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FCC Form 500 Instructions

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Released: August 8, 2014
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FCC Form 500 OMB Control No. 3060-0853

Estimated Average Burden Hours Per Response: 1.5 hours

Universal Service for Schools and Libraries

Funding Commitment Adjustment Request Form

Instructions for Completing the

Universal Service for Schools and Libraries

Funding Commitment Adjustment Request Form

This form is used ONLY to adjust service start dates, contract expiration dates, request service delivery extensions for

non-recurring services, cancel or reduce funding commitments and/or notify the Universal Service Administrative

Company (USAC) about equipment transfers within three (3) years due to permanent or temporary entity closures.

Note: You are still required to file an FCC Form 486, Receipt of Service Confirmation Form, to notify USAC that your

service provider(s) are permitted to begin submitting invoices to USAC.

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. No authorization can be

granted unless all information requested is provided. 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.

I. INTRODUCTION

The FCC Form 500, Funding Commitment Adjustment Request Form, is used by the Billed Entity who filed an FCC Form

471, Description of Services Ordered and Certification Form, on behalf of an eligible school, library, library consortium or

consortium of multiple entities, and who received a commitment of funds to inform the fund administrator, the Schools and

Libraries Division (SLD) of the Universal Service Administrative Company (USAC), that it wishes to accomplish one or

more of the following:

- To adjust the Funding Year Service Start Date reported on a previously filed FCC Form 486 for this Funding

Year

- To adjust the Contract Expiration Date listed on its FCC Form 471 application for this Funding Year

- To request an extension of the service delivery and installation deadline for non-recurring services

- To cancel irrevocably and totally a Funding Request Number (FRN)

- To reduce irrevocably the amount of a Funding Request Number (FRN)

- To notify USAC of an equipment transfer within the three year prohibition on equipment transfers due to a

temporary or permanent entity closure

Throughout these Instructions, the Billed Entity will be referred to as “applicant” or “Billed Entity” or “you.” A Billed Entity

may be a school, school district, library, library consortium or consortium of multiple entities, or an entity filing on their

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OMB Control No. 3060-0853

behalf. The same applicant that filed the FCC Form 471 application should be identified as the applicant for the FCC Form

500.

The applicant must submit the relevant information on an FCC Form 500 for each FRN approved by USAC that is affected

by a change. The FRNs cited on this FCC Form 500 must be based on the Funding Commitment Decision Letter(s)

(FCDL) issued by the fund administrator.

Cancellations or reductions of a funding commitment cannot be made until USAC receives a completed FCC Form 500.

USAC will send a written notification to you and your service provider to acknowledge receipt of an FCC Form 500 for each

FRN for which the service provider’s SPIN is listed. You may end up owing the service provider for discounts issued prior

to the service provider’s receipt of the FCC Form 500 notification cancelling or reducing such discounts.

II. FILING REQUIREMENTS AND GENERAL INSTRUCTIONS

Who Must File the FCC Form 500?

The Billed Entity representing a school, school district, library, library consortium, or consortium of multiple entities

authorized to submit Funding Commitment Adjustment Requests regarding the FCC Form 471 to which this FCC Form

500 relates, must be the entity filing the FCC Form 500 with USAC. Your FCDL from USAC cites your Billed Entity

Number, which you must also record in Block 1, Item 2 of this FCC Form.

How Many FCC Form(s) 500 to File?

1. You may choose to submit one FCC Form 500 setting forth the required information for the type(s) of adjustment

requested for one funding year. Alternatively, you may choose to submit a separate FCC Form 500 for each affected

FRN. When deciding whether to file multiple FCC Form 500 applications or a single FCC Form 500 containing the

information for multiple FRNs, consider that it is possible to submit multiple Block entries each covering one FRN, all

under the same FCC Form 500.

Form 500 Instructions

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OMB Control No. 3060-0853

2. Is all of the information necessary to complete successfully the FCC Form 500 available? If any of the information

required for a particular FRN is missing, the applicant should submit a separate FCC Form 500 for the particular FRN

in question. In order for your FCC Form 500 to be accepted for processing, all components of information should be

completed. If required information is missing or an invalid entry is made, your FCC Form 500 may be rejected and

returned to you without being accepted and processed.

When to File?

