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DA-13-363A2

Approved by OMB 3060-0856
Estimated time per response: 1.0 hour

FCC Form 472

Universal Service for Schools and Libraries

BILLED ENTITY APPLICANT REIMBURSEMENT FORM

Instructions for Completing the

Universal Service for Schools and Libraries

Billed Entity Applicant Reimbursement (BEAR) Form

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 2 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 (3060-0856), 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 3060-0856.
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.

PURPOSE OF FORM

The FCC Form 472, Billed Entity Applicant Reimbursement (BEAR) Form is used by the Billed Entity that received a Funding
Commitment Decision Letter (FCDL) from the fund administrator, the Schools and Libraries Division (SLD) of the Universal
Service Administrative Company (USAC), and filed an FCC Form 486, Receipt of Service Confirmation Form, indicating that
the Billed Entity intended to submit to USAC an invoice for reimbursement of discounts on eligible services received on or
after the effective date of discounts and already paid for by the applicant.
In the case of qualified preexisting contracts, discounts may be effective as of January 1, 1998, the beginning of the first
program year. In other situations, the discounts will be effective as of a date following the award of a contract that resulted
from posting of a request for new services in an FCC Form 470, Description of Services Requested and Certification Form, to
the USAC website.
Completion of the BEAR Form is mandatory unless the Billed Entity and service provider have made their own, mutually
agreed-upon arrangements for reimbursement or implementation of the discounts. If such an arrangement has been
mutually agreed upon, reimbursement of the discounts can be achieved by submission of an FCC Form 474, Service
Provider Invoice Form to the fund administrator, following the implementation of the discounts. The applicant should prepare
and submit a BEAR Form to the fund administrator when ALL of the following conditions occur:
1. The applicant receives a FCDL from the fund administrator which approves discounts for services; AND
2. The applicant is already receiving or has received these services, and has already paid for the services, including the
price of the discounts; AND
FCC Form 472 Instructions
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3. The applicant has filed an FCC Form 486; AND
4. The service provider has filed an FCC Form 473.
A Billed Entity will prepare a BEAR Form for the amount of the discounts associated with the services set forth in a specific
Funding Request Number (FRN from the associated FCC Form 471 which the applicant has already received and paid for. If
the applicant will be seeking reimbursement for services provided by more than one service provider, as designated by a
Service Provider Identification Number (SPIN) in the applicant’s FCC Form 486, the applicant will prepare a separate BEAR
for each SPIN. The reimbursement period for each FRN will begin with the Funding Year Service Start Date reported by
USAC in your FCC Form 486 Notification Letter.
On the BEAR Form, the service provider must sign an Acknowledgment that:
(1) The service provider must remit the discount amount authorized by the fund administrator to the Billed Entity who
prepared and submitted this BEAR as soon as possible after the fund administrator’s notification to the service provider of
the amount of the approved discounts on this BEAR, but in no event later than 20 business days after receipt of the
reimbursement payment from the fund administrator, subject to the restriction set forth in (2) below
(2) The service provider must remit payment of the approved discount amount to the Billed Entity prior to tendering or making
use of the payment issued by the Universal Service Administrative Company to the service provider of the approved
discounts for the BEAR.

Important Note

: This Acknowledgment, which is Block 4 of the BEAR Form, must be submitted by the Billed Entity as part
of
the completed, entire BEAR Form to the fund administrator. If the BEAR Form is submitted without the signature of your
service provider on the Acknowledgment, the BEAR will not be processed and it may be returned to you.

FILING REQUIREMENTS AND GENERAL INSTRUCTIONS

Who Must File?


The Billed Entity representing a school, library, library consortium, or consortium of multiple entities (hereinafter referred to as
“school or library”) who:
(1) completed and submitted the FCC Form 471; and
(2) filed the FCC Form 486; and
(3) seeks to receive reimbursement for the discounts for services already received and paid for since the actual service start
date
must submit this BEAR Form to the fund administrator. The Billed Entity must complete the BEAR Form and obtain the
signature of the relevant service provider on the Service Provider Acknowledgment before sending the BEAR Form to the
fund administrator.
Throughout these Instructions, the Billed Entity Applicant will be referred to as “applicant” or “you,” the relevant service
provider will be referred to as “your service provider,” and the BEAR Form will be referred to as “BEAR” or “Form.”

How Many BEARs to File at One Time?


