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FCC Form 500

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Released: April 29, 2014
OMB Control No. 3060-0853
FCC Form 500 OMB Control No. 3060-0853

DO NOT STAPLE


D
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1.5 hours

Universal Service for Schools and Libraries

Funding Commitment Adjustment Request Form



Please read instructions before completing.


(To be completed by schools, libraries or consortia.)
Applicant’s Form Identifier:
FCC Form 500 Application Number:
(Create your own code to identify THIS FCC Form 500)
(To be assigned by administrator.) ___________________

Block 1: Applicant Information


1. Name of Billed Entity
2. Billed Entity Number
3. Funding Year


4. Complete Mailing Address of Billed Entity
Street Address, P. O. Box or Route Number City State Zip Code


Telephone Number Fax Number Email Address

5. Contact Person Information
Contact Person Name

Mailing Address
Street Address, P. O. Box or Route Number City State Zip Code


Telephone Number Fax Number Email Address

Type of Adjustment (Check all that apply)

Block 2: Services Adjustment

Block 4: Equipment Transfer Notification

Block 3: Cancellation or Reduction of an FRN


FCC Form 500
Page 1 of 6



December 2013

OMB Control No. 3060-0853

DO NOT STAPLE
Billed Entity Name _____________________________ Contact Name ____________________________________

Billed Entity Number __________________ Contact Telephone Number ___________________________Page 2__


Block 2: Services Adjustment

Remember: The Funding Request Number(s) (FRNs) listed on this form must be for the same Funding Year as
listed in Block 1, Item 3.

New Service Start Date:
Complete if you wish to change the Service Start Date you listed on a previously filed FCC Form
486 in the funding year listed in Block 1, Item 3. This action will NOT increase funding.

Contract Expiration Date:
Complete if the contract expiration date has changed and you wish to report the change to
USAC. This action will NOT increase funding but you could combine it with a funding reduction.

Service Delivery Extension:
Complete if you are requesting an extension of the deadline for delivery and installation of
non-recurring services. You must submit this request to USAC on or before the September 30 following the close of the
funding year. This action will NOT increase funding.

Note

: Complete the Contract Expiration Date (Item 7) also if your
contract will expire prior to the installation or delivery of services.

6. Service Start Date

FCC Form 471

FRN(s)

Original Date (mm/dd/yyyy):
New Date (mm/dd/yyyy):













7. Contract Expiration Date

FCC Form 471

FRN(s)

Original Date (mm/dd/yyyy):
New Date (mm/dd/yyyy):













Make as many copies of this page as needed, and number the completed pages so that they are all processed
correctly. Please number your pages 2A, 2B, 2C, etc. and provide the number in space provided in Block 2.


8. Service Delivery Extension Request
FCC Form 471
FRN
Certify the reason for the service delivery and instal ation request by checking one of the boxes below:

⧠ The service provider was unable to complete delivery and installation for reasons beyond the service provider's control.

⧠ The service provider has been unwilling to complete delivery and installation after USAC withheld payment for those
services on a properly-submitted invoice for more than 60 days after submission of the invoice.

FCC Form 500
Page 2 of 6



December 2013

OMB Control No. 3060-0853

DO NOT STAPLE
Billed Entity Name _____________________________ Contact Name ____________________________________

Billed Entity Number __________________ Contact Telephone Number ___________________________Page 3__




Block 3: Cancellation or Reduction of an FRN


Remember: The FRNs listed on this form must be for the same Funding Year as listed in Block 1, Item 3.


Cancel:

Complete if you wish to cancel an FRN. This action is irrevocable and the FRN cannot be reinstated later. This
action would allow money to be put back into the Universal Service Fund for possible commitment to other applicants.

Reduce:

Complete if you wish to reduce the amount of your funding commitment for a particular FRN. This action is
irrevocable and the FRN cannot be increased later. This action would allow money to be put back into the Universal
Service Fund for possible commitment to other applicants.

Make as many copies of this page as needed, and number the completed pages so that they are all processed
correctly. Please number your pages 3A, 3B, 3C, etc. and provide the number in space provided in Block 3

9. Cancel FRN

FCC Form 471

FRN (s) (list individually)

Write in “CANCEL ALL”
below if you wish to cancel
all FRNs on FCC Form 471













10. Reduce FRN

FCC Form 471

FRN(s)

Original Commitment

New Commitment Amount AFTER

Amount from FCDL

Reduction

















FCC Form 500
Page 3 of 6



December 2013

OMB Control No. 3060-0853

DO NOT STAPLE
Billed Entity Name _____________________________ Contact Name ____________________________________

Billed Entity Number __________________ Contact Telephone Number __________________________Page 4__


Block 4: Equipment Transfer Notification


Remember: The FRNs listed on this form must be for the same Funding Year as listed in Block 1, Item 3.


11.

Equipment Transfer:

Complete this section if you are transferring equipment from a closed entity to other
eligible entities within three years of the date of purchase. Both the transferring and receiving entities must
maintain detailed records documenting the transfer and the reason for the transfer for at least five years (or
whatever retention period is required by the rules in effect at the time of this certification).

Make as many copies of this page as needed, and number the completed pages so that they are all processed
correctly. Please number your pages 4A, 4B, 4C, etc. and provide the number in space provided in Block 4

FCC Form 471
FRN

Closed Entity Number
Closed Entity Name


Purchase Date
Transfer Date
Transfer Reason






⧠ Check here if transfer is temporary. Enter projected return date __________________________
List all entities receiving the
Receiving Entity Name (s)
Equipment Received
equipment.
Equipment name, make and model
Receiving Entity(s) Number(s)













FCC Form 500
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December 2013

OMB Control No. 3060-0853

DO NOT STAPLE
Billed Entity Name _____________________________ Contact Name ____________________________________


Billed Entity Number __________________ Contact Telephone Number _________________________________




Block 5: Certification


12. I certify that I am authorized to submit this form on behalf of the above-named billed entity, that I have examined
this request, and that, to the best of my knowledge, information, and belief, all statements of fact contained herein
are true.
13. I understand that the discount level used for shared services is conditional, for future years, upon ensuring that
the most disadvantaged schools and libraries that are treated as sharing in the services receive an appropriate
share of benefits from those services.
14. I 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 discount services (or after the date of transfer for equipment
transfers), (1) any and all records that I rely upon to complete this form 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 I may be audited pursuant to this application and the applicant must
produce such records as required by 47 C.F.R. § 54.516.
15. Signature
16. Date


17. Printed name of authorized person


18. Title or position of authorized person


19. Telephone number of authorized person


20. Email address of authorized person


21. Address of authorized person


22. Name of Authorized Person’s Employer




FCC Form 500
Page 5 of 6



December 2013

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 range from 1 to 1.5 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-
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 an authorized signature in Block 5, Item 15 should be mailed to:

SLD Form 500
P. O. Box 7026
Lawrence, KS 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: Form 500
3833 Greenway Dr.
Lawrence, KS 66046
888-203-8100


FCC Form 500
Page 6 of 6



December 2013

Document Outline

  • P. O. Box 7026
  • Lawrence, KS 66044-7026
    • Lawrence, KS 66046

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