FCC Form 471

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 asks schools and libraries to list the eligible telecommunications-related 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.sl.universalservice.org.)
The instructions include information on the deadlines for filing this application.

Applicant’s Form Identifier

Form 471 Application#:_____________________
(To be assigned by administrator)

(Create your own code to identify THIS Form 471)

Block 1: Billed Entity Information (The “Billed Entity” is the entity paying the bills for the services listed on this form.)
Name of

1 a Billed Entity
2a

Funding Year: July 1,

through June 30,

3 Billed Entity Number

Street Address,

4 a P.O. Box,

or Route Number

City

State

Zip Code
Ext

Telephone
Number

b
5 a Type of

Application

Ext

c

Fax
Number

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

Check here if any members of this consortium are ineligible or non-governmental entities.

Contact

6 Person’s

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

If not, please complete the entries

b Street Address,

P.O. Box,
or Route Number
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.

c

Telephone
Number

Ext

Ext

d

Fax
Number

E-mail Address

e
f

Holiday/vacation/summer
contact information:

0 4 7 0 0 1 0 1 0
Page 1 of 7

FCC Form 471 - November 2004

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

Phone Number _________________________________

This information will facilitate the processing of your applications. Please complete all rows that apply to services for which you are requesting
discounts. Complete this information on the FIRST Form 471 you file, to encompass this and all other Forms 471 you will file for this funding year. You
need not complete this information on subsequent Forms 471. Provide your best estimates for the services ordered across ALL of your Forms 471.
Schools/school districts complete Item 7. Libraries complete Item 8. Consortia complete Item 7 and/or Item 8.

Block 2: Impact of Services Ordered on Schools
IF THIS APPLICATION INCLUDES SCHOOLS…

7a

AFTER ORDER

BEFORE ORDER

AFTER ORDER

Number of students to be served

b

Telephone service: Number of classrooms with phone service

c

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

d

BEFORE ORDER

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

Less than 10 mbps
Between 10 mbps and 200 mbps
Greater than 200 mbps

e
f
g

Direct connections to the Internet: Number of drops
Number of classrooms with Internet access
Number of computers or other devices with Internet access

Block 3: Impact of Services Ordered on Libraries
IF THIS APPLICATION INCLUDES LIBRARIES…

8a

Number of library patrons to be served

b

Telephone service: Number of rooms with phone service

c

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

d

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

Less than 10 mbps
Between 10 mbps and 200 mbps
Greater than 200 mbps

e
f
g

Direct connections to the Internet: Number of drops
Number of buildings with Internet access
Number of computers or other devices with Internet access

Block 4: Discount Calculation Worksheets
You must complete a separate worksheet for each group of entities sharing one or more services. If you are filing as a consortium and your members
include school districts or library systems, you must complete a separate worksheet for each of those members. In addition, if you are applying for
discounts for administrative buildings or other non-instructional facilities, you must complete a worksheet for all schools in the school district or all library
outlets/branches in the library system in order to calculate the appropriate discount for those facilities. In general, the following columns must be
completed:
INDIVIDUAL SCHOOLS:
SCHOOLS IN ONE SCHOOL DISTRICT (SHARED SERVICES):
SCHOOL DISTRICTS:
LIBRARY OUTLETS/BRANCHES
LIBRARY OUTLETS/BRANCHES IN ONE LIBRARY SYSTEM (SHARED SERVICES):
LIBRARY SYSTEMS:
CONSORTIA (after completing a worksheet or worksheet entry for each member entity as needed):

Columns 1–7 and Columns 9–10
Columns 1–10 and Item 9b, Line 1
Columns 1–10 and Item 9b, Line 1
Columns 1–7 and Column 11
Columns 1–7, Column 11, and Item 9b, Line 2
Columns 1–7, Column 11, and Item 9b, Line 2
Columns 1–2, Column 12, and Item 9b, Line 3

Please refer to the Form 471 Instructions for specific information on each Item in the worksheet.

Page 2 of 7

FCC Form 471 –November 2004

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.
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

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)

Discount
from
Discount
Matrix

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

Pre-K
Adult Ed
Or
Juvenile
Justice

Alt
Disc
Mech

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

Discount
of
Member
Entity

Shared
Discount

ALL ENTITIES

SCHOOLS AND LIBRARIES

Schools with
Shared Services

Schools

Library
Outlets/Branches

Consortia

9b Shared Services
SCHOOL DISTRICTS: (Including groups of schools within school districts.)
Calculate the totals of Columns 4 and 8. Divide the total of Column 8 by
the total of Column 4. Enter the result in Column 13.
LIBRARY SYSTEMS: Calculate the total of Column 7. Divide this total by
the number of outlets/branches. Enter the result in Column 13.
CONSORTIA: Calculate the total of Column 12. Divide this total by the
number of member entities. Enter the result in Column 13.

Page 3 of 7

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.

Category of Service ( only ONE category should be checked)

Internet Access

13

14

FRN ______________________
(to be assigned by administrator)

23 Calculations

PRIORITY 2
Internal Connections Other than Basic
Maintenance

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

Basic Maintenance of Internal
Connections

Form 470 Application Number

SPIN – Service Provider Identification Number

Recurring Charges

PRIORITY 1
Telecommunications
Service

12

of

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:

10

11

Block 5, page

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
(C x D)

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).

15c

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:

15d

16a

16b

19
20a
20b
21

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

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

Check this box if there are multiple Billing Account Numbers and attach a
complete list of those numbers to this page.
Allowable Vendor Selection/Contract Date (mm/dd/yyyy)

H. Annual eligible pre-discount amount for non-recurring charges
(F minus G)

(based on Form 470 filing)

17
18

F. Annual non-recurring charges
Non-Recurring Charges

15b

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

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

Description of This Service:

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

15a

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

Attachment

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.
a. If the service is site-specific (provided to one site
and not shared by others), list the Entity Number of
22
Entity/Entities Receiving This Service:
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 4 of 7

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.
Secs. 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

e

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

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 all of the schools and libraries or library consortia listed in Block 4 of 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):
a

an individual technology plan for using the services requested in this application; and/or

b

higher-level technology plan(s) for using the services requested in this application; or

c

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

27

I certify that I posted my Form 470 and (if applicable) made my 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. 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 Billed Entity has not received anything of value or a promise of anything of value, other than
services and equipment requested under this form, from the service provider(s). 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- November 2004

Do not write in this area

Entity Number __________________________________ Applicant’s Form Identifier __________________________________
Contact Person __________________________________ Phone Number __________________________________
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. Secs. 502, 503(b), or fine or imprisonment under Title 18 of the
United States Code, 18 U.S.C. Sec. 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.
Sec. 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 beginning with Funding
Year 2005 as required by the Commission's rules at 47 C.F.R. Sec. 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

Signature of authorized person
_________________________________________________________

39

Date

Printed name of authorized person

Title or position of authorized person

Street Address, P.O. Box, or Route Number
42a

City

State

42b

42d

42e

Zip Code

Telephone number of authorized person

Ext

42c Fax number of authorized person

E-mail address of authorized person

Name of authorized person’s employer

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FCC Form 471 – November 2004

The Americans with Disabilities Act, the Individuals with Disabilities Education Act and the Rehabilitation Act may impose obligations on
entities to make the services purchased with these discounts accessible to and usable by people with disabilities.

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.
The collection of information stems from the Commission's authority under Section 254 of the Communications Act of 1934, as amended. 47U.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 – November 2004