You must submit a separate BEAR for each service provider with a separate Service Provider Identification Number (SPIN)
whose services you have already received and paid for since your actual service start date. For each SPIN, your BEAR
should contain information for each and every one of the multiple FRNs for services delivered by that service provider AND
for which you have received your FCDL. Please be sure that each BEAR that you complete contains only one SPIN.
Examples

You receive one FCDL (based on one FCC Form 471) that has five FRNS approved for discounts:

SPIN #111111111 is associated with three FRNs

SPIN #222222222 is associated with one FRN
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SPIN #333333333 is associated with one FRN.
You can submit three BEARs: one listing all the FRNs associated with SPIN #111111111, and one each for SPIN
#222222222 and SPIN #333333333.

You receive two FCDLs on the same date, based on two FCC Forms 471.

One letter approves discounts for two FRNs associated with SPIN #111111111.

The other letter approves discounts for three FRNs also associated with SPIN #111111111.
You can file just one BEAR listing all the FRNs associated with SPIN #111111111.

When to File?


The BEAR should be filed after you have received and paid for eligible services covered by your FCC Form(s) 471 and you
have filed an FCC Form 486 for the pertinent FRNs approved in your FCDL.
You may submit the BEAR once a year for reimbursement of the discounts for non-recurring services for the entire year, or
you may file more frequently (e.g., quarterly, bimonthly, monthly) if that is more convenient.

NOTE:

If USAC has adjusted your Funding Year Service Start Date, as reflected on your FCC Form 486 Notification Letter,
USAC will not honor BEARs with recurring services dates in Column 12 or non-recurring services dates in Column 13 prior to
that adjusted Funding Year Service Start Date.

Service Provider Annual Certification Form

The FCC Form 473 is used by the service provider to confirm that invoice forms submitted or approved by the service
provider are completed in compliance with FCC rules governing the schools and libraries universal service support
mechanism. The FCC Form 473 must be completed and submitted by the service provider prior to the service provider
submitting its first invoice form to USAC. No invoices will be paid without an FCC Form 473 filed for the pertinent funding
year. If your service provider has not done so already, please be sure to ask your service provider to complete and submit
the FCC Form 473.

Where to File?


The BEAR can be filed either online or on paper.

If you are filing online:

You may complete, submit and certify the BEAR in the Apply Online section of our website.
The system is designed so that once you make the appropriate certifications, the service provider featured is notified that
the BEAR is available for their review and online certification or response to you. If you file a BEAR online, do not also
mail a printed copy to USAC.
– OR –

If you are filing on paper:

Do not staple the BEAR Form,

You may complete and submit the BEAR by filing a paper
copy of the completed BEAR, including

BOTH

the completed and signed Block 3 AND Block 4 certification pages, with
USAC. The signed BEAR must be filed with USAC at the address listed at the bottom of the BEAR:

SLD BEAR FCC
Form 472, P.O. Box 7026, Lawrence, KS 66044-7026.

For those applicants using express delivery services or U.S.
Postal Service Return Receipt Requested, send to:

SLD Forms, ATTN: SLD BEAR FCC Form 472, 3833 Greenway
Drive, Lawrence, KS 66046,

phone 1-888-203-8100. DO

NOT

FILE THIS OR ANY OTHER UNIVERSAL SERVICE
FORM WITH THE FCC.
In addition, if you are filing on paper, you may want to work directly with your service provider in filling out this BEAR; at
minimum, you must provide the completed BEAR when you contact your service provider to obtain a signature on the Block
4 Service Provider Acknowledgment. Contact your service provider to find out who on its staff should be your contact person
for these purposes.

Compliance.


Anyone filing false information is subject to penalties for false statements, including fine or forfeiture, under the
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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 in the BEAR must be completed, in order for this BEAR to be accepted by the fund
administrator for entry into our data system. A valid entry must be submitted by the Billed Entity for each component of
information required. These instructions set forth the requirements for a valid entry. If you have any questions about
completing this BEAR or any Program form, please contact the SLD Client Service Bureau at 1-888-203-8100, or visit the
USAC website, before submitting the BEAR. If the BEAR is not properly completed, it may be rejected and returned to you.

Where to Get More Information?


You may call the SLD Client Service Bureau at 1-888-203-8100, send an email from the USAC website using “Submit a
Question” or a fax to 1-888-276-8736 for more information on how to complete this or other universal service forms.
Information is also available on the USAC website.

SPECIFIC INSTRUCTIONS

Type or clearly print in the spaces provided. Applicants may attach additional pages if necessary.

Block 1 Header Information

Item (1) - Billed Entity Name.

Provide your name as indicated on the corresponding FCDL.

Item (2)

-

Billed Entity Number.

