address.

Item (5)

- Provide the name of the person who should be contacted with questions about this form. The contact person
must be able to answer questions in a timely manner regarding the information included in this form and the eligible
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OMB Control No. 0360-0853
services that have been, will be, or are being provided. Provide the mailing address phone number, fax number and email
address of the contact person.

Type of Adjustment

Indicate which requests you are submitting. Check all applicable Blocks.
Block 2 Service Adjustment

New Services Start Date

Contract Expiration Date

Service Delivery Extension
Block 3 Cancellation or Reduction of an FRN
Block 4 Equipment Transfer Notification

B. Block 2: Services Adjustment:

Block 2 of FCC Form 500 asks you to provide information about the FCC Form 471 application number and FRN, as well
as the changes being made to the service start date or contract expiration date or whether you are requesting an
extension of the deadline for delivery and installation of non-recurring services. Make additional copies of Block 2 to report
changes to additional FRNs. Please number your pages, such as 2A, 2B, 2C, etc. and provide the number in the space
provided in Block 2.

Item (6)
Service Start Date

: Complete one row for each FRN for which you wish to change the Funding Year Service Start Date
previously reported on an FCC Form 486 for this funding year. If you are simply trying to indicate that you have started
services or to report a service start date different from the date indicated in the FCDL, please file an FCC Form 486 and
NOT an FCC Form 500. Enter the FCC Form 471 Application Number and the FRN from your FCC Form 486 Notification
Letter. Enter the Original Date which is the Funding Year Service Start Date from your Form 486 Notification Letter from
USAC and the New Date that services will begin. The new Service Start Date cannot be before July 1 of the relevant
funding year. The change in Funding Year Service Start Date will NOT result in an increase in funding. The New Funding
Year Service Start Date must be provided in month, day and four-digit year (mm/dd/yyyy) format and must comply with
program rules.

Item (7) -
Contract Expiration Date

: Complete one row for each FRN for which you wish to change the contract expiration date,
based on early termination or an extension of the contract. Enter the FCC Form 471 Application Number and the FRN, the
Original Date (for the contract expiration) and the New Date the contract will expire. An extension date may be entered, if
and only if, the amount of the funding commitment is NOT increased; the type of services received pursuant to the FRN
remains the same; the extension is within the funding year or within an extension period authorized by the FCC; and such
extension is acceptable under state and local procurement rules and regulations. Provide this information in month, day
and four-digit year (mm/dd/yyyy) format.

Item (8) -
Service Delivery Extension Request

: Complete this row if you wish to extend the deadline for service delivery and
installation for non-recurring services Applicants have three additional months after the end of the funding year (until
September 30) to install one-time services known as non-recurring services. USAC may extend the September 30
deadline if the applicant falls within at least one of four designated circumstances: (1) applicants whose FCDLs are issued
by the Administrator on or after March 1 of the funding year for which discounts are authorized; (2) applicants who receive
service provider change or service substitution authorizations from the Administrator on or after March 1 of the funding
year for which discounts are authorized; (3) applicants whose service providers are unable to complete implementation for
reasons beyond the service provider's control; or (4) applicants whose service providers are unwilling to complete
installation because funding disbursements are delayed while the Administrator investigates their application for program
compliance. USAC automatically extends the service delivery deadline for non-recurring services if either of the first two
criteria is met. Applicants must affirmatively request an extension of the September 30 deadline for either (3) or (4). Enter
the FCC Form 471 application number and FRN, and certify by checking off the reason you are requesting the service
Form 500 Instructions
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delivery deadline extension. Note that the applicant must request an extension on or before the September 30 deadline.
Funding will not be increased when an extension is granted.

C. Block 3: Cancellation or Reduction of an FRN:
Item (9) -
Cancel FRN

: Use this row if you wish to cancel an FRN completely (for the total amount, for the whole approved funding
period). This action is irrevocable. Enter the FCC Form 471 application number and FRN shown on your FCDL. You may
also check off the box indicating you wish to cancel all FRNs on the indicated FCC Form 471. You may use this row if, for
instance, you have decided not to purchase services after all for example, if you had an FRN for T-1 telecommunication
service and you decided not to install that service. Cancelling the FRN allows money to be put back in the Universal
Service fund for possible commitment to other applicants.

It is important to discuss cancellation with your service
provider so that prompt action can be taken to avoid inappropriate payments (or discounts) being made.

