Form FCC Form 470 FCC Form 470 Description of Services Requested and Certification

Universal Service - Schools and Libraries Universal Service Program, FCC Forms 470 and 471

0806_FCC470_090110

Universal Service - Schools and Libraries Universal Service Program - FCC Form 470, Private Sector

OMB: 3060-0806

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FCC Form 470

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3060-0806

Do not write in this area.

Schools and Libraries Universal Service
Description of Services Requested and Certification Form 470
Estimated Average Burden Hours per Response: 3 hours
This form is designed to help you describe the eligible services you seek so that this data can be posted on the Fund Administrator Internet Site
and interested service providers can identify you as a potential customer and compete to serve you.

Please read instructions before beginning this form. (You can also file online at www.usac.org/sl)
Applicant’s Form Identifier (Optional: Create an identifier for your own reference)

Form 470 Application #:

(To be assigned by administrator)

Block 1: Applicant Address and Information
1

Name of Applicant

X XX X
2

Funding Year

(Funding years run from July 1 through the following June 30)

3 Entity Number
4a Street Address, P.O. Box, or Route Number

City

State

4b Telephone Number

Zip Code

Ext

4c Fax Number
5a Eligible Entities That Will Receive Services:
Check the ONE choice in 5a that best describes the eligible entities that will receive the services described in this
form. You will then list in Item 15 the entity/entities that will pay the bills for these services.
Individual School (individual public or non-public school)
School District

(LEA; public or non-public [e.g. diocesan] local district representing multiple schools)

Library

(including library system, library outlet/branch or library consortium as defined under LSTA)

Consortium

(intermediate service agencies, non-statewide or regional consortia of schools and/or libraries)

Statewide application for (enter 2-letter state code)
representing (check all that apply)
All public schools/districts in the state
All non-public schools in the state
All libraries in the state
5b Recipient(s) of Services - Check all that apply:
Private

Public

Charter

Tribal

Head Start

State Agency

5c Number of eligible entities for which services are sought

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FCC Form 470
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Entity Number __________________________________ Applicant’s Form Identifier __________________________________
Contact Person __________________________________ Contact Telephone Number __________________________________

Block 1: Applicant Address and Information (continued)
6a Contact Person’s Name

If the Contact Person’s Street Address is the same as Item 4a above, check here.

If not, complete Item 6b.

6b Street Address, P.O. Box, or Route Number
NOTE: USAC will use this address to mail correspondence about this form.

City

State

Zip Code

Check the box next to your preferred mode of contact and provide your contact information. One box MUST be checked
and an entry provided.
6c

Telephone Number

Ext.

6d Fax Number
6e E-mail Address
Re-enter E-mail Address

If a consultant is assisting you with your application process, please complete Item 7 below:
7

Consultant Name

Name of Consultant’s Employer
Consultant’s Street Address
City

State

Consultant’s Telephone Number

Zip Code
Ext.

Consultant’s Fax Number
Consultant’s E-mail Address
Re-enter E-mail Address
Consultant Registration Number

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FCC Form 470
Month 2010

Block 2: Summary Description of Needs or Services Requested (Attach additional pages if needed)
8 Telecommunications Services
If you check YES to indicate you have a Request for Proposals (RFP) that specifies the services you are seeking, your
RFP must be available to all interested bidders for at least 28 days. If your RFP is not available to all interested
bidders, or if you check NO and you have or intend to have an RFP, you risk denial of your funding requests.
YES, I have released or intend to release an RFP for these services. It is available or will become available on the
Internet at:

or via (check one)

the contact person in Item 6 or

the contact person listed in Item 12

Your RFP Identifier:
b

NO, I have not released and do not intend to release an RFP for these services.
Whether you check YES or NO, you must list below the Telecommunications Services you seek. Specify each service (e.g., local
voice service) and quantity and/or capacity (e.g., 20 existing lines plus 10 new ones).

Service

Quantity and/or Capacity

9 Internet Access
If you check YES to indicate you have a Request for Proposals (RFP) that specifies the services you are seeking, your
RFP must be available to all interested bidders for at least 28 days. If your RFP is not available to all interested
bidders, or if you check NO and you have or intend to have an RFP, you risk denial of your funding requests.
YES, I have released or intend to release an RFP for these services. It is available or will become available on the
Internet at:

or via (check one)

the contact person in Item 6 or

the contact person listed in Item 12.

Your RFP Identifier:
b

NO, I have not released and do not intend to release an RFP for these services.
Whether you check YES or NO, you must list below the Internet Access services you seek. Specify each service (e.g., monthly
Internet service) and quantity and/or capacity (e.g., for 500 users).