Provide the Billed Entity Number as it appears on your FCDL.

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

Item (3) - Service Provider Identification Number (SPIN).

Provide the number assigned to the service provider who is
delivering the services for which you are submitting this BEAR. Remember, only one SPIN is permitted per BEAR. Please
be sure to obtain this information from your FCDL for the FRNs for which you are seeking reimbursement.

Item (4) - Contact Name.

Provide the name of the person who should be contacted if the fund administrator has questions
about this BEAR. The contact person must be able to answer questions in a timely manner regarding the information
included in this BEAR and the eligible services that have been or are being provided.

Item (5) - Contact Telephone Number.

Provide the telephone number with area code for contacting the person identified in
Item (4). You may also include an extension of up to four (4) digits for a total of 14 digits.

Item (6) - Applicant Form Identifier.

Please assign a unique number to identify this BEAR for your own records. This
number (which can include both numerals and letters) could be generated by your usual billing system, or created specifically
for this purpose. For example, if you have an accounting system which assigns an invoice number to bills and receivables,
you may use the identification number assigned by your billing system. We will refer to this number to identify this particular
invoice should we need to contact you concerning this BEAR.

Item (7) - Date Submitted to USAC.

Provide the date that you completed and mailed this BEAR to the fund administrator.

Item (8) - Total Reimbursement Amount.

Provide the total amount associated with this BEAR.

This amount should be the
sum of the entries in Column (15).

This figure can be a maximum of 14.2 digits, to accommodate dollars and cents.

Block 2 Line Item Information per Funding Request Number

Columns (9) through (15)

The information requested in the following Columns should be completed for each FRN when:
(1) you are already receiving or have received the service(s);
(2) the service was delivered to you on or after the start date of discounts reported on your FCC Form 486 Notification
Letter;
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(3) you already paid for the services you are receiving or have received; and
(4) your service provider has filed an FCC Form 473 for the funding year.
Please remember that all FRNs included on this BEAR must be associated with the same service provider whose SPIN is
listed in Item (3) of Block 1.

Column (9)

-

FCC Form 471 Application Number.

This is the number USAC assigned to the FCC Form 471 with which this
line of the BEAR is associated. This number must be obtained from your FCDL.

Column (10) - Funding Request Number (FRN).

This is the number USAC assigned to each FRN on your FCC Form 471.
Each FRN is set forth in your FCDL.

Column (11) - Bill Frequency.

Please do not complete this Column, as this Column will be completed by the fund
administrator.

Please note that only Column 12 OR Column 13 should be completed for each FRN (i.e

., each line on the form).
Please do NOT complete BOTH Columns 12 and 13 for the same FRN. Also, the date featured in this column cannot
be earlier than the Service Start Date featured in the FCC Form 486 Notification Letter. Only paid services received
in the applicable Funding Year for each FRN are eligible for discounts.

Column (12) - Customer Billed Date.

Use this Column for reimbursement of bills for recurring services and for multiple
installments for non-recurring services. The month and year you enter in this column should be for the first month you
received services represented by the amount in Column (14). The date must be in month and 4-digit year (mm/yyyy) format
and must be within the funding year. For example:

If you receive a monthly bill dated June 15, 2012 for recurring services from July 1 to July 31, you should enter
07/2012.

If you receive a quarterly bill dated November 1, 2012 for recurring services from October 1 to December 31, you
should enter 10/2012.

If you receive a bimonthly installment bill dated September 10, 2012 for non-recurring services from September 1 to
October 31, you should enter 09/2012.

Column (13) - Shipping Date or Last Day of Work Performed.

Use this Column for reimbursement for non-recurring
services billed one time only such as Internal Connections. The date in Column (13) should be either the date that the
products were shipped or the last date that the service provider performed its work. This date should be in month/day/four-
digit year (mm/dd/yyyy) format.

Column (14) - Total (Undiscounted) Amount for Service per FRN.

The total undiscounted amount represents the total
amount paid per FRN for which you are seeking reimbursement of the discount on this BEAR. You must deduct charges for
any ineligible services, or for eligible services delivered for ineligible recipients or used for ineligible purposes. You should
gather your customer bills and any other documentation you need to support your calculations. This figure can be no more
than 14.2 digits, including dollars and cents.

Column (15) - Discount Amount Billed to USAC.

This column is calculated by multiplying the amount in Column 13 by the
applicant’s approved discount percentage. You can find this discount percentage for each FRN in the FCDL. This figure can
be no more than 14.2 digits, including dollars and cents.

