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Commission Document Attachment

DA-13-363A5

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FCC Form 473
Approved by OMB
Do not write in this area.
3060 – 0856
Estimated time
per response: 1.0 hour

Universal Service for Schools and Libraries

Service Provider Annual Certification Form

Please read instructions before completing.
(To be completed by Service Provider)

Block 1: Service Provider Information

1. Name of Service Provider
2. Service Provider Identification Number (SPIN)
3. Funding Year:

July 1, _________ through June 30,_________

4. Contact Name
5. Complete Mailing Address of Contact Person
Street Address, P. O. Box or Route Number

City State Zip Code
6. Telephone Number with Area Code
7. Fax Number with Area Code
_____ - _____ - ___________________
_____ - _____ - _______________
8. Email Address

Block 2: Certification

I declare under penalty of perjury that the foregoing is true and correct:
I am an Officer who is authorized to submit this Service Provider Annual Certification Form on behalf of the above-named
Service Provider, which has been assigned the above-referenced Service Provider Identification Number, and that based on
information known to me or provided to me by employees responsible for the data being submitted, I hereby certify that the
data set forth in this Form has been examined and reviewed and is true, accurate and complete. I acknowledge that any
false statement on this Form or on the Service Provider Invoice Form (FCC Form 474) 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 this service provider to liability under the False Claims Act.
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.
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.
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).
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.
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FCC Form 473
Month 2013

Do not staple this form.

Service Provider Name _______________________________________________________________________________

SPIN _______________________________________________________

Contact Name ______________________________________________________________________________________

Contact Telephone Number _____ - _____ - _______________
Block 2: Certification (Continued)

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.
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.
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).
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.
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.
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.
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.
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).
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).
22. I certify that this Service Provider is not suspended or debarred from participating in Federal programs.
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.
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FCC Form 473
Month 2013

Do not staple this form.
24. Signature of Officer
25. Date
26. Printed name of Officer
27. Title or position of Officer
28. Telephone number of Officer
29. Address of Officer

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 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.

A paper copy of this form, with signature in Block 2, Item 24 should be mailed to:


SLD FCC Form 473

P. O. Box 7026
Lawrence, Kansas 66044-7026

If sent by express delivery services or U.S. Postal Service, Return Receipt Requested, the form should be mailed
to:

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

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FCC Form 473
Month 2013

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