Service

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Quantity and/or Capacity

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FCC Form 470
Month 2010

Block 2: Summary Description of Needs or Services Requested (Attach additional pages if needed)
10 Internal Connections Other Than Basic Maintenance
If you check YES to indicate you have a Request for Proposals (RFP) that specifies the services you are seeking, your
RFP must be available to all interested bidders for at least 28 days. If your RFP is not available to all interested bidders, or
if you check NO and you have or intend to have an RFP, you risk denial of your funding requests.

YES, I have released or intend to release an RFP for these services. It is available or will become available on the Internet
at:

or via (check one)

the contact person in Item 6 or

the contact person listed in Item 12.

Your RFP Identifier:
b

NO, I have not released and do not intend to release an RFP for these services.
Whether you check YES or NO, you must list below the Internal Connections services you seek. Specify each service (e.g., a router,
hub and cabling) and quantity and/or capacity (e.g., connecting 1 classroom of 30 students).

Service

Quantity and/or Capacity

11 Basic Maintenance of Internal Connections
If you check YES to indicate you have a Request for Proposals (RFP) that specifies the services you are seeking, your
RFP must be available to all interested bidders for at least 28 days. If your RFP is not available to all interested
bidders, or if you check NO and you have or intend to have an RFP, you risk denial of your funding requests.

YES, I have released or intend to release an RFP for these services. It is available or will become available on the Internet
at:

or via (check one)

the contact person in Item 6 or

the contact person listed in Item 12.

Your RFP Identifier:
b

NO, I have not released and do not intend to release an RFP for these services.
Whether you check YES or NO, you must list below the Basic Maintenance services you seek. Specify each service (e.g., basic
maintenance of routers) and quantity and/or capacity (e.g., for 10 routers).

Service

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Quantity and/or Capacity

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FCC Form 470
Month 2010

Block 2: Summary Description of Needs or Services Requested (Continued)
12

(Optional) Please name the person on your staff or project who can provide additional technical details or answer
specific questions from service providers about the services you are seeking. This person does not need to be the
contact person(s) listed in Item 6 nor the Authorized Person who signs this form.
Name

Title

Telephone Number

Ext.

Fax Number
Email Address
Re-enter E-mail Address

Check this box if there are any restrictions imposed by state or local laws or regulations on how or when service
providers may contact you or on other bidding procedures. Please describe below any such restrictions or
procedures and/or provide an Internet address where they are posted and a contact name and telephone number.
Check this box if no state and local procurement/competitive bidding requirements apply to the procurement of
services sought on this Form 470.
If you are requesting services for a funding year for which a Form 470 cannot yet be filed online, include that
information here.

Block 3:
14

[Reserved]

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FCC Form 470
Month 2010

Block 4: Recipients of Service
15

Billed Entities

List the entity/entities that will be paying the bills directly to the provider for the services requested in this form.
These are known as Billed Entities. At least one line of this item must be completed. If a Billed Entity cited on your
Form 471 is not listed below, funding may be denied for the funding requests associated with this Form 470. Attach
additional pages if needed.

Entity Number

Entity Name

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

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FCC Form 470
Month 2010

Do not write in this area.

Block 5: Certifications and Signature
16

I certify that the applicant includes: (Check one or both.)
schools under the statutory definitions of elementary and secondary schools found in the No Child Left Behind Act of
2001, 20 U.S.C. §§ 7801 (18) and (38), that do not operate as for-profit businesses, and do not have endowments
a
exceeding $50 million; and/or

libraries or library consortia eligible for assistance from a State library administrative agency under the Library Services
and Technology Act of 1996 that do not operate as for-profit businesses and whose budgets are completely separate from
any schools (including, but not limited to elementary and secondary schools, colleges, and universities).

I certify that, if required by Commission rules, all of the individual schools and libraries receiving services under this form are
covered by technology plans that are written, that cover all 12 months of the funding year, and that have been or will be approved
by a state or other authorized body, or an SLD-certified technology plan approver, prior to the commencement of service.
Or I certify that no technology plan is required by Commission rules.

I certify that I will post my Form 470 and (if applicable) make my RFP available for at least 28 days before considering all bids
received and selecting a service provider. I certify that all bids submitted will be carefully considered and the bid selected will be for
the most cost-effective service or equipment offering, with price being the primary factor, and will be the most cost-effective means
of meeting educational needs and technology plan goals.
I certify that I will retain required documents for a period of at least five years after the last day of service delivered. I certify that I
will retain all documents necessary to demonstrate compliance with the statute and Commission rules regarding the form for,
receipt of, and delivery of services receiving schools and libraries discounts. I acknowledge that I may be audited pursuant to
participation in the schools and libraries program.