Item (10) -
Reduce FRN

: Use this row if you wish to report to us lower costs, perhaps because you will obtain fewer products or
services or partially cancel an FRN, such as a cancellation part way through the funding year. This action is irrevocable;
the post-reduction amount may not be increased at a later date. Enter the FCC Form 471 application number and the
FRN and write in the Original Commitment Amount as shown on your FCDL. Enter the New Commitment Amount AFTER
Reduction. Reducing the commitment allows money to be put back in the Universal Service fund for possible commitment
to other applicants.

It is important to discuss reduction with your service provider so that prompt action can be
taken to avoid inappropriate payments (or discounts) being made.

Form 500 Instructions
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D. Block 4: Equipment Transfer Notification:

Item (11)
Equipment Transfer

: Complete Block 4 if you are transferring equipment from a closed entity to other eligible entities
within three years of the date of purchase. Schools and libraries are prohibited from transferring eligible services and the
equipment components of eligible services to other schools within three years of their purchase, even without receiving
money or other consideration in return, with one exception. If the school or library that orders the eligible services or
equipment permanently or temporarily closes, then that school or library can transfer any services and equipment
components of those services to another school or library, so long as the school or library notifies USAC of the transfer.
Enter the FCC Form 471 application number and FRN as shown on the FCDL and provide the entity number(s) and
name(s) of the transferring entity/entities. Include the purchase date, transfer date and transfer reason in the spaces
provided. Check the box if the transfer is temporary and indicate the projected return date. For the receiving entities, list
all of the entity numbers and names for the entities receiving the equipment, and the equipment name, make and model
for the equipment to be received.
Both the transferor and recipient must maintain detailed records documenting the transfer and the reason for the transfer
for a period of at least five years from the date of transfer or whatever retention period is required by the rules in effect at
the time of the transfer.

E. Block 5: Certification

Item (12)

- Certify that the individual signing on behalf of the applicant is authorized to submit the information contained in
the FCC Form 500 on behalf of the eligible entities receiving eligible services. The individual signing on behalf of the
applicant must certify that the information contained in FCC Form 500 is true to the best of his or her knowledge,
information and belief. Persons knowingly making false statements on this form can be punished by fine, forfeiture, or
imprisonment under federal law.

Item (13)

Certify 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.

Item (14)

Certify that you will retain for 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 delivery of discount services (or after the transfer date for equipment
transfer) any and all records relied upon to complete this form and all documents necessary to demonstrate compliance
with the statutory or regulatory requirements for the schools and libraries universal service support program. Certify also
to your recognition that you may be audited pursuant to this application and, if audited, must produce such records at the
request of a representative identified in 54.516 of the FCC's rules. .

Item (15)

- The signature of the authorized person certifying to the accuracy of the information contained in FCC Form 500
on behalf of the applicant is required in this block.

Item (16) -

Enter the date the FCC Form 500 was signed, using mm/dd/yyyy format.

Item (17) -

Print the name of the authorized person certifying the information contained in FCC Form 500 on behalf of the
applicant.

Item (18) -

Enter the title or position of the authorized person certifying the information contained in FCC Form 500 on
behalf of the applicant.

Item (19) -

Enter the telephone number of the authorized person certifying the information contained in FCC Form 500 on
behalf of the applicant. This information is required in order to expedite any communications that may be necessary
between the authorized person responsible for signing the FCC Form 500 and the fund administrator.

Item (20)

Enter the email address of the authorized person certifying the information contained in FCC Form 500 on
behalf of the applicant. This component is required in order to expedite any communications that may be necessary
between the authorized person responsible for signing the FCC Form 500 and the fund administrator.

Item (21) -

Enter the address (including street address, PO Box, or route no.; city; state and zip code) of the authorized
person certifying the information contained in FCC Form 500 on behalf of the applicant.
Form 500 Instructions
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Item (22)

Enter the name of the authorized person's employer. If a consultant is acting as the authorized person, this will
be the name of the company that employs the consultant and not the name of the applicant.

Submit completed forms to:

SLD Form 500
P.O. Box 7026
Lawrence, Kansas 66044-7026

For express delivery services or U.S. Postal Service, Return Receipt Requested:

SLD Forms
ATTN: Form 500
3833 Greenway Drive
Lawrence, Kansas 66046
888-203-8100

Form 500 Instructions
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