FCC Form 470

FCC Form 470.pdf

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

FCC Form 470

OMB: 3060-0806

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FCC Form 470

Approval by OMB
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: 4 hours
This form is designed to help you describe the eligible telecommunications-related services you seek so that this data can be posted on the Fund Administrator Web Site
and interested service providers can identify you as a potential customer and compete to serve you.

Please read instructions before beginning this application. (You can also file online at www.sl.universalservice.org)

Applicant’s Form Identifier (Create your own code to identify THIS Form 470)

Form 470 Application #:

(To be assigned by administrator)

Block 1: Applicant Address and Identifications
1 Name of Applicant

X XX X
2 Funding Year
July 1,

3 Entity Number

Ythrough June 30,

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

City

State

Zip Code

b Telephone Number

Ext

c Fax Number

X
5 Type of Application
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, states, state networks, special consortia of schools
and/or libraries)

Page 1 of 14

7 0

FCC Form 470 October 2004

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

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

First, if the Contact Person’s Street Address is the same as in Item 4 above, check this box.
please complete the entries for the Street Address below.

If not,

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

City

X
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.
c

d Fax Number

Telephone Number
Ext

e E-mail Address

Block 2: Summary Description of Needs or Services Requested
7 This form 470 describes (check all that apply):
a.

Tariffed or month-to-month services to be provided without a written contract. A new Form 470 must be filed
for non-contracted tariffed or month-to-month services for each funding year.

Services for which a new written contract is sought for the funding year in Item 2.
Check if you are seeking

a multi-year contract and/or

a contract featuring voluntary extensions.

A multi-year contract signed on or before 7/10/97 but for which no Form 470 has been filed in a previous
funding year.
NOTE: Services that are covered by a signed, written contract executed pursuant to posting of a Form 470
in a previous funding year OR a contract signed on/before 7/10/97 and previously reported on a Form 470
as an existing contract do NOT require filing of a new Form 470.

What kinds of service are you seeking: Telecommunications Services, Internet Access, Internal
Connections Other than Basic Maintenance, or Basic Maintenance of Internal Connections? Refer to
the Eligible Services List at www.sl.universalservice.org for examples. Check the relevant category or
categories (8, 9, 10 and/or 11 below), and answer the questions in each category you select.

Page 2 of 14

FCC Form 470
October 2004

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

Item 8, page

Do you have a Request for Proposal (RFP) that specifies the services you are seeking? If you check YES, your RFP
must be available to all interested bidders for at least 28 days. If you check YES and 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 Web at:

or via (check one)
b

the Contact Person in Item 6 or

the contact listed in Item 12.

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 or function
(e.g. local voice service) and quantity and/or capacity (e.g. 20 existing lines plus 10 new ones). See the Eligible Services List at
www.sl.universalservice.org for examples of eligible Telecommunications Services. Remember that only eligible telecommunications
providers can provide these services under the universal service support mechanism. Attach additional pages if needed.

Check this box if you prefer
discounts on your bill.

Check this box if you prefer reimbursement
after paying your bill in full.

Check this box if you do not
have a preference.

Service or Function

1) Quantity and/or Capacity

Service or Function
2) Quantity and/or Capacity

Service or Function
3) Quantity and/or Capacity

Service or Function
4) Quantity and/or Capacity

Service or Function
5) Quantity and/or Capacity

Page 3 of 14

FCC Form 470
October 2004

Block 2: Summary Description of Needs or Services Requested (Continued)
9 Internet Accessons Services

Item 9, page

Do you have a Request for Proposal (RFP) that specifies the services you are seeking? If you check YES, your
RFP must be available to all interested bidders for at least 28 days. If you check YES and 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 Web at:

or via (check one)
b

the Contact Person in Item 6 or

the contact listed in Item 12.

NO, I have not released and do not intend to release an RFP for these services.
Whether you checked YES or NO, you must list below the Internet Access services you seek. Specify each service or function (e.g.,
monthly Internet service) and quantity and/or capacity (e.g., for 500 users). See the Eligible Services List at
www.sl.universalservice.org for examples of eligible Internet Access services. Attach additional pages if needed.

