Certification by Administrative Authority to Billed Entity of Compliance with the Children's Internet Protection Act

FCC Form 500

Approval by OMB 3060-0853
Estimated Average Burden Hours Per Response: 1.5 hours
Universal Service for Schools and Libraries
Receipt of Service Confirmation Form
Instructions for Completing the
Universal Service for Schools and Libraries
Adjustment of Funding Commitment and
Modification to Receipt of Service Confirmation Form

This form is used ONLY to adjust funding commitments and/or modify the dates for receipt of services. You are still
required to file an FCC Form 486, Receipt of Service Confirmation Form, to notify the USAC that your service provider(s)
are permitted to begin submitting invoices to the 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 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 (3060-0853), 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, Adjustment to Funding Commitment and Modification to Receipt of Service Confirmation Form, is
used by the Billed Entity who filed an FCC Form 471, 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 reduce the funding commitment amount on the Funding Request Number (FRN) level, or about a
modification in the beginning or ending date for services received during the funding year.
The Form 500 must be filed to accomplish the following:
- To adjust the Funding Year Service Start Date reported on a previously filed Form 486 for this Funding Year
- To adjust the Contract Expiration Date listed on your Form 471 application for this Funding Year
- To cancel irrevocably and totally a Funding Request Number (FRN)
- To reduce irrevocably the amount of a Funding Request Number (FRN)
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
behalf. The same applicant that filed the Form 471 application should be identified as the applicant for the Form 500.

Form 500 Instructions

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The applicant must submit the relevant information on a Form 500 for each Funding Request Number approved by USAC
that is affected by a change. The FRNs cited on this 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 the USAC receives a completed Form 500.
USAC will send a written notification to you and your service provider to acknowledge receipt of a 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 Form 500 notification canceling or reducing such discounts.

II. FILING REQUIREMENTS AND GENERAL INSTRUCTIONS
Who Must File the Form 500?
The Billed Entity representing a school, school district, library, library consortium, or consortium of multiple entities who
completed and submitted the Form 471 to which this Form 500 relates, must be the entity filing the Form 500 with the
USAC. Your FCDL from USACD cites your Billed Entity Number, which you must also record in Block 1, Item 2 of this
form.
How Many Form(s) 500 to File?
1. You may choose to submit one Form 500 setting forth the required information for each FRN on a separate Block 2.
Alternatively, you may choose to submit a separate Form 500 for each affected FRN. When deciding whether to file
multiple Form 500 applications or a single Form 500 containing the information for multiple FRNs, consider that it is
possible to enter multiple Blocks 2 each covering one FRN, all under the same Form 500.
2. Is all of the information necessary to complete successfully the Form 500 available? If any of the information required
for a particular FRN is missing, the applicant should submit a separate Form 500 for the particular FRN in question.
In order for your 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 Form 500 may be rejected and returned to you
without being accepted and processed.
When to File?
You may file a Form 500 no earlier than the receipt of an FCDL from the USAC. You should file a Form 500 as soon as
you are aware of new circumstances requiring adjustment of FRNs and as soon as you are able.
Where to File?
The 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. THIS FORM MAY NOT BE FILED ELECTRONICALLY.
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 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 Form 500 for each component of information. These
Instructions set forth the requirements for a valid entry. If you have any questions about completing this form, please visit
the USAC website at www.usac.org/sl and if you have remaining questions, please contact the SLD Client Service
Bureau at 1-888-203-8100, before submitting the form. If the form is not properly completed, it may be rejected and
returned to you.
Where to Get More Information?
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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 and detailed guidance is also available on our web site .

