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FCC Form 479

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Released: August 5, 2014
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OMB Control No. 3060-0853

FCC Form 479 OMB Control No. 3060-0853

Estimated time per response: 1 hour

DO NOT SEND THIS FORM TO THE UNIVERSAL SERVICE ADMINISTRATIVE COMPANY

OR TO THE FEDERAL COMMUNICATIONS COMMISSION

Schools and Libraries Universal Service

Certification by Administrative Authority to Billed Entity of

Compliance with the Children’s Internet Protection Act

Please read instructions before completing.

(To be completed by the Administrative Authority and provided to your Billed Entity)

Administrative Authority’s Form Identifier: __________________________________________

Create your own code to identify THIS FCC Form 479.

Block 1: Administrative Authority Information

1. Name of Administrative Authority

2. Funding Year

3. Mailing Address and Contact Information for Administrative Authority

Street Address, P. O. Box or Route Number

City State Zip Code

Name of Contact Person

Telephone Number Fax Number Email Address

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.

Block 2: Certifications and Signature

4. I am the Administrative Authority for one or more schools or libraries for which Universal Service Support Mechanism

discounts have been requested or approved for eligible services. The Administrative Authority must make the

required certification(s) for the purposes of the Children’s Internet Protection Act (CIPA) in order to receive

discounted services.

5. I recognize that I may be audited pursuant to this form 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) any and all records that I rely upon to complete

this form.

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FCC Form 479

December 2013

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OMB Control No. 3060-0853

Name of Administrative Authority _________________________________________________________________

Administrative Authority’s Form Identifier __________________________________________________________

Contact Person _________________________________________________________________________

Telephone Number______________________________________________________________________________

Block 2: Certifications and Signature (Continued)

6. I certify that as of the date of the start of discounted services:

a the recipient(s) of service under my administrative authority and represented in the Funding Request Number(s)

for which you have requested or received Funding Commitments has (have) complied with the requirements of

the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l).

b pursuant to the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), the recipient(s) of

service under my administrative authority and represented in the Funding Request Number(s) for which you

have requested or received Funding Commitments:

(FOR SCHOOLS and FOR LIBRARIES IN THE FIRST FUNDING YEAR FOR PURPOSES OF CIPA) is

(are) undertaking such actions, including any necessary procurement procedures, to comply with the

requirements of CIPA for the next funding year, but has (have) not completed all requirements of CIPA for

this funding year.

(FOR FUNDING YEAR 2003 ONLY: FOR LIBRARIES IN THE SECOND OR THIRD FUNDING YEAR FOR

PURPOSES OF CIPA) is (are) in compliance with the requirements of CIPA under 47 U.S.C. § 254(l) and

undertaking such actions, including any necessary procurement procedures, to comply with the

requirements of CIPA under 47 U.S.C. § 254(h) for the next funding year.

c the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), does not apply because the

recipient(s) of service under my administrative authority and represented in the Funding Request Number(s) for

which you have requested or received Funding Commitments is (are) receiving discount services only for

telecommunications services.

CIPA Waiver. Check the box below if you are requesting a waiver of CIPA requirements for the Second Funding Year

after the recipients of service under your administrative authority have applied for discounts:

d I am providing notification that, as of the date of the start of discounted services, I am unable to make the

certifications required by the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l),

because my state or local procurement rules or regulations or competitive bidding requirements prevent the

making of the certification(s) otherwise required. I certify that the recipient(s) of service under my administrative

authority and represented in the Funding Request Number(s) for which you have requested or received Funding

Commitments will be brought into compliance with the CIPA requirements before the start of the Third Funding

Year in which they apply for discounts.

(CIPA WAIVER FOR LIBRARIES FOR FUNDING YEAR 2004. Check the box above if you are requesting this waiver

of CIPA requirements for Funding Year 2004 for the library(ies) under your administrative authority that has (have)

applied for discounts for Funding Year 2004. By checking this box, you are certifying that the library(ies) represented

in the Funding Request Number(s) on this FCC Form 479 will be brought into compliance with the CIPA requirements

before the start of the Funding Year 2005.)

The certification language above is not intended to fully set forth or explain all the requirements of the statute.

7. Signature of authorized person

8. Date

9. Printed name of authorized person

10. Title or position of authorized person

11. Telephone number of authorized person

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FCC Form 479

December 2013

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OMB Control No. 3060-0853

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 (3060-0853), 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 3060-0853.

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 a signature in Block 2, Item 7, must be mailed or delivered to your Billed Entity.

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FCC Form 479

December 2013

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, Word Document, or as plain text.

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