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FCC Form 474
Approved by OMB 3060-0856
Estimated time per response: 1.0 hour

Universal Service for Schools and Libraries

Service Provider Invoice Form

Instructions for Completing the

Universal Service for Schools and Libraries

Service Provider Invoice 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.

I. INTRODUCTION

The FCC Form 474, Service Provider Invoice Form, is to be completed and submitted by a service provider that has
provided discounted eligible services to eligible schools and libraries, in order to seek universal service support in the
amount of the discounts. The service provider must have provided the service and given a discounted bill to the applicant
prior to submitting the FCC Form 474.

II. FILING REQUIREMENTS AND GENERAL INSTRUCTIONS

Who Must File?

The service provider that has provided discounted eligible services and discounted bills to eligible schools, school districts,
libraries, library consortia and consortia of multiple entities, pursuant to a Funding Commitment Decision Letter (FCDL)
issued by the Schools and Libraries Division (SLD) of the Universal Service Administrative Company (USAC), must file this
FCC Form 474 to seek reimbursement for the cost of the discounts. The service provider must be the entity whose
Service Provider Identification Number (SPIN) is associated with a service or group of services in a Funding Request
Number (FRN) approved by USAC. An FRN is a service or group of services for which funding was requested in a distinct
Block 5 of the applicant’s FCC Form 471, Services Ordered and Certification Form. USAC will issue an FCDL to each
applicant who submitted the FCC Form 471 and to each service provider whose SPIN is identified on an FCC Form 471 as
the provider of the services for which discounts have been requested. The FCDL will identify the amount of discounts that
FCC Form 474 Instructions
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Month 2013

have been approved for each FRN and the SPIN for the service provider that is authorized to provide the discounted
services. Throughout these Instructions, the service provider will be referred to as “you.”

When to File?

The service provider may file the FCC Form 474 seeking reimbursement of discounts provided pursuant to an approved
FRN upon the occurrence of all of the following conditions:

upon receipt of an acknowledgment from USAC that the billed entity applicant has filed an FCC Form 486, Receipt of
Services Confirmation Form;

upon providing discounted, eligible services to an eligible school, school district, library, library consortium or
consortium of multiple entities on or after the effective date of the discounts as set forth in the FCC Form 486
Notification Letter;

after billing the Billed Entity for eligible services, showing the total prediscount amount, the discount portion and the
undiscounted amount that the applicant must pay;

after the service provider completes and submits its FCC Form 473, Service Provider Annual Certification Form, to
USAC for the Funding Year; and

no later than 120 days after the end of the pertinent funding year service delivery period. The delivery period for
recurring services is generally July 1 through June 30 of the following year; the period for non-recurring services is
generally July 1 through September 30 of the following year. See USAC’s website for specific information about
invoice due dates.

Service Provider Annual Certification Form

The FCC Form 473 is submitted by the service provider to confirm that the service provider’s invoice forms will be
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 you have
not done so already, please be sure to complete and submit the FCC Form 473.

Where to File?

The FCC Form 474 may be submitted online, manually, or electronically.
To file online, service providers should check the USAC website under Forms. Scroll down to the Service Provider Forms
and locate the option to file the FCC Form 474 online. Forms submitted online are considered a completed form. Do NOT
mail a printed form to USAC.
For FCC Forms 474 submitted on paper:

Do not staple the FCC Form 474 or include additional documents.

Only the
FCC Form 474 should be mailed to USAC. The FCC Form 474 should be mailed to USAC at:

SLD FCC Form 474, P.O.
Box 7026, Lawrence, KS 66044-7026,

or alternatively, for those service providers using express delivery services or U.S.
Postal Service Return Receipt, the following address should be used:

SLD Forms ATTN: FCC Form 474, 3833
Greenway Drive, Lawrence, KS 66046,

telephone number 1-888-203-8100.
Service providers that prefer to submit their invoices to USAC electronically should follow the instructions in the Electronic
Invoicing document in the Reference Area of the USAC website.
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 in the FCC Form 474 must be completed, in order for this form to be accepted by USAC for
entry into our data system. These instructions set forth the requirements for a valid entry. If you have any questions about
completing this form, please contact the SLD Client Service Bureau at 888-203-8100, or visit the USAC website before
submitting the form. If it is not properly completed, the form may be rejected and returned to you.
FCC Form 474 Instructions
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Month 2013

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
our website 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 in the Reference Area of the USAC website.

III. SPECIFIC INSTRUCTIONS

Type or clearly print in the spaces provided. Please attach additional pages only when necessary.

Block 1: Items 1 though 7

Item (1) - Service Provider Name.

Provide your name as indicated on the corresponding FCDL.

Item (2) - Service Provider Identification Number (SPIN).

