FCC Form 474 Service Provider Invoice Form

FCC Form 474

Do not write in this space.

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

Schools and Libraries Universal Service
Service Provider Invoice Form 474
This form can be filed online or by mail.
Form 474 Invoice # ________________________________________
(To be inserted by administrator)

Please read instructions before completing
Block 1: Service Provider Information
1. Service Provider Name
2a. Service Provider Identification Number (SPIN)
3. Contact Person’s Name
4. Contact Telephone Number Area Code:
Contact Fax Number

Area Code:

Phone Number:

Ext.

Fax Number:

Contact Email Address
5.

Invoice Number

6.

Invoice Date to USAC

7.

Total Invoice Amount

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FCC Form 474

November 2006

SPIN _________________________________________________________________________________________________
Service Provider Form Identifier __________________________________________________________________________
Contact Person ________________________________________________________________________________________
Contact Telephone Number ______________________________________________________________________________
Block 2, Page ___ of ___
Make as many copies of this page as necessary,
and number the completed pages to assure that they are all processed correctly.

BLOCK 2: Funding Request Number Information
8
9
10
Form 471
Funding Request
Bill Frequency
Application
Number (FRN)
(e.g., Monthly,
Number
(from Funding
Quarterly, Annually,
(from Funding
Commitment
One-time, Other)
Commitment
Decision Letter)
Decision Letter)

11
Customer Billed
Date
(mm/yyyy)

12
Shipping Date to
Customer or Last
Day of Work
Performed
(mmddyyyy)

13
Total
(Undiscounted)
Amount for
Service per FRN
(14.2 digits max.)

14
Discount Amount
Billed to USAC
(41.2 digits max.)

For each FRN, there should be an entry in
Column 11 or Column 12 but NOT BOTH

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

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FCC Form 474

November 2006

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.
Please submit this form to:
SLD SPI Form 474
P. O. Box 7026
Lawrence, KS 66044-7026
For express delivery services or U.S. Postal Service, Return Receipt Requested, mail this form (pages 1-4) to:
SLD Forms
ATTN: SLD SPI Form 474
3833 Greenway Drive
Lawrence, KS 66046
888-203-8100

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FCC Form 474

November 2006