FCC Form 471 Descripton of Services Ordered and Certification

FCC Form 471

Do not write in this area.

Approval by OMB
3060-0806

Schools and Libraries Universal Service
Description of Services Ordered and Certification Form 471
Estimated Average Burden Hours per Response: 4 hours
This form is designed to help schools and libraries to list the eligible services they have ordered and estimate the annual
charges for them so that the Fund Administrator can set aside sufficient support to reimburse providers for services.
Please read instructions before beginning this application. (You can also file online at www.usac.org/sl.)
The instructions include information on the deadlines for filing this application.

Applicant’s Form Identifier (Create an identifier for your own reference)

Form 471 Application #:

X

(To be assigned by administrator)

Block 1: Billed Entity Address and Information
1 Name of Billed Entity

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

2 Funding Year

3a Entity Number

3b FCC Registration Number
4a Street Address, P.O. Box, or Route Number

City

Zip Code

State

4b Telephone Number

Ext

4c Fax Number

5a Type of Application (check only one)
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, 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:
Private

Public

Charter

Tribal

Head Start

State Agency

Page 1 of 8 DRAFT

FCC Form 471 - Month 2010

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

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

If the Contact Person’s Street Address is the same as Item 4 above, check here.
6b Street Address, P.O. Box, or Route Number

City

If not, complete Item 6b.

NOTE: USAC will use THIS address to mail correspondence about this form.

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

6f Holiday/vacation/summer contact information: please include name of alternate contact (if applicable) and
alternate phone, fax or E-mail address

If a consultant is assisting you with your application process, please complete Item 6g below:
6g Consultant Name
Name of Consultant’s Employer
Consultant’s Street Address
City
Consultant’s Telephone Number

State

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 471 - Month 2010

Entity Number __________________________________ Applicant’s Form Identifier _________________________________
Contact Person __________________________________

Phone Number _________________________________

Complete this information on EVERY Form 471 you file for the services requested on that form. Please complete all rows that apply to services for which
you are requesting discounts.
Schools/school districts complete the left-hand column and libraries complete the right-hand column. Consortia complete all that apply.

Block 2: Impact of Services Ordered for Schools and Libraries from this Form 471
Schools

7a

Number of students or patrons to be served

b

Telephone service: Number of classrooms or rooms with phone
service

c

Direct connections to the Internet: Number of drops

d

Number of classrooms or rooms with Internet access

e

Number of computers or other devices with Internet access

f

Libraries

Dial-up Internet access: Number of connections (up to 56kbps)

Less than 200 kbps

Between 200 kbps and 1.5 mbps

Between 1.5 mbps and 3 mbps

Between 3 mbps and 10 mbps

g

Direct broadband
services: Number of
buildings served at
the following
speeds:

Between 10 mbps and 25 mbps

Between 25 mbps and 50 mbps

Between 50 mbps and 100 mbps

Greater than 100 mbps

Block 3:
8.

[Reserved]

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FCC Form 471 - Month 2010

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

Block 4: Discount Calculation Worksheet

Worksheet _______
Page ______ of _______

The Block 4 worksheet is used to calculate your discount for services. You will complete one or more worksheets depending on the type of application
you are filing. If you file more than one worksheet, please number the completed worksheets to assure that they are all processed correctly. Please
refer to the instructions for information specific to the Type of Application you indicated in Block 1, Item 5.
Check here if this worksheet contains all eligible entities in the school district or library system.
9a List entities and calculate discount(s):
School District or Library System Name:

(For Administrator’s Use)
School District or Library System Entity Number:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Name of Eligible Entity

Entity Number AND
NCES Code (for Schools) or
FSCS Code (for Libraries)

Urban
or
Rural
U or R

Total
Number of
Students

Number of
Students
Eligible for
NSLP

Percent of
Students
Eligible for
NSLP
(Col. 5 / Col 4)

Disc.
from
Disc.
Matrix

New
Cons
tructi
on

Admin
Entity
or NIF

Alt
Disc
Mech

Weighted Product
for Calculating
Shared Discount
(Col. 4 x Col. 7)

Insert appropriate code(s):
P = pre-K, H = Head Start,
A = Adult Education,
J = Juvenile Justice,
E = ESA, D = Dormitory
Schools

Entity Number of School
District in which Library
Outlet/Branch is Located

Discount
of
Member
Entity

Shared
Discount

Library Outlet/Branch

Consortia

ALL ENTITIES

SCHOOLS AND LIBRARIES

Schools with
shared services

9b Shared Services
SCHOOL DISTRICTS: (Including groups of schools within
school districts.) Calculate the totals of Columns 4 and 11.
Divide the total of Column 11 by the total of Column 4. Enter
the result in Column 15.
LIBRARY SYSTEMS: Calculate the total of Column 7.
Divide this total by the number of outlets/branches. Enter the
result in Column 15.
CONSORTIA: Calculate the total of Column 14. Divide this
total by the number of member entities. Enter the result in
Column 15.