Provide the number assigned to your company for delivering
the services included within the Funding Request Numbers (FRNs) for which you are submitting this Service Provider
Invoice Form. An FRN refers to a distinct service or group of services included in a Block 5 of the applicant’s FCC Form
471.

Item (3) - Contact Name.

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 services that have been or are being provided.

Item (4) - Contact Telephone Number, Fax Number and Email Address.

Provide the telephone number with area code
for contacting the person identified in Item (3). You may also include an extension of up to four (4) digits, for a total of 14
digits. Also, provide the fax number with area code and the email address for contacting the person identified in Item (3).

Item (5) - Invoice Number.

Please assign a unique number to identify this Service Provider Invoice Form for your own
records. This number could be generated by your usual billing system or created specifically for this purpose. We will refer
to this number to identify this particular invoice should we need to contact you.

Item (6) - Invoice Date to USAC.

Provide the date that the service provider completed and mailed this form to USAC.
Please note that this date is expected to be later than the date that the service provider submitted the bill to the school or
library for the eligible services.

Item (7) - Total Invoice Amount.

Provide the total amount of this invoice.

This amount should be the sum of the
entries in Column (14).

Block 2: Columns (8) through (14)

The information requested in the following columns should be completed for the eligible services in each FRN for which
the service provider with the SPIN set forth in Item (2) has delivered services on or after the effective date of discounts as
reported in the FCC Form 486 Notification Letter, consistent with the FCDL and for which the service provider has billed
the applicant.

Column (8)

-

FCC Form 471 Application Number.

This number is assigned by USAC to the FCC Form 471 that the
applicant submitted. This number should be obtained from the FCDL.

Column (9) - Funding Request Number (FRN).

This number is assigned by USAC to each Block 5 of the FCC Form
471 application containing a request for funding of discounts for a service or group of services. Each FRN is set forth on
the FCDL.

Column (10) - Bill Frequency.

Provide the appropriate billing frequency from the drop down box for online filing or enter
one of the following choices on the paper form: Monthly, Quarterly, Annually, One-Time, or Other.

Please note that only Column 11 OR Column 12 should be completed for each FRN (i.e

., each line on the form).
Please do NOT complete BOTH Columns 11 and 12 for the same FRN. Also, the date featured in this column

FCC Form 474 Instructions
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Month 2013

cannot be earlier than the Service Start Date featured in the FCC Form 486 Notification Letter. Only services
received in the applicable Funding Year for each FRN are eligible for discounts.

Column (11) - 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
provided services represented by the amount in Column (13). The date must be in month and 4-digit year (mm/yyyy)
format and must be within the funding year. For example:

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

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

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

Column (12) - Shipping Date to Customer 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 (12) should be either the
date that the products were shipped or the last date that you performed your work. This date should be in month/day/four-
digit year (mm/dd/yyyy) format.

Column (13) - Total (Undiscounted) Amount for Service per FRN.

This column represents the total undiscounted
monthly and one-time charges for all eligible services on the individual invoice or bill issued to the customer. This column
represents the total price for eligible service before any eligible discount is applied. The total undiscounted amount may
include all reasonable associated charges, such as federal and state taxes, that are incurred by the customer in obtaining
services.

Column (14) - 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. The
discount amount represents the total amount of funds billed to USAC, and for which the service provider requests
reimbursement on this invoice. This is the amount of support that, when combined with the school or library payment to
the service provider, equals the total undiscounted amount in Column (13).

Block 3: Service Provider Certifications and Signature

After completing the top of page 3 (

Service Provider Form Identifier, Contact Person and Contact Telephone number),

this
Block requests that a person authorized to submit the Service Provider Invoice Form on behalf of the Service Provider. A
person authorized to sign this form must be responsible for the service provider’s preparation and submission of invoice
forms to seek reimbursement from the schools and libraries universal service support mechanism. This person must be
able to certify to the accuracy of the invoice forms and their compliance with FCC rules.
The authorized person must certify under penalty of perjury, to the best of his/her knowledge, information and belief, that:
A. I certify that this Service Provider is in compliance with the 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.
B. I certify that the certifications made on the Service Provider Annual Certification Form (FCC Form 473) by this Service
Provider are true and correct.
C. 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 (15) - 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 (16) - Date.

Provide the date that the service provider signed the Acknowledgment.

Item (17) - Printed name of authorized person.

Please print the name of the authorized person whose
signature was provided in Item 15.
FCC Form 474 Instructions
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Item (18) - Title or position of authorized person.

Please provide the title or position of the authorized person
whose signature was provided in Item 21.

Item (19) - 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 (20) - Address of authorized person.

Please provide the address of the authorized person.

Reminder:

You must complete and submit an FCC Form 473 to USAC in order for any invoice form to be processed
promptly for each Funding Year being invoiced. Please be sure to complete and submit the FCC Form 473 before you
submit this FCC Form 474 to USAC.
FCC Form 474 Instructions
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Month 2013

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