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DA-13-363A4

Approved by OMB 3060-0856
Estimated Average Burden Hours Per Response: 1.0 hour

FCC Form 473

Universal Service for Schools and Libraries

Service Provider Annual Certification Form

Instructions for Completing the

Universal Service for Schools and Libraries

Service Provider Annual Certification Form (FCC Form 473)

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

Part 54 of the Commission’s Rules authorizes the Federal Communications Commission (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 (3060-0856), 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

An FCC Form 473, Service Provider Annual Certification Form, is required to be submitted each Funding Year to the fund
administrator in order for a service provider to complete the procedure for submitting an invoice form. The FCC Form 473
must be completed by each service provider, for each separate Service Provider Identification Number (SPIN), to confirm
that the invoice forms submitted by each service provider are in compliance with the FCC’s rules governing the schools
and libraries universal service support mechanism (Program). The FCC Form 473 can be found on the USAC website at
http://www.usac.org. " title="http://www.usac.org. ">http://www.usac.org. 
Throughout these instructions, the service provider may be referred to as “you.” A service provider is any provider of
eligible services or products to an eligible entity – a school, school district, library, library consortium or consortia of
multiple entities. A service provider must obtain a SPIN by completing FCC Form 498, Service Provider Identification
Number and General Contact Information Form, and submitting the completed FCC Form 498 to the Universal Service
Administrative Company (USAC). For more information about SPINs, please contact the USAC’s Customer Resource
Center 1-888-641-8722.

Universal service support will not be paid to a service provider on an approved funding commitment prior to the
fund administrator’s receipt of the properly completed FCC Form 473.

FCC Form 473 Instructions
Page 1 of 5
Month 2013

FILING REQUIREMENTS AND GENERAL INSTRUCTIONS

Who must file the FCC Form 473?


An FCC Form 473 is required to be completed by each service provider, for each separate SPIN, to confirm that the
invoices submitted by each service provider are in compliance with the FCC’s rules governing Universal Service for
Schools and Libraries. An FCC Form 473 must be completed and submitted separately for each distinct SPIN assigned to
a service provider that intends to submit invoices, pursuant to FCC Form 474, or approve applicant invoices, pursuant to
FCC Form 472, for reimbursement of universal service support under the Program.

When to File?


An FCC Form 473 should be submitted once each year after the fund administrator issues a Funding Commitment
Decision Letter (FCDL) in which the service provider’s SPIN is identified. The FCC Form 473 must be submitted prior to
the fund administrator’s payment of invoices (FCC Form 472 or 474) for payment of universal service support under the
Program. Service Providers are encouraged to complete and submit FCC Form 473 as soon as they receive a FCDL
which identifies one of the service provider’s SPINs as providing services to an eligible school, library or consortium of
those entities.

A service provider is required to file an FCC Form 473 once each year for each SPIN

.

Where to File?


Submit the FCC Form 473 by filing a paper copy of the completed form, including the completed and signed certification
page, to USAC. The signed form must be filed with USAC at the address listed at the bottom of the FCC Form 473:

SLD
FCC Form 473, 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 FCC Form 473, 3833 Greenway Drive,
Lawrence, KS 66046,

phone 1-888-203-8100. DO

NOT

FILE THIS OR ANY OTHER UNIVERSAL SERVICE FORM
WITH THE FCC.

Compliance


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.

All of the required information in the FCC Form 473 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 473 for each component of required
information. These instructions set forth the requirements for a valid entry. If you have any questions about completing
this form, please visit the Forms section of the USAC website. You may also contact the SLD Client Service Bureau at 1-
888-203-8100, before submitting the form. If the form is not properly completed, the form 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 using the “Submit a Question” feature on
the website or send a fax 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 website.

SPECIFIC INSTRUCTIONS

Type or clearly print in the spaces provided. Do not staple the FCC Form 473.
FCC Form 473 Instructions
Page 2 of 5
Month 2013

A.