I certify that the services the applicant purchases at discounts provided by 47 U.S.C. § 254 will be used solely for educational
purposes and will not be sold, resold or transferred in consideration for money or any other thing of value, except as permitted by
the Commission’s rules at 47 C.F.R. §§ 54.500, 54.513. Additionally, I certify that the entity or entities listed on this form have not
received anything of value or a promise of anything of value, other than services and equipment sought by means of this form, from
the service provider, or any representative or agent thereof or any consultant in connection with this request for services.

I acknowledge that support under this support mechanism is conditional upon the school(s) and/or library(ies) I represent securing
access, separately or through this program, to all of the resources, including computers, training, software, internal connections,
maintenance, and electrical capacity necessary to use the services purchased effectively. I recognize that some of the
aforementioned resources are not eligible for support. I certify that I have considered what financial resources should be available
to cover these costs.

I certify that I am authorized to procure eligible services for the eligible entity(ies). I certify that I am authorized to submit this
request on behalf of the eligible entity(ies) listed on this form, that I have examined this request, and to the best of my knowledge,
information, and belief, all statements of fact contained herein are true.

I certify that I have reviewed all applicable FCC, state, and local procurement/competitive bidding requirements and that I have
complied with them. I acknowledge that persons willfully making false statements on this form can be punished by 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.

I acknowledge that FCC rules provide that persons who have been convicted of criminal violations or held civilly liable for certain
acts arising from their participation in the schools and libraries support mechanism are subject to suspension and debarment from
the program.

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FCC Form 470
Month 2010

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Block 5: Certifications and Signature (Continued)
25

27a
27b

Signature of
authorized
person
Printed name
of authorized
person

Date

Title or position
of authorized
person
Check here if the consultant in Item 7 is the Authorized Person.

27c

Street Address, P.O. Box, or Route Number

City

State

27d

Zip Code

Telephone Number
of Authorized
Person

Ext.

27e
Fax Number of Authorized Person

27f

E-mail Address
of Authorized
Person
Re-enter E-mail Address

Name of Authorized
Person’s Employer

27g

Service provider involvement with preparation or certification of a Form 470
can taint the competitive bidding process and result in the denial of funding requests.
For more information, refer to the Schools and Libraries area of the USAC web site at
www.usac.org/sl or call the SLD Client Service Bureau at 1-888-203-8100.

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FCC Form 470
Month 2010

Entity Number _________________________Applicant’s Form Identifier __________________________________
Contact Person ________________________Contact Telephone Number __________________________________

Block 5: Certifications and Signature (Continued)
NOTICE: In accordance with Section 54.504 of the Federal Communications Commission’s rules, certain schools and libraries ordering
services that are eligible for and seeking universal service discounts must file this Description of Services Requested and Certification
Form (FCC Form 470) with the Universal Service Administrator. 47 C.F.R. § 54.504(b). The collection of information stems from the
Commission’s authority under Section 254 of the Communications Act of 1934, as amended. 47 U.S.C. § 254. The data in the
report will be used to ensure that schools and libraries comply with the competitive bidding requirement contained in 47 C.F.R. §
54.504. Schools and libraries must file this form themselves or as part of a consortium.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number.
The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. We
will use the information you provide to determine whether approving this application is in the public interest. If we believe there
may be a violation or a potential violation of any applicable statute, regulation, rule or order, your application may be referred to
the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation or
order. In certain cases, the information in your application may be disclosed to the Department of Justice or a court or adjudicative
body when (a) the FCC; or (b) any employee of the FCC; or (c) the United States Government is a party of a proceeding before the
body or has an interest in the proceeding. In addition, information provided in or submitted with this form or in response to
subsequent inquiries may also be subject to disclosure consistent with the Communications Act of 1934, FCC regulations, the
Freedom of Information Act, 5 U.S.C. § 552, or other applicable law.
If you owe a past due debt to the federal government, the information you provide may also be disclosed to the Department of the
Treasury Financial Management Service, other Federal agencies and/or your employer to offset your salary, IRS tax refund or other
payments to collect that debt. The FCC may also provide the information to these agencies through the matching of computer
records when authorized.
If you do not provide the information we request on the form, the FCC may delay processing of your application or may return your
form without action.
The foregoing Notice is required by the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. § 3501, et seq.
Public reporting burden for this collection of information is estimated to average 3 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing, and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the reporting burden to the Federal Communications Commission, Performance Evaluation and
Records Management, Washington, DC 20554.

Please submit this form to:
SLD-Form 470
P.O. Box 7026
Lawrence, Kansas 66044-7026
1-888-203-8100
For express delivery services or U.S. Postal Service, Return Receipt Requested, mail this form
to:
SLD Forms
ATTN: SLD Form 470
3833 Greenway Drive
Lawrence, Kansas 66046
1-888-203-8100

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FCC Form 470
Month 2010

File Type	application/pdf
File Modified	2010-09-02
File Created	2010-08-31