Block 3 Billed Entity Certification

The Billed Entity must sign the Certification and declare under penalty of perjury that:
(A) The discount amounts listed in Column (15) of this Billed Entity Applicant Reimbursement Form represent charges for
eligible services delivered to and used by eligible schools, libraries, or consortia of those entities for educational purposes, on
or after the service start date reported on the associated FCC Form 486.
(B) The discount amounts listed in Column (15) of this Billed Entity Applicant Reimbursement Form were already billed by the
service provider and paid by the Billed Entity Applicant on behalf of eligible schools, libraries, and consortia of those entities.
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(C) The discount amounts listed in Column (15) of this Billed Entity Applicant Reimbursement Form are for eligible services
approved by the fund administrator pursuant to a Funding Commitment Decision Letter.
(D) I recognize that I may be audited pursuant to this application 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), after the last day of service delivered in this funding
year any and all records that I rely upon to fill in this form.
(E) I certify that, in addition to the foregoing, this Billed Entity is in compliance with the other rules and orders governing the
schools and libraries universal service support program and I acknowledge that failure to be in compliance and remain in
compliance with those rules and orders may result in the denial of discount funding and/or cancellation of funding
commitments. I acknowledge that failure to comply with the rules and orders governing the schools and libraries universal
service support program could result in civil or criminal prosecution by law enforcement authorities.

Item (16) - Signature.

Provide the signature of the authorized person.

Item (17) - Date.

Provide the date that the Billed Entity signed the BEAR.

Item (18) - Printed name of authorized person.

Provide the printed name of the authorized person.

Item (19) - Title or position of authorized person.

Provide the title or position of the authorized person.

Item (20) - Telephone number of the authorized person.

Provide the telephone number of the authorized person, should
the fund administrator need to contact this person.

Item (21) - Address of authorized person.

Provide the address of the authorized person.

Block 4 Service Provider Acknowledgment

After completing the top of page 4 (Billed Entity Name, Billed Entity Number, Contact Name, and Contact Telephone
Number), provide a copy of all four pages of the BEAR to your service provider. Your service provider must complete and
sign Block 4: Service Provider Acknowledgment, and return it to you via fax, mail, or in person. An original ink signature is
NOT required on Block 4.
The service provider whose SPIN is listed in Item 3 of Block 1 must sign the Acknowledgment that confirms the following:
(A) The service provider must remit the discount amount authorized by the fund administrator to the Billed Entity Applicant
who prepared and submitted this Billed Entity Applicant Reimbursement Form as soon as possible after the fund
administrator’s notification to the service provider of the amount of the approved discounts on this Billed Entity Applicant
Reimbursement Form, but in no event later than 20 business days after receipt of the reimbursement payment from the fund
administrator, subject to the restriction set forth in B. below.
(B) The service provider must remit payment of the approved discount amount to the Billed Entity Applicant prior to tendering
or making use of the payment issued by the Universal Service Administrative Company to the service provider of the
approved discounts for the Billed Entity Applicant Reimbursement Form.
(C) I certify that, in addition to the foregoing, this Service Provider is in compliance with the other rules and orders governing
the schools and libraries universal service support program and I acknowledge that failure to be in compliance and remain in
compliance with those rules and orders may result in the denial of discount funding and/or cancellation of funding
commitments.
(D) I acknowledge that failure to comply with the rules and orders governing the schools and libraries universal service
support program could result in civil or criminal prosecution by law enforcement authorities.

Item (22) - Signature of authorized person.

The original, fax or copy of the signature of an authorized person
on behalf of a service provider must be provided. An authorized person is an individual who works for the service provider
and who has the knowledge required by the Acknowledgment.

Item (23) - Date.

Provide the date that the service provider signed the Acknowledgment.

Item (24) - Printed name of authorized person.

Please print the name of the authorized person whose
signature was provided in Item 21.

Item (25) - Title or position of authorized person.

Please provide the title or position of the authorized person
FCC Form 472 Instructions
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Month 2013

whose signature was provided in Item 21.

Item (26) - Telephone number of authorized person.

Please provide the telephone number of the authorized person, so
that the fund administrator may contact the authorized person if necessary.

Item (27) - Address of authorized person.

Please provide the address of the authorized person.

Important Note:

This Acknowledgment, which is Block 4 of the BEAR, must be submitted by the Billed Entity Applicant as
part of
the completed, entire BEAR to the fund administrator. If the BEAR is submitted without the signature of your service
provider on the Acknowledgment, the BEAR will not be processed and will be returned to you.

Do not staple the BEAR Form.

FCC Form 472 Instructions
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