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 Form 471 on one Form 500; nor is it necessary to limit the Form 500 to one FCDL.
However, in the rare event that you have more than one Billed Entity Number as identified in more than one FCDL, you
must complete a separate Form 500 for each Billed Entity Number.
Note also that only one funding year can be featured on a Form 500.
Top of Form
The data at the top of Form 500 will help both you and USAC identify each particular Form 500 you file.
“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 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 Form 500. This Applicant’s Form
Identifier can be very simple; for example, if you are filing three 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.
Form 500 Application Number: USAC will assign and insert your 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 Number (from Item 2,
below), your Applicant’s Form Identifier, 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 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 Form 471. Please be sure
to obtain this information from your FCDL, as the information may have been reported differently in your Form
471 application.
Item (3) - Provide the funding year for which your funds were approved, e.g., "07/01/2000 – 06/30/2001." The funding year
you supply here must be the same as the funding year contained in your FCDL for the corresponding Form 471. The 2000
funding year runs from July 1, 2000 through June 30, 2001. 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 telephone number including the area code; fax number; and e-mail 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
services that have been, will be or are being provided. Provide the mailing address for the contact person, and phone
number, fax number and e-mail address if different from the address information in Item (4). If the mailing address for the
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contact person is left blank or incomplete, the address and phone number of the applicant will be filled in for the address
and telephone number of the contact person.
B. Block 2: Services Adjustment:
Block 2 of Form 500 asks you to provide information about the application number, FRN, billing account number as well
as the changes being made (cancel, reduce, start date change, change contract expiration date). Please complete a
Block 2 for EACH FRN affected. For each Block 2 that you complete, please number your pages, such as 2A, 2B, 2C,
etc. and provide the number in the space provided in Block 2.
Item (6) – Information to complete Rows A – E will be contained on the FCDL sent to you by USAC.
Rows (A), (B), (C), (D) and (E)
The applicant must provide the following information for columns (A), (B), (C), (D), and (E). All of this information must be
obtained from the FCDL.
(A) 471 Application Number;
(B) Funding Request Number (FRN) for the services affected;
(C) Billing Account Number (required, if contained in your FCDL);
(D) Service Provider Name;
(E) Service Provider SPIN.
Row (F)
Service Start Date: Use this row if you wish to change the Funding Year Service Start Date from a previously filed 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 a Form 486 (and NOT a Form 500). Check the box and fill in the
dates. The Original Date column should be used to enter the Funding Year Service Start Date you reported on your Form
486 Notification Letter from USAC. 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.
Row (G)
Contract Expiration Date: Use this row if you wish to change the contract expiration date, based on early termination or
an extension of the contract. Check the box and fill in the dates. 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.
Row (H)
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. Check the box and write in the Original Commitment Amount which is shown on your
FCDL. The New Commitment Amount is already filled in with $0.00. You may use this row if you have decided not to
purchase services after all. For example, if you had an FRN for T-1 telecommunication service and you decided not to
install that service. Canceling the FRN would allow 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) being made.
Row (I)
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. Check the box and write in the Original Commitment
Amount as shown on your FCDL and the New Commitment Amount AFTER Reduction. Reducing the commitment
would allow 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.
C.

Block 3: Certification

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Item (7) - Certify that the individual signing on behalf of the applicant is authorized to submit the information contained in
the 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 Form 500 is true to the best of his or her knowledge, information and belief.
Persons knowingly making false statements on this form can be punished by fine, forfeiture, or imprisonment under
federal law.
Item (8) – 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 (9) – Certify to your recognition that you may be audited pursuant to this application and will retain for five years any
and all records that you rely upon to complete this form.
Item (10) - The signature of the authorized person certifying to the accuracy of the information contained in Form 500 on
behalf of the applicant is required in this block. Please note that it is essential that the SIGNATURE be provided to
the fund administrator.
Item (11) - Enter the date the Form 500 was signed, using mm/dd/yyyy format.
Item (12) - Print the name of the authorized person certifying the information contained in Form 500 on behalf of the
applicant.
Item (13) - Enter the title or position of the authorized person certifying the information contained in Form 500 on behalf of
the applicant.
Item (14) - Enter the telephone number of the authorized person certifying the information contained in 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 Form 500 and the fund administrator.
Item (15) – Enter the email address (if available) of the authorized person certifying the information contained in Form
500 on behalf of the applicant. This component is required, if available, in order to expedite any communications that may
be necessary between the authorized person responsible for signing the Form 500 and the fund administrator.
Item (16) - 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 Form 500 on behalf 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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REMINDERS
•

If you are starting services (rather than making a change to a service start date that you already informed the SLD
about), please file a Form 486 instead of this Form 500.

•

All applicants participating in Universal Service for Schools and Libraries must file Form 500 within ten (10) business
days after the decision is made to make one of the covered adjustments or modifications to a Funding Request
Number, but no sooner than the date of receipt of the Funding Commitment Decision Letter.

•

The person authorized to provide the information required by Form 500 on behalf of a school, library, or consortium
must sign and date Form 500.

•

Provide data for all required information items. If you choose not to complete an information item that is optional,
please leave the item blank.

Form 500 Instructions

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