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FCC Form 472 Do not write in this space
Approved by OMB

DO NOT STAPLE THIS FORM

3060 – 0856
Estimated time per response: 1.0 hour

Universal Service for Schools and Libraries

Please read instructions before completing.
(To be completed by schools, libraries, or consortia.)

BILLED ENTITY APPLICANT REIMBURSEMENT FORM

For reimbursement of discounts on approved services already paid for by the Billed Entity Applicant.

Only one Service Provider Identification Number (SPIN) per form.

Must be completed and signed by the Billed Entity Applicant and signed by the relevant service provider.

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.

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.

BLOCK 1: HEADER INFORMATION

1. Billed Entity Name
2. Billed Entity Number
3. Service Provider Identification Number (SPIN)
4. Contact Name
5. Contact Telephone Number
6. Applicant Form Identifier
7. Date Submitted to USAC
8. Total Reimbursement Amount (total from Block 2, Column 15)
Page 1 of 5
FCC Form 472
Month 2013

Billed Entity Applicant Reimbursement Form

For reimbursement of discounts on approved services already paid for by the Billed Entity Applicant.

Billed Entity Name ___________________________________________________ Billed Entity Number ______________

Contact Name________________________________________________ Contact Telephone Number_______________________________

Applicant Form Identifier_____________________

BLOCK 2: LINE ITEM INFORMATION PER FUNDING REQUEST NUMBER
(9)
(10)
(11)
(12)
(13)
(14)
(15)
FCC Form 471
Funding Request
Bill Frequency
Customer Billed Date
Shipping Date
Total (Undiscounted)
Discount Amount
Application
Number (FRN)
(mm/yyyy)
to Customer or
Amount for Service
Billed to USAC
Number
(10 digits)
Last Day of Work
(from Funding
Performed
(from Funding
Commitment
(mm/dd/yyyy)
Commitment Decision
Decision Letter)
Letter)
DO NOT WRITE IN For each FRN, complete either Column (12)
THIS COLUMN.
or Column (13), but not both Columns
1
2
3
4
5
6
7
8
9
10
11
12
13
14

TOTAL REIMBURSEMENT AMOUNT TO BE ENTERED INTO ITEM (8)

Page 2 of 5
FCC Form 472
Month 2013

BILLED ENTITY APPLICANT Reimbursement Form

Billed Entity Name ___________________________________________________

Billed Entity Number ___________

Contact Name____________________________________________________________________

Applicant Form Identifier_____________________
Block 3: Billed Entity Certification

I declare under penalty of perjury that the foregoing is true and correct and that I am authorized to submit this Billed
Entity Applicant Reimbursement Form on behalf of the eligible schools, libraries, or consortia of those entities
represented on this Form, and I certify to the best of my knowledge, information and belief, as follows:
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.
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 Applicant 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.
16. Signature of authorized person
17. Date
18. Printed name of authorized person
19. Title or position of authorized person
20. Telephone number of authorized person
21. Address of authorized person
Page 3 of 5
FCC Form 472
Month 2013

BILLED ENTITY APPLICANT Reimbursement Form

Billed Entity Name ___________________________________________________

Billed Entity Number ___________

Contact Name____________________________________________________________________

Applicant Form Identifier_____________________
Block 4: Service Provider Acknowledgment

I declare under penalty of perjury that the foregoing is true and correct and that I am authorized to submit this
Service Provider Acknowledgment for this Billed Entity Applicant Reimbursement Form, and acknowledge to the
best of my knowledge, information and belief, as follows:
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. 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.
22. Signature of authorized person (fax, copy or original signature)
23. Date
24. Printed name of authorized person
25. Title or position of authorized person
26. Telephone number of authorized person
27. Address of authorized person

A paper copy of this Form (pages 1-4) should be mailed to:

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

Page 4 of 5
FCC Form 472
Month 2013

If sent by express delivery services or U.S. Postal Service, Return Receipt Requested, the form (pages
1-4) should be mailed to:
SLD Forms

ATTN: SLD BEAR FCC Form 472
3833 Greenway Drive
Lawrence, KS 66046
Phone: 1-888-203-8100

Page 5 of 5
FCC Form 472
Month 2013

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