Form 470 Form 470 Description of Services Requested and Certification - Fi

Non-Public OMB 3060-0806

Schools and Libraries Universal Service

Description of Services Requested and Certification Form 470

(Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual representation of what each applicant will see).

Item Number	Field Description	Purpose/Instructions
1	Applicant’s Form Nickname	To create unique identifier for this submission, the user simply enters a nickname (e.g., 2016 FY Applewood SD Form 470).
2	FCC Form 470 Application Number	Auto-generated by the system: This is a USAC-assigned unique identifier for this submission.
3	Applicant Name	This is the name of the organization submitting this form—school, school district, library (outlet/branch or system) or a consortium of those entities (schools, libraries, or schools and libraries). If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
4	Funding Year	Auto-generated by the system based on the funding year of the next application window: This is the Funding Year for which service are sought.
5	Entity Number	Auto-generated by the system: This is the Unique identifier assigned by USAC to the organization listed in Applicant Name.
6	FCC Registration Number	This is the unique FCC identifier for the organization listed as the applicant. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
7	Mailing Address	This is the mailing address for the applicant. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
8	Type of Eligible Entities that Will Receive Services	User is required to pick whether the applicant is an individual school, school district, library, consortium or statewide application.
9	Type of Eligible Entities that Will Receive Services: If Statewide Application	If the user chooses “statewide application” in Item 8, the user will be required to select which state and whether the application includes public schools, and/or non-public schools, and/or libraries.
10	Recipients of Service	User must select from a list all that apply. Choices include private, public, charter, tribal, head start, and state agency.
11	Number of Eligible Sites for Which Products or Services are Sought	User must provide the number of eligible sites for which products or services are being sought.
12	Contact Person Name	User must provide the name of the person who should be contacted with questions about this application. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
13	Contact Person Mailing Address	User must provide the mailing address of the person who should be contacted with questions about this application. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
14	Contact Person Telephone Number	User must provide the telephone number of the person who should be contacted with questions about this application. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
15	Contact Person Email Address	User must provide the email address of the person who should be contacted with questions about this application. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
16	Consultant Information	If user uses a consultant to submit its application, the user must provide the name of the consulting company, consultant registration number, name of the consultant representing the applicant, consultant telephone number, consultant email address, and consultant physical address. If this information has already been entered into the user’s profile, it will be pre-populated into this submission.
17	Needs or Services Requested: Category One (telecommunications, voice, Internet Access)—Service Description	User is required to provide a description of any Category One services (the type of telecommunications, voice or Internet Access services) sought.
18	Needs or Services Requested: Category One (telecommunications, voice, Internet Access)—Quantity and/or Capacity	User is required to provide a description of the circuit speeds requested as well as the quantity of lines at each speed. For items that do not have an associated speed (e.g., telephone service), user will only list quantity.
19	Indicate Whether a Separate Request for Proposal (RFP) will be Released for this Category One Service	User must indicate whether they are using an RFP. If an RFP is used, it must be attached so that it can be “released” with the posting of the Form 470. If one RFP covers both Category One and Category Two services, it will only need to be attached once.
20	Installment Payments for Category One Charges	User must indicate whether it is seeking an installment payment plan for their non-discounted portion of special construction charges for lit fiber, dark fiber, or self-construction.
21	Needs or Services Requested: Category 2: Internal Connections, Basic Maintenance of Internal Connections, and Managed Internal Broadband Services – Product or Service Description	User must describe the type of Internal Connections, Basic Maintenance of Internal Connections, and Managed Internal Broadband Services sought.
22	Needs or Services Requested: Category 2: Internal Connections, Basic Maintenance of Internal Connections, and Managed Internal Broadband Services - Quantity	User must indicate the quantity of the product or service sought.
23	Indicate Whether a Separate Request for Proposal (RFP) will be Released for this Category Two Product or Service	User must indicate whether they are using an RFP. If an RFP is used, it must be attached so that it can be “released” with the posting of the Form 470. If one RFP covers both Category One and Category Two services, it will only need to be attached once.
24	Technical Contact	User must provide contact information for the appropriate person to provide additional technical details regarding the services sought.
25	State or Local procurement Restrictions	User must provide a description of any applicable state or local procurement restrictions or indicate that no state or local procurement/competitive bidding requirements apply to this procurement.
26	Billed Entities	User must list the Billed Entity or Billed Entities that will be purchasing products or services based on this application.
27	Certifications If user is authorized only to submit an FCC Form 470 and not order services on behalf of the listed entities, user fills in certifications in item numbers 28-33. If user is authorized to submit an FCC Form 470 and order services on behalf of the listed entities, user fills in certifications in item numbers 34-39.	User must indicate whether it has rights to submit the form only, or rights to submit the form and order services on behalf of the listed entities. Based on the answer to that question, the system will present the applicable certifications necessary for rule compliance.
28	I certify that the applicant includes: 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 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).
29	I certify that this FCC Form 470 and any applicable RFP will be available for review by potential bidders 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 goals.
30	I certify that I will retain required documents for a period of at least 10 years (or whatever retention period is required by the rules in effect at the time of this certification) after the later of the last day of the applicable funding year or the service delivery deadline for the associated funding request. 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.
31	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.
32	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 may 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.
33	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.
34	I certify that the applicant includes: 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 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).
35	I certify that this FCC Form 470 and any applicable RFP will be available for review by potential bidders 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 goals.
36	I certify that I will retain required documents for a period of at least 10 years (or whatever retention period is required by the rules in effect at the time of this certification) after the later of the last day of the applicable funding year or the service delivery deadline for the associated funding request. 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 primarily for educational purposes, see 47 C.F.R. § 54.500, 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. § 54.513. 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.
37	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.
38	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 may 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.
39	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.
40	Signature of Authorized Person	The form must be signed by an authorized person.
41	Date Signed	Auto generated by system.
42	Name of Authorized Person	This is the name of the authorized person signing the form.
43	Title or Position of Authorized Person	This is the title of the authorized person signing the form.
44	Physical or mailing address of Authorized Person	This is the address (can be physical address or mailing address) of the authorized person signing the form.
45	Telephone Number of Authorized Person	This is the telephone number of the authorized person signing the form.
46	Email address of Authorized Person	This is the email address of the authorized person signing the form.
47	Name of Authorized Person’s Employer	This is the name of the employer of the authorized person signing the form.

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