You may file an FCC Form 500 no earlier than the receipt of an FCDL from USAC. You should file an FCC Form 500 as

soon as you are aware of new circumstances requiring adjustment of FRNs and as soon as you are able. For service

delivery extension requests for non-recurring services, you MUST submit the request for the deadline extension to USAC

on or before the September 30 following the close of the funding year.

Where to File?

The FCC Form 500 must be filed manually by completing and mailing an originally signed form to: SLD Form 500, P.O.

Box 7026, Lawrence, KS 66044-7026. Alternatively, for those applicants using express delivery services or U.S. Postal

Service Return Receipt, applicants should use the following address: SLD Forms, ATTN: Form 500, 3833 Greenway

Drive, Lawrence, KS 66046, 888-203-8100.

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 to successfully process your request(s) in the FCC Form 500 must be completed, in order

for this form to be accepted by the fund administrator for processing. A valid entry must be submitted on the FCC Form

500 for each component of information being provided to USAC. These Instructions set forth the requirements for a valid

entry. If you have any questions about completing this form, please visit the USAC website and if you have remaining

questions, please contact the SLD Client Service Bureau toll-free at 1-888-203-8100, before submitting the form. If the

form is not properly completed, it may be rejected and returned to you.

Form 500 Instructions

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Where to Get More Information?

You may call the SLD Client Service Bureau toll-free at 1-888-203-8100, send an email using the “Submit a Question”

feature on the Administrator’s website or a fax toll-free to 1-888-276-8736 for more information on how to complete this or

other universal service forms. Information and detailed guidance is also available on the Administrator’s website.

III. SPECIFIC INSTRUCTIONS

Type or clearly print in the spaces provided. Applicants may attach additional pages if necessary. It is not necessary to

include all changed FRNs from one FCC Form 471 on one FCC Form 500; nor is it necessary to limit the FCC Form 500

to one FRN.

Note also that only one funding year can be featured on an FCC Form 500.

Top of Form

The data at the top of FCC Form 500 will help both you and USAC identify each particular FCC Form 500 you file.

Do Not Staple – Please do not staple the pages of any program forms. This will delay processing of your request.

“Do Not Write In This Area” - USAC uses this space to apply a bar code to your form upon receipt, so that we can

properly track and archive your form.

Applicant’s Form Identifier: If you are filing more than one FCC Form 500, please use this space to assign a unique

number or letter of your own devising to facilitate communication with us about THIS particular FCC Form 500. This

Applicant’s Form Identifier can be very simple; for example, if you are filing three FCC Forms 500, you might label them

“A,” “B,” and “C.” The Applicant’s Form Identifier can also be descriptive, such as “Internet.” Choose identifiers that suit

your own record keeping needs.

FCC Form 500 Application Number: USAC will assign and record your FCC Form 500 Application Number. Leave this

item blank.

Top of each page after page 1: If you are filing this form on paper, please provide the Billed Entity Name (from Item 1),

Billed Entity Number (from Item 2, below), and name and phone number of the contact person (from Item 5, below) at the

top of each page of the form in the space provided. This will help alleviate problems caused if the pages become

separated.

A. Block 1: Applicant Information

Block 1 of FCC Form 500 asks you for your address and basic identification information. "You" refers to the applicant – a

school, school district, library, library consortium, or consortium of multiple entities, or entity filing on their behalf.

Item (1) - Provide your name as indicated on the corresponding FCDL. You may be an individual school, school district,

library, library consortium, or a consortium of multiple entities, including a school district, a county, a city, a state, or an

entity created solely as an agent for eligible entities to participate in this universal service discount mechanism.

Item (2) - Provide the Billed Entity Number as it appears on your FCDL for the corresponding FCC Form 471. Please be

sure to obtain this information from your FCDL or RFCDL, as the information may have been reported differently

in your FCC Form 471 application.

Item (3) - Provide the funding year for which your funds were approved, e.g., "07/01/2013 – 06/30/2014." The funding year

you supply here must be the same as the funding year contained in your FCDL for the corresponding FCC Form 471. For

example, Funding Year (FY) 2013 runs from July 1, 2013 through June 30, 2014. Each subsequent funding year is expected

to begin on July 1 of that year. Cite only one funding year in this item.

Item (4) - Provide your organization’s full mailing address, whether a street address, Post Office Box number, or route

number; 10-digit phone number including the area code; fax number; and email address.