Block 1: Service Provider Information

Block 1 of FCC Form 473 asks you for your basic identification information and contact person data. "You" refers
hereinafter to the service provider. A service provider is any provider of eligible services to an eligible entity – a school,
school district, library, library consortium or consortium of multiple entities.

Item (1)

- Provide the name of the service provider as indicated on FCC Form 498.

Item (2)

- Provide the SPIN as it appears on the FCC Form 471 FCDLs for the Funding Request Numbers (FRNs) for
which you will be seeking payment of the discount from the fund administrator. One form must be completed for each
SPIN assigned by USAC. All entries in Item (1) must have a corresponding entry in Item (2).

Item (3)

- Provide the Funding Year for which your funds were approved, e.g., "2012." The funding year you supply here
must be the same as the funding year contained in the FCDL for the corresponding FCC Form 471. Funding Years begin
on July 1 and end on the following June 30. For example, the 2012 Funding Year runs from July 1, 2012, through June 30,
2013.

Item (4)

- Provide the name of a contact 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.

Item (5)

- Provide the mailing address for the contact person.

Item (6)

- Provide the telephone number with area code (containing 10 digits) for the contact person identified in Item (5).

Item (7)

- Provide the fax telephone number with area code (containing 10 digits) for the contact person identified in Item
(5).

Item (8)

- Provide the email address of the contact person identified in Item (5).

B. Block 2: Certification

This Block requests that an Officer who is authorized to submit the Service Provider Annual Certification Form on behalf of
the service provider, which has been assigned the above-referenced Service Provider Identification Number, and declares
under penalty of perjury that based on information known to me or provided to the Officer by employees responsible for the
data being submitted, the Officer certifies that the data set forth in the FCC Form 473 has been examined and reviewed
and is true, accurate and complete. The Officer acknowledges that any false statement of this Form or on the Service
Provider Invoice Form can be punished by 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, and that any such false statement could
subject the service provider to liability under the False Claims Act. The Officer certifies to the following statements.
Item (9). I certify that the Service Provider Invoice Forms (FCC Form 474) that are submitted by this service provider
contain requests for universal service support for services which have been billed to the service provider’s customers on
behalf of schools, libraries, and consortia of those entities, as deemed eligible for universal service support by the fund
administrator.
Item (10). I certify that the Service Provider Invoice Forms (FCC Form 474) that are submitted by this service provider are
based on bills or invoices issued by the service provider to the service provider’s customers on behalf of schools, libraries,
and consortia of those entities as deemed eligible for universal service support by the fund administrator, and exclude any
charges previously invoiced to the fund administrator for which the fund administrator has not yet issued a reimbursement
decision.
Item (11). I certify that any requests for reimbursement that are sought under a Service Provider Invoice Form (FCC Form
474) for discounts for products or services that contain both eligible and ineligible components are properly allocated as
required by the Commission’s rules at 47 C.F.R. § 54.504(e) (1) and (2).
Item (12). I certify that this service provider makes available to customers, upon their request, separate prices for distinct
services to assist Billed Entity Applicants in identifying the portions of their bills that represent the costs of services
provided to eligible entities for eligible purposes.
FCC Form 473 Instructions
Page 3 of 5
Month 2013