Page 4 of 8

FCC Form 471 – November 2004

Entity Number __________________________________ Applicant’s Form Identifier _________________________________
Contact Person __________________________________

Phone Number _________________________________

Block 5: Discount Funding Request(s)
Instructions: Use one Block 5 page for EACH service (Funding Request Number)
for which you are requesting discounts. Make as many copies of this page as
needed, and number the completed pages to assure that they are all processed correctly.

11

12

13

14

of

FRN ______________________
(to be assigned by administrator)

If this is a duplicate Funding Request (e.g., of an FRN that is not yet approved, under appeal,
etc.), check this box and enter the original FRN in the space provided:
Category of Service ( only ONE category should be checked)

23 Calculations

A. Monthly charges (total amount per month for service)

PRIORITY 1
Telecommunications
Service

PRIORITY 2
Internal Connections Other than Basic
Maintenance

Internet Access

Basic Maintenance of Internal
Connections

Form 470 Application Number

Recurring Charges

10

Block 5, page

SPIN – Service Provider Identification Number

B. How much of the amount in A is ineligible?

C. Eligible monthly pre-discount amount

(A minus B)

Service Provider Name

D.

Number of months service provided in funding year

E. Annual pre-discount amount for eligible recurring charges

15a
15b
15c
15d
16a

16b

Check this box if this Funding Request is for non-contracted tariffed or
month-to-month services.

Contract Number

Check this box if this Funding Request is covered under a master contract (a
contract negotiated by a third party, the terms and conditions of which are then made
available to an eligible entity that purchases directly from the service provider).
Check this box if this Funding Request is a
continuation of an FRN from a previous
funding year based on a multi-year contract.
If so, provide that FRN here:

Non-Recurring Charges

(C x D)

F. Annual non-recurring charges

G. How much of the amount in F is ineligible?

Billing Account Number (e.g., billed telephone number)

H. Annual eligible pre-discount amount for non-recurring charges

Check this box if there are multiple Billing Account Numbers and attach a
complete list of those numbers to this page.

(F minus G)

Allowable Vendor Selection/Contract Date (mm/dd/yyyy)
(based on Form 470 filing)

17

19
20a
20b
21

Contract Award Date (mm/dd/yyyy)
Service Start Date (mm/dd/yyyy)
Service End Date (mm/dd/yyyy)
Contract Expiration Date
(mm/dd/yyyy)

I. Total funding year pre-discount amount (E + H)
Total Charges

18

J. Discount from Block 4 Worksheet
K. Funding Commitment Request (I x J)

Description of This Service: NOTE: All Item 21 Attachments must be filed before the close of the filing window.

You MUST attach a description of the service, including a breakdown of components, costs, manufacturer name, make and model number. You
must include any additional account or telephone numbers if the billed account has multiple numbers. Label the description with an Attachment
Number, and note number in space provided.

22

Entity/Entities Receiving This Service:

Attachment

a. If the service is site-specific (provided to one site
and not shared by others), list the Entity Number of
the entity from Block 4 receiving this service:
b. If the service is shared by all entities on a Block 4
worksheet, list the worksheet number (e.g., 1):

Page 5 of 8
FCC Form 471 –
November 2004

Do not write in this area

Entity Number __________________________________ Applicant’s Form Identifier _________________________________
Contact Person __________________________________

Phone Number _________________________________

Block 6: Certifications and Signature
24

I certify that the entities listed in Block 4 of this application are eligible for support because they are: (Check one or both.)

25

a

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 exceeding $50 million; and/or

b

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, secondary schools, colleges, or universities.

I certify that the entity I represent or the entities listed on this application have secured 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 the entities I represent or
the entities listed on this application have secured access to all of the resources to pay the discounted charges for eligible services from funds to
which access has been secured in the current funding year. I certify that the Billed Entity will pay the non-discount portion of the cost of the goods
and services to the service provider(s).
a

Total funding year pre-discount amount on this Form 471
(Add the entries from Items 23I on all Block 5 Discount Funding Requests.)

b

Total funding commitment request amount on this Form 471
(Add the entries from Items 23K on all Block 5 Discount Funding Requests.)

c

Total applicant non-discount share
(Subtract Item 25b from Item 25a.)

d

Total budgeted amount allocated to resources not eligible for E-rate support

e

Total amount necessary for the applicant to pay the non-discount share of the
services requested on this application AND to secure access to the resources
necessary to make effective use of the discounts. (Add Items 25c and 25d.)
Check this box if you are receiving any of the funds in Item 25e directly from a service provider listed on any of the Forms 471 filed by this
Billed Entity for this funding year, or if a service provider listed on any of the Forms 471 filed by this Billed Entity for this funding year assisted
you in locating funds in Item 25e.

f

26

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.