Check this box if you prefer
discounts on your bill.

Check this box if you prefer
reimbursement after paying your bill
in full.

Check this box if you do not
have a preference.

Service or Function

1) Quantity and/or Capacity

Service or Function
2) Quantity and/or Capacity

Service or Function
3) Quantity and/or Capacity

Service or Function
4) Quantity and/or Capacity

Service or Function
5) Quantity and/or Capacity

Page 4 of 14

FCC Form 470
October 2004

Block 2: Summary Description of Needs or Services Requested (Continued)
10 Internal Connections Other than Basic Maintenance

Item 10, page

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

or via (check one)
b

the Contact Person in Item 6 or

the contact listed in Item 12.

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 or function
(e.g., a router, hub and cabling) and quantity and/or capacity (e.g., connecting 1 classroom of 30 students). See the Eligible Services
List at www.sl.universalservice.org for examples of eligible Internal Connections services. Attach additional pages if needed.

Check this box if you prefer
discounts on your bill.

Check this box if you prefer reimbursement
after paying your bill in full.

Check this box if you do
not have a preference.

Service or Function

1) Quantity and/or Capacity

Service or Function
2) Quantity and/or Capacity

Service or Function
3) Quantity and/or Capacity

Service or Function
4) Quantity and/or Capacity

Service or Function
5) Quantity and/or Capacity

Page 5 of 14

FCC Form 470
October 2004

Block 2: Summary Description of Needs or Services Requested (Continued)
11 Basic Maintenance of Internal Connections

Item 11, page

Do you have a Request for Proposal (RFP) that specifies the services you are seeking? If you check YES, your RFP must be
available to all interested bidders for at least 28 days. If you check YES and 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 Web at:

or via (check one)
b

the Contact Person in Item 6 or

the contact listed in Item 12.

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 or function (e.g.,
basic maintenance of routers) and quantity and/or capacity (e.g., for 10 routers). See the Eligible Services List at
www.sl.universalservice.org for examples of eligible Basic Maintenance services. Attach additional pages if needed.

Check this box if you prefer
discounts on your bill.

Check this box if you prefer reimbursement
after paying your bill in full.

Check this box if you do not
have a preference.

Service or Function

1) Quantity and/or Capacity

Service or Function
2) Quantity and/or Capacity

Service or Function
3) Quantity and/or Capacity

Service or Function
4) Quantity and/or Capacity

Service or Function
5) Quantity and/or Capacity

Page 6 of 14

FCC Form 470
October 2004

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 need not be the contact person listed
in Item 6 nor the Authorized Person who signs this form.
Name

Title

Telephone Number

Ext.

Fax Number

E-mail Address

13a

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 a Web 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.

13b

If you have plans to purchase additional services in future years, or expect to seek new contracts for existing services,
you may summarize below (including the likely timeframes). If you are requesting services for a funding year for
which a Form 470 cannot yet be filed online, include that information here.

Page 7 of 14

FCC Form 470
October 2004

Block 3: Technology Resources
14

Basic telephone service only: If your application is for basic telephone service and voice mail
only, check this box and skip to Item 16. Basic telephone service is defined as wireline or wireless
single line voice service (local, cellular/PCS, and/or long distance) and mandatory fees associated
with such service (e.g., federal and state taxes and universal service fees).
Although the following services and facilities are ineligible for support, they are usually necessary to make effective use
of the eligible services requested in this application. Unless you indicated in Item 14 that your application is ONLY for
basic telephone service, you must check one or both boxes in Items 15a through 15e. You may provide details for
purchases being sought.
Desktop software: Software required
a

has been purchased; and/or

is being sought.

Electrical systems:
b

adequate electrical capacity is in place or
has already been arranged; and/or

upgrading for electrical capacity is being sought.

Computers: a sufficient quantity of computers
c

has been purchased; and/or

is being sought.

Computer hardware maintenance: adequate arrangements
d

have been made; and/or

are being sought.