Item (13). I certify that no non-discount portion of the costs for eligible services will be waived, paid, or promised to be paid
by this service provider. I certify that the pre-discount costs of eligible services sought by any applicant on an FCC Form
471 are net of any rebates or discounts offered by this service provider. I certify that for purposes of program rules the
provision by any service provider of a supported service, or of free services or products unrelated to the supported service
or product constitutes a rebate of the non-discount portion of the supported services.
Item (14). I certify that no kickbacks, as defined in 41 U.S.C. § 8701, were paid by this service provider to anyone in
connection with the schools and libraries universal support program.
Item (15). I certify that this service provider has complied with and will continue to comply with the Commission’s rule and
orders regarding gifts and this service provider and has not directly or indirectly offered or provided any gifts, gratuities,
favors, entertainment, loans, or any other thing of value to any eligible schools, libraries, or consortium that includes
eligible schools or libraries, except as permitted by the Commission’s rule at 47 C.F.R. § 54.503(d).
Item (16). I certify that if the Fund Administrator, as necessary, requests additional supporting information, this service
provider will make all documents requested available to the Fund Administrator. I certify that this service provider 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 discounted services, (1) any and all records that I rely upon to complete this form and each
Service Provider Invoice Form (FCC Form 474) that is submitted by this service provider during the present funding year
and (2) all documents necessary to demonstrate compliance with the statutory or regulatory requirements for the schools
and libraries universal service support program. I recognize that this service provider may be audited and that the service
provider must provide such records as required by 47 C.F.R. § 54.516.
Item (17). I certify that the prices in any offer that this service provider makes pursuant to the schools and libraries
universal service support program have been arrived at independently, without, for the purpose of restricting competition,
any consultation, communication, or agreement with any other offeror or competitor relating to (i) those prices, (ii) the
intention to submit an offer, or (iii) the methods or factors used to calculate the prices offered.
Item (18). I certify that the prices in any offer that this service provider makes pursuant to the schools and libraries
universal service support program will not be knowingly disclosed by this service provider, directly or indirectly, to any other
offeror or competitor before bid opening (in the case of a sealed bid solicitation) or contract award (in the case of a
negotiated solicitation) unless otherwise required by law.
Item (19). I certify that no attempt will be made by this service provider to induce any other concern to submit or not to
submit an offer for the purpose of restricting competition.
Item (20). I certify that this Service Provider is in compliance with and has taken reasonable steps to implement the lowest
corresponding price rule as required by the Commission’s rules at 47 C.F.R. § 54.511(b).
Item (21). I certify that this Service Provider is in compliance with state and local bidding requirements as required by the
Commission’s rules at 47 C.F.R. § 54.503(b).
Item (22). I certify that this Service Provider is not suspended or debarred from participating in Federal programs.
Item (23). 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 acknowledges 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 further certify that prior to submitting any and all Service Provider Invoicing Forms (FCC Form
474), this Service Provider will be in compliance with all rules and orders governing the schools and libraries universal
service support program. 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 (24)

- The signature of an Officer certifying to the accuracy of the information contained in FCC Form 473 on behalf
of the service provider is required in this block.

Please note that it is essential that the signature be provided to the
fund administrator.

An Officer is a person who occupies a position specified in the corporate by-laws (or partnership
agreement), and would typically be president, vice president for operations, vice president for finance, comptroller,
treasurer, or a comparable position. If the filer is a sole proprietorship, the owner must sign the certification.

Item (25) -

Enter the date the FCC Form 473 was signed. This date must include the month, day and year. This
information is required to be provided.
FCC Form 473 Instructions
Page 4 of 5
Month 2013

Item (26) -

Print the name of the authorized person certifying the information contained in FCC Form 473 on behalf of the
service provider. This information is required to be provided.

Item (27) -

Provide the title or position of the authorized person certifying the information contained in FCC Form 473 on
behalf of the service provider. This information is required to be provided.

Item (28) -

Provide the telephone number of the authorized person certifying the information contained in FCC Form 473
on behalf of the service provider. This information is required to be provided.

Item (29) -

Provide the address of the authorized person certifying the information contained in FCC Form 473 on behalf of
the service provider. This information is required to be provided.
Submit completed forms to:

SLD FCC Form 473
P.O. Box 7026
Lawrence, Kansas 66044-7026

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

SLD Forms
ATTN: SLD FCC Form 473
3833 Greenway Drive
Lawrence, Kansas 66046
Phone: 1-888-203-8100

FCC Form 473 Instructions
Page 5 of 5
Month 2013

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