27

I certify that (if applicable) I posted my Form 470 and (if applicable) made any related RFP available for at least 28 days before considering all bids
received and selecting a service provider. I certify that all bids submitted were carefully considered and the most cost-effective service offering was
selected, with price being the primary factor considered, and is the most cost-effective means of meeting educational needs and technology plan
goals.

28

I certify that the entity responsible for selecting the service provider(s) has reviewed all applicable FCC, state, and local procurement/competitive
bidding requirements and that the entity or entities listed on this application have complied with them.

29

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 application 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.

30

I certify that I and the entity(ies) I represent have complied with all program rules and I acknowledge that failure to do so may result in denial of
discount funding and/or cancellation of funding commitments. There are signed contracts covering all of the services listed on this Form 471
except for those services provided under non-contracted tariffed or month-to-month arrangements. I acknowledge that failure to comply with
program rules could result in civil or criminal prosecution by the appropriate law enforcement authorities.

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FCC Form 471 - [MONTH] 2010

Do not write in this area

Entity Number __________________________________ Applicant’s Form Identifier __________________________________
Contact Person __________________________________ Phone Number __________________________________

Block 6: Certification and Signature (Continued)
31

I acknowledge 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 service, receive an appropriate share of benefits from those services.

32

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 application for, receipt of, and delivery of
services receiving schools and libraries discounts, and that if audited, I will make such records available to the Administrator. I acknowledge that I
may be audited pursuant to participation in the schools and libraries program.

33

I certify that I am authorized to order telecommunications and other supported services for the eligible entity(ies) listed on this application. I certify
that I am authorized to submit this request on behalf of the eligible entity(ies) listed on this application, that I have examined this request, that all of
the information on this form is true and correct to the best of my knowledge, that the entities that are receiving discounts pursuant to this application
have complied with the terms, conditions and purposes of the program, that no kickbacks were paid to anyone and that 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 and civil violations of the False Claims Act.

34

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. I will institute
reasonable measures to be informed, and will notify USAC should I be informed or become aware that I or any of the entities listed on this
application, or any person associated in any way with my entity and/or the entities listed on this application, is convicted of a criminal violation or
held civilly liable for acts arising from their participation in the schools and libraries support mechanism.

35

I certify that if any of the Funding Requests on this Form 471 are for discounts for products or services that contain both eligible and ineligible
components, that I have allocated the cost of the contract to eligible and ineligible components as required by the Commission's rules at 47 C.F.R.
§ 54.504(g)(1), (2).

36

I certify that this funding request does not constitute a request for internal connections services, except basic maintenance services, in violation of
the Commission requirement that eligible entities are not eligible for such support more than twice every five funding years as required by the
Commission's rules at 47 C.F.R. § 54.506(c).

37

I certify that the non-discount portion of the costs for eligible services will not be paid by the service provider. The pre-discount costs of eligible
services featured on this Form 471 are net of any rebates or discounts offered by the service provider. I acknowledge that, for the purpose of this
rule, the provision, by the provider of a supported service, of free services or products unrelated to the supported service or product constitutes a
rebate of some or all of the cost of the supported services.

38

40
41

39

Signature of
authorized
person
Printed name
of authorized
person

Date

Title or position
of authorized
person
Check here if the consultant in Item 6g is the Authorized Person.

42a

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

City

State

Page 7 of 8

Zip Code

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FCC Form 471 – Month 2010

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

42b
42c

42d

.

Telephone Number
of Authorized
Person

Ext.

Fax Number of Authorized Person

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

42e

Name of Authorized
Person’s Employer

NOTICE: Section 54.504 of the Federal Communications Commission's rules requires all schools and libraries ordering services that are eligible for and seeking
universal service discounts to file this Services Ordered and Certification Form (FCC Form 471) with the Universal Service Administrator. 47 C.F.R.§ 54.504(c).
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 47C.F.R. § 54.504. All schools
and libraries planning to order services eligible for universal service discounts 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, consistent with the Communications Act of 1934, FCC regulations and orders, the Freedom of Information Act, 5
U.S.C. § 552, or other applicable law, information provided in or submitted with this form or in response to subsequent inquiries may be disclosed to the public.
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 application 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 4 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 471
P.O. Box 7026
Lawrence, Kansas 66044-7026

For express delivery services or U.S. Postal Service, Return Receipt Requested, mail this form to:
SLD Forms
ATTN: SLD Form 471
3833 Greenway Drive
Lawrence, Kansas 66046
(888) 203-8100

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FCC Form 471 – Month 2010