Staff development:
all staff have had an appropriate level of
training/additional training has been scheduled;
and/or

e
f

training is being sought.

Additional details: Use this space to provide additional details to help providers to identify the ineligible services
you desire.

Block 4: Recipients of Service
16

Eligible Entities That Will Receive Services:
Check the ONE choice (Item 16a, 16b or 16c) that best describes this application and the eligible entities that will
receive the services described in this application. You will then list in Item 17 the entity/entities that will pay the bills for
these services.
a

Individual school or single-site library.

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.
c

School district, library system or consortium application to serve multiple eligible entities (see
next page).

Does your application include INELIGIBLE entities?
Page 8 of 14

Yes. If yes, complete item 18.
FCC Form 470
October 2004

Block 4: Recipients of Service (Continued)
16c
(cont.)

School district, library system or consortium application to serve
multiple eligible entities:

Item 16c, page

Number of eligible entities
For these eligible entities, please provide the following:

Area Codes
(list each
unique area
code)

Prefixes associated with each area code
(first 3 digits of 7-digit phone number)

10)

11)

12)

13)

14)

Page 9 of 14

FCC Form 470
October 2004

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

Block 4: Recipients of Service (Continued)
17 Billed Entities
rary system or consortium application to serve
Item 17, page
of
List the entity/entities that will be paying the bills directly to the provider for the services requested in this application.
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

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

Page 10 of 14

FCC Form 470
October 2004

Block 4: Recipients of Service (Continued)
18 Ineligible Participating Entities:
List the names of any entity/entities here
Item 18, page
for whom services are requested that are not eligible for the Universal Service Program.
Attach additional pages if needed.

Ineligible Participating Entity

Area Code and Prefix

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

Page 11 of 14

FCC Form 470
October 2004

Do not write in this area.

Block 5: Certification and Signature
19

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
a
2001, 20 U.S.C. Secs. 7801 (18) and (38), that do not operate as for-profit businesses, and do not have endownments
exceeding $50 million; and/or
b

libraries or library consortia eligible for asssistance 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 school (including, but not limited to elementary and secondary schools, colleges, and universities).
I certify that all of the individual schools, libraries, and library consortia receiving services under this application 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, and an SLD-certified technology plan approver, prior to the commencement of service. The plans were
written at the following level(s):

individual technology plans for using the services requested in the application; and/or

higher-level technology plans for using the services requested in the application; or

no technology plan needed; application requests basic local, cellular, PCS, and/or long distance telephone service and/or
voice mail only.
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 application 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.

c
21

I certify that the services the applicant purchases at discounts provided by 47 U.S.C. Sec. 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. Sec. 54.500(k). 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.

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 am authorized to order telecommunications and other supported 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 application, 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. Secs. 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18
U.S.C. Sec. 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.

Page 12 of 14

FCC Form 470
October 2004

Do not write in this area.

Block 5: Certification and Signature (Continued)
27
29

Signature of
authorized
person
Printed name
of authorized
person
Title or position
of authorized
person
Street Address, P.O. Box, or Route Number

Date

31a

City

State

Zip Code

31b

Telephone number
of authorized
person

31d

E-mail address
of authorized
person

31e

Ext.

31c Fax number of authorized person

Name of authorized person’s employer

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 SLD web site at
www.sl.universalservice.org or call the SLD Client Service Bureau at 1-888-203-8100.

Page 13 of 14

FCC Form 470
October 2004

Entity Number __________________________ Applicant’s Form Identifier _______________________________
Contact Person __________________________ Contact Telephone Number _______________________________

Block 5: Certification and Signature (Continued)
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 Description of Services Requested and Certification
Form (FCC Form 470) with the Universal Service Administrator. 47 C.F.R. § 54.504. 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. 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, 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
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 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 4703833 Greenway Drive
Lawrence, Kansas 66046
1-888-203-8100

Page 14 of 14

FCC Form 470
October 2004

File Type	application/pdf
File Title	Microsoft Word - FY2005_470_OMBapp.doc
Author	jnoran
File Modified	2005-04-28
File Created	2005-04-28