Item (5) - 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

Form 500 Instructions

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OMB Control No. 3060-0853

services that have been, will be, or are being provided. Provide the mailing address phone number, fax number and email

address of the contact person.

Type of Adjustment

Indicate which requests you are submitting. Check all applicable Blocks.

Block 2 Service Adjustment

New Services Start Date

Contract Expiration Date

Service Delivery Extension

Block 3 Cancellation or Reduction of an FRN

Block 4 Equipment Transfer Notification

B. Block 2: Services Adjustment:

Block 2 of FCC Form 500 asks you to provide information about the FCC Form 471 application number and FRN, as well

as the changes being made to the service start date or contract expiration date or whether you are requesting an

extension of the deadline for delivery and installation of non-recurring services. Make additional copies of Block 2 to report

changes to additional FRNs. Please number your pages, such as 2A, 2B, 2C, etc. and provide the number in the space

provided in Block 2.

Item (6) –

Service Start Date: Complete one row for each FRN for which you wish to change the Funding Year Service Start Date

previously reported on an FCC Form 486 for this funding year. If you are simply trying to indicate that you have started

services or to report a service start date different from the date indicated in the FCDL, please file an FCC Form 486 and

NOT an FCC Form 500. Enter the FCC Form 471 Application Number and the FRN from your FCC Form 486 Notification

Letter. Enter the Original Date which is the Funding Year Service Start Date from your Form 486 Notification Letter from

USAC and the New Date that services will begin. The new Service Start Date cannot be before July 1 of the relevant

funding year. The change in Funding Year Service Start Date will NOT result in an increase in funding. The New Funding

Year Service Start Date must be provided in month, day and four-digit year (mm/dd/yyyy) format and must comply with

program rules.

Item (7) -

Contract Expiration Date: Complete one row for each FRN for which you wish to change the contract expiration date,

based on early termination or an extension of the contract. (Note: The applicant and the service provider should have

already extended the contract prior to filing the FCC Form 500). Enter the FCC Form 471 Application Number and the

FRN, the Original Date (for the contract expiration) and the New Date the contract will expire. An extension date may be

entered, if and only if, the amount of the funding commitment is NOT increased; the type of services received pursuant to

the FRN remains the same; the extension is within the funding year or within an extension period authorized by the FCC;

and such extension is acceptable under state and local procurement rules and regulations. Provide this information in

month, day and four-digit year (mm/dd/yyyy) format.

Item (8) -

Service Delivery Extension Request: Complete this row if you wish to extend the deadline for service delivery and

installation for non-recurring services Applicants have three additional months after the end of the funding year (until

September 30) to install one-time services known as non-recurring services. USAC may extend the September 30

deadline if the applicant falls within at least one of four designated circumstances: (1) applicants whose FCDLs are issued

by the Administrator on or after March 1 of the funding year for which discounts are authorized; (2) applicants who receive

service provider change or service substitution authorizations from the Administrator on or after March 1 of the funding

year for which discounts are authorized; (3) applicants whose service providers are unable to complete implementation for

reasons beyond the service provider’s control; or (4) applicants whose service providers are unwilling to complete

installation because funding disbursements are delayed while the Administrator investigates their application for program

compliance. USAC automatically extends the service delivery deadline for non-recurring services if either of the first two

criteria is met. Applicants must affirmatively request an extension of the September 30 deadline for either (3) or (4). Enter

the FCC Form 471 application number and FRN, and certify by checking off the reason you are requesting the service

Form 500 Instructions

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delivery deadline extension. Note that the applicant must request an extension on or before the September 30 deadline.

Funding will not be increased when an extension is granted.

C. Block 3: Cancellation or Reduction of an FRN:

Item (9) -

Cancel FRN: Use this row if you wish to cancel an FRN completely (for the total amount, for the whole approved funding

period). This action is irrevocable. Enter the FCC Form 471 application number and FRN(s) shown on your FCDL. Write

CANCEL ALL if you wish to cancel all FRNs on the indicated FCC Form 471. You may use this row if, for instance, you

have decided not to purchase services after all. For example, if you had an FRN for T-1 telecommunications service and

you decided not to install that service. Cancelling the FRN allows money to be put back in the Universal Service fund for

possible commitment to other applicants. It is important to discuss cancellation with your service provider so that

prompt action can be taken to avoid inappropriate payments (or discounts).

