FCC Form 472 Billed Entity Applicant Reimbursement Form

Do not write in this space.

FCC Form 472

Approval by OMB
3060 – 0856
Estimated time per response: 1.5 hours

Universal Service for Schools and Libraries
Please read instructions before completing.

(To be completed by schools, libraries, or consortia.)

BILLED ENTITY APPLICANT REIMBURSEMENT FORM
For reimbursement of discounts on approved services already paid for by the Billed Entity Applicant.
Only one Service Provider Identification Number (SPIN) per form.
Must be completed and signed by the Billed Entity Applicant and signed by the relevant service provider.
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.
FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT
Part 54 of the Commission’s Rules authorizes the FCC to collect the information on this form. Failure to provide all requested information will delay the processing of the application or result in the application being
returned without action. Information requested by this form will be available for public inspection. Your response is required to obtain the requested authorization.
The public reporting for this collection of information is estimated to range from 1 to 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the required data, and completing and reviewing the collection of information. If you have any comments on this burden estimate, or how we can improve the collection and reduce the burden it causes you, please
write to the Federal Communications Commission, AMD-PERM, Paperwork Reduction Act Project (3060-0856), Washington, DC 20554. We will also accept your comments regarding the Paperwork Reduction Act
aspects of this collection via the Internet if you send them to [email protected]. PLEASE DO NOT SEND YOUR RESPONSE TO THIS FORM TO THIS ADDRESS.
Remember – You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid
OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-0856.
THE FOREGOING NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. 552a(e)(3) AND THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC
LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

BLOCK 1: HEADER INFORMATION
1. 471 Billed Entity Name
2. 471 Billed Entity Number
3. Service Provider Identification Number (SPIN)
4. Contact Name
5. Contact Telephone Number
6. Reimbursement Form Number
7. Reimbursement Date to USAC
8. Total Reimbursement Amount (total of Block 2, Item 15 – 14.2 digits maximum)

Page 1 of 4

FCC Form 472

November 2006

Billed Entity Applicant Reimbursement Form
For reimbursement of discounts on approved services already paid for by the Billed Entity Applicant.
471 Billed Entity Name ___________________________________________________ 471 Billed Entity Number ______________
Contact Name________________________________________________ Contact Telephone Number_______________________________
Reimbursement Form Number_____________________

BLOCK 2: LINE ITEM INFORMATION PER FUNDING REQUEST NUMBER
(9)
FCC Form 471
Application
Number
(10 digits)
(from Funding
Commitment Decision
Letter)

(10)
Funding Request
Number (FRN)
(10 digits)
(from Funding
Commitment
Decision Letter)

(11)
Bill Frequency

(12)
Customer Billed Date
(mm/yyyy)

(13)
Shipping Date
to Customer or
Last Day of Work
Performed
(mm/dd/yyyy)

DO NOT WRITE IN For each FRN, complete either Column (12)
THIS COLUMN.
or Column (13), but not both Columns

(14)
Total (Undiscounted)
Amount for Service
(14.2 digits max.)

(15)
Discount Amount
Billed to USAC
(14.2 digits max.)

14.2 digits allows for dollars and cents

1
2
3
4
5
6
7
8
9
10
11
12
13
14
TOTAL REIMBURSEMENT AMOUNT TO BE ENTERED INTO ITEM (8)

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FCC Form 472

November 2006

BILLED ENTITY APPLICANT Reimbursement Form
471 Billed Entity Name ___________________________________________________
471 Billed Entity Number ___________
Contact Name____________________________________________________________________
Reimbursement Form Number_____________________
Block 3: Billed Entity Certification
I certify that I am authorized to submit this Billed Entity Applicant Reimbursement Form on behalf of the eligible
schools, libraries, or consortia of those entities represented on this Form, and certify to the best of my knowledge,
information and belief, as follows:
A. The discount amounts listed in Column (15) of this Billed Entity Applicant Reimbursement Form represent
charges for eligible services delivered to and used by eligible schools, libraries, or consortia of those entities for
educational purposes, on or after the service start date reported on the associated Form 486.
B. The discount amounts listed in Column (15) of this Billed Entity Applicant Reimbursement Form were already
billed by the service provider and paid by the Billed Entity Applicant on behalf of eligible schools, libraries, and
consortia of those entities.
C. The discount amounts listed in Column (15) of this Billed Entity Applicant Reimbursement Form are for eligible
services approved by the fund administrator pursuant to a Form 471 Funding Commitment Decision Letter.
D. I recognize that I may be audited pursuant to this application and will retain for five years any and all records
that I rely upon to fill in this form.
16. Signature of authorized person
17. Date

18. Printed name of authorized person

19. Title or position of authorized person

20. Telephone number of authorized person

21. Address of authorized person

Page 3 of 4

FCC Form 472

November 2006

BILLED ENTITY APPLICANT Reimbursement Form
471 Billed Entity Name ___________________________________________________
471 Billed Entity Number ___________
Contact Name____________________________________________________________________
Reimbursement Form Number_____________________

Block 4: Service Provider Acknowledgment
I certify that I am authorized to submit this Service Provider Acknowledgment for this Billed Entity Applicant
Reimbursement Form, and acknowledge to the best of my knowledge, information and belief, as follows:
A. The service provider must remit the discount amount authorized by the fund administrator to the Billed Entity
Applicant who prepared and submitted this Billed Entity Applicant Reimbursement Form as soon as possible
after the fund administrator’s notification to the service provider of the amount of the approved discounts on this
Billed Entity Applicant Reimbursement Form, but in no event later than 20 business days after receipt of the
reimbursement payment from the fund administrator, subject to the restriction set forth in B. below.
B. The service provider must remit payment of the approved discount amount to the Billed Entity Applicant prior to
tendering or making use of the payment issued by the Universal Service Administrative Company to the service
provider of the approved discounts for the Billed Entity Applicant Reimbursement Form.
22. Signature of authorized person (fax, copy or original signature)
23. Date

24. Printed name of authorized person

25. Title or position of authorized person

26. Telephone number of authorized person

27. Address of authorized person

A paper copy of this Form (pages 1-4) should be mailed to:
SLD BEAR Form
P. O. Box 7026
Lawrence, KS 66044-7026
If sent by express delivery services or U.S. Postal Service, Return Receipt Requested, the form (pages
1-4) should be mailed to:
SLD Forms
ATTN: SLD BEAR Form 472
3833 Greenway Drive
Lawrence, KS 66046
Phone: 1-888-203-8100

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FCC Form 472

November 2006