FCC Form 473 Service Provider Annual Certification Form

FCC Form 473

Approval by OMB
3060 – 0856
Estimated time
per response: 1.0 hour

Do not write in this area.

Universal Service for Schools and Libraries
Service Provider Annual Certification Form
Please read instructions before completing.
(To be completed by Service Provider)
Block 1: Service Provider Information
1. Name of Service Provider

2. Service Provider Identification Number

3. Funding Year:
July 1, _________ through June 30,_________

4. Contact Name
5. Complete Mailing Address of Contact Person
Street Address, P. O. Box or Route Number

City

State

Zip Code

7. Fax Number with Area Code
_____ - _____ - _______________

6. Telephone Number with Area Code
_____ - _____ - ___________________
8. Email Address

Block 2: Certification
I certify that I am authorized to submit this Service Provider Annual Certification Form on behalf of the above-named service
provider, which has been assigned the above-referenced Service Provider Identification Number, and certify to the best of my
knowledge, information and belief, as follows:
9. Based on information known to me or provided to me by employees responsible for the data being submitted, I hereby
certify that the data set forth in this Form has been examined and reviewed and is true, accurate and complete.
10. The Service Provider Invoice Forms that are submitted by this service provider contain requests for universal service
support for services which have been billed to the service provider’s customers on behalf of schools, libraries, and consortia
of those entities, as deemed eligible for universal service support by the fund administrator.
11. The Service Provider Invoice Forms that are submitted by this service provider are based on bills or invoices issued by
the service provider to the service provider’s customers on behalf of schools, libraries, and consortia of those entities as
deemed eligible for universal service support by the fund administrator, and exclude any charges previously invoiced to the
fund administrator for which the fund administrator has not yet issued a reimbursement decision.
12. This service provider makes available to customers, upon their request, separate prices for distinct services to assist
Billed Entity Applicants in identifying the portions of their bills that represent the costs of services provided to eligible entities
for eligible purposes.
13. I acknowledge the Fund Administrator’s authority to request additional supporting information as may be necessary. I
recognize that I may be audited pursuant to this form and will retain for three years any and all records that I rely upon to
complete this form and each Service Provider Invoice Form that is submitted by this service provider during the present
funding year.
14. The prices in any offer that this service provider makes pursuant to the schools and libraries universal service support
program have been arrived at independently, without, for the purpose of restricting competition, any consultation,
communication, or agreement with any other offeror or competitor relating to (i) those prices, (ii) the intention to submit an
offer, or (iii) the methods or factors used to calculate the prices offered;
15. The prices in any offer that this service provider makes pursuant to the schools and libraries universal service support
program will not be knowingly disclosed by this service provider, directly or indirectly, to any other offeror or competitor before
bid opening (in the case of a sealed bid solicitation) or contract award (in the case of a negotiated solicitation) unless
otherwise required by law; and
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FCC Form 473

November 2006

Service Provider Name _______________________________________________________________________________
SPIN _______________________________________________________
Contact Name ______________________________________________________________________________________
Contact Telephone Number _____ - _____ - _______________
Block 2: Certification (Continued)
16. No attempt will be made by this service provider to induce any other concern to submit or not to submit an offer for the
purpose of restricting competition.
17. Signature
18. Date
19. Printed name of authorized person
20. Title or position of authorized person
21. Telephone number of authorized person
22. Address of authorized person

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 be 1 hour 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.
A paper copy of this form, with signature in Block 2, Item 14 should be mailed to:
SLD Form 473
P. O. Box 7026
Lawrence, Kansas 66044-7026
If sent by express delivery services or U.S. Postal Service, Return Receipt Requested, the form should be mailed
to:
SLD Forms
ATTN: Form 473
3833 Greenway Drive
Lawrence, Kansas 66046
Phone: 1-888-203-8100
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FCC Form 473

November 2006