Item (10) -

Reduce FRN: Use this row if you wish to report to us lower costs, perhaps because you will obtain fewer products or

services or partially cancel an FRN, such as a cancellation part way through the funding year. This action is irrevocable;

the post-reduction amount may not be increased at a later date. Enter the FCC Form 471 application number and the

FRN and write in the Original Commitment Amount as shown on your FCDL. Enter the New Commitment Amount AFTER

Reduction. Reducing the commitment allows money to be put back in the Universal Service fund for possible commitment

to other applicants. It is important to discuss reduction with your service provider so that prompt action can be

taken to avoid inappropriate payments (or discounts) being made.

Form 500 Instructions

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D. Block 4: Equipment Transfer Notification:

Item (11) –

Equipment Transfer: Complete Block 4 if you are transferring equipment from a closed entity to other eligible entities

within three years of the date of purchase. Schools and libraries are prohibited from transferring eligible services and the

equipment components of eligible services to other schools within three years of their purchase, even without receiving

money or other consideration in return, with one exception. If the school or library that orders the eligible services or

equipment permanently or temporarily closes, then that school or library can transfer any services and equipment

components of those services to another school or library, and must notify USAC of the transfer. Enter the FCC Form 471

application number and FRN as shown on the FCDL and provide the entity number(s) and name(s) of the transferring

entity/entities. Include the purchase date, transfer date and transfer reason in the spaces provided. Check the box if the

transfer is temporary and indicate the projected return date. For the receiving entities, list all of the entity numbers and

names for the entities receiving the equipment, and the equipment name, make and model for the equipment to be

received.

Both the transferor and recipient must maintain detailed records documenting the transfer and the reason for the transfer

for a period of at least five years from the date of transfer or whatever retention period is required by the rules in effect at

the time of the transfer.

E. Block 5: Certification

Item (12) - Certify that the individual signing on behalf of the applicant is authorized to submit the information contained in

the FCC Form 500 on behalf of the eligible entities receiving eligible services. The individual signing on behalf of the

applicant must certify that the information contained in FCC Form 500 is true to the best of his or her knowledge,

information and belief. Persons knowingly making false statements or certifications on this form can be punished by fine,

forfeiture, or imprisonment under federal law.

Item (13) – Certify 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.

Item (14) – Certify that you 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 transfer date for equipment

transfer) any and all records relied upon to complete this form and all documents necessary to demonstrate compliance

with the statutory or regulatory requirements for the schools and libraries universal service support program. Certify also

to your recognition that you may be audited pursuant to this application and, if audited, must produce such records at the

request of a representative identified in § 54.516 of the FCC’s rules. .

Item (15) - The authorized person certifying to the accuracy of the information contained in FCC Form 500 on behalf of the

applicant must sign this block.

Item (16) - Enter the date the FCC Form 500 was signed, using mm/dd/yyyy format.

Item (17) - Print the name of the authorized person certifying the information contained in FCC Form 500 on behalf of the

applicant.

Item (18) - Enter the title or position of the authorized person certifying the information contained in FCC Form 500 on

behalf of the applicant.

Item (19) - Enter the telephone number of the authorized person certifying the information contained in FCC Form 500 on

behalf of the applicant. This information is required in order to expedite any communications that may be necessary

between the authorized person responsible for signing the FCC Form 500 and the fund administrator.

Item (20) – Enter the email address of the authorized person certifying the information contained in FCC Form 500 on

behalf of the applicant. This component is required in order to expedite any communications that may be necessary

between the authorized person responsible for signing the FCC Form 500 and the fund administrator.

Item (21) - Enter the address (including street address, PO Box, or route no.; city; state; and zip code) of the authorized

person certifying the information contained in FCC Form 500 on behalf of the applicant.

Form 500 Instructions

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Item (22) – Enter the name of the authorized person’s employer. If a consultant is acting as the authorized person, this will

be the name of the company that employs the consultant and not the name of the applicant.

Submit completed forms to:

SLD Form 500

P.O. Box 7026

Lawrence, Kansas 66044-7026

For express delivery services or U.S. Postal Service, Return Receipt Requested:

SLD Forms

ATTN: Form 500

3833 Greenway Drive

Lawrence, Kansas 66046

888-203-8100

Form 500 Instructions

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