Skip Navigation

Federal Communications Commission

English Display Options

Commission Document Attachment

DA-13-363A7

FCC Form 474 Do not write in this space. Approved by
OMB

Do Not Staple This Form

3060 – 0856
Estimated time per response: 1.0 hour

Schools and Libraries Universal Service

Service Provider Invoice FCC Form 474

This form can be filed online or by mail.

Please read instructions before completing
FCC Form 474 Invoice # ________________________________________
(To be inserted by administrator)

BLOCK 1: Service Provider Information

1. Service Provider Name
2a. Service Provider Identification Number (SPIN)
3. Contact Person’s Name
4. Contact Telephone Number Area Code: Phone Number: Ext.
Contact Fax Number

Area Code: Fax Number:

Contact Email Address
5. Invoice Number
6. Date Submitted to USAC
7. Total Invoice Amount (total of Block 2, Column 14)
Page 1 of 4
FCC Form 474
Month 2013

SPIN _________________________________________________________________________________________________
Service Provider Form Identifier __________________________________________________________________________
Contact Person ________________________________________________________________________________________
Contact Telephone Number ______________________________________________________________________________

Block 2, Page ___ of ___

Make as many copies of this page as necessary,
and number the completed pages to assure that they are all processed correctly.

BLOCK 2: Funding Request Number Information

8
9
10
11
12
13
14

FCC Form 471

Funding Request

Bill Frequency

Customer Billed

Shipping Date to

Total

Discount Amount

Application

Number (FRN)

(e.g., Monthly,

Date

Customer or Last

(Undiscounted)

Billed to USAC

Number

(from Funding

Quarterly, Annually,

(mm/yyyy)

Day of Work

Amount for

(from Funding

Commitment

One-time, Other)

Performed

Service per FRN

Commitment

Decision Letter)

(mmddyyyy)

Decision Letter)

For each FRN, there should be an entry in

Column 11 or Column 12 but NOT BOTH

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

TOTAL REIMBURSEMENT AMOUNT TO BE ENTERED INTO ITEM 7

Page 2 of 4
FCC Form 474
Month 2013

Service Provider Invoice FCC Form 474

Service Provider Form Identifier ______________________________________________________

Contact Person ____________________________________________________________________

Contact Telephone Number ___________________________________________________________

Block 3: Service Provider Certifications & Signature

I declare under penalty of perjury that the foregoing is true and correct and that I am authorized to submit this
Service Provider Invoice Form (FCC Form 474) and acknowledge to the best of my knowledge, information and
belief, as follows:
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.
15. Signature of authorized person
16. Date
17. Printed name of authorized person
18. Title or position of authorized person
19. Telephone number of authorized person
20. Address of authorized person
Page 3 of 4
FCC Form 474

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.

Do not staple the FCC Form 474.

Please submit this form to:

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

For express delivery services or U.S. Postal Service, Return Receipt Requested, mail this form (pages 1-4) to:

SLD Forms
ATTN: SLD SPI FCC Form 474
3833 Greenway Drive
Lawrence, KS 66046
888-203-8100

Page 4 of 4
FCC Form 474

Note: We are currently transitioning our documents into web compatible formats for easier reading. We have done our best to supply this content to you in a presentable form, but there may be some formatting issues while we improve the technology. The original version of the document is available as a PDF, , or as plain text.

close
FCC

You are leaving the FCC website

You are about to leave the FCC website and visit a third-party, non-governmental website that the FCC does not maintain or control. The FCC does not endorse any product or service, and is not responsible for, nor can it guarantee the validity or timeliness of the content on the page you are about to visit. Additionally, the privacy policies of this third-party page may differ from those of the FCC.