Form FCC Form 500 FCC Form 500 Universal Service for Schools and Libraries, Adjustment

FCC Form 500

Approval by 3060-0853
Estimated time per response:
1.5 hours

Do Not Write In This Area

Universal Service for Schools and Libraries
Adjustment to Funding Commitment and
Modification to Receipt of Service Confirmation Form

Please read instructions before completing.
Applicant’s Form Identifier:
(Create your own code to identify THIS Form 500)
Block 1: Applicant Information
1. Name of Billed Entity
4. Complete Mailing Address of Billed Entity Applicant
Street Address, P. O. Box or Route Number

10-Digit Phone Number

(To be completed by Schools and Libraries or Consortia.)
Form 500 Application Number:
(To be assigned by administrator.) ___________________
2. Billed Entity Number

City

State

Fax Telephone Number

3. Funding Year

Zip Code

Email Address

5. Contact Person Information
Contact Person Name
Mailing Address
Street Address, P. O. Box or Route Number

10-Digit Phone Number

City

Fax Telephone Number

State

Zip Code

Email Address

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 (3060-0853), 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 3060-0853.
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.

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FCC Form 500

November 2006

Billed Entity Name ___________________________________ Contact Name _________________________________
Billed Entity Number ________________________ Contact Telephone Number ______________________________
Block 2: Services Adjustment: Fill in one Block 2 for EACH Funding Request (FRN) affected. If you are
submitting more than one Block 2, please number your pages 2A, 2B, 2C, etc. and write the number in the space
provided here:
Page 2 _____
5. Provide the following information about each service cited in your Form 471 Block 5, Discount Funding Request,
(FRN) for which you want to take one of the following actions:
Remember: The FRNs listed on this form must be for the same Funding Year as listed in Item 3, Block 1.
New Start Date: If you wish to change the Funding Year Service Start Date you listed on a previously filed
Form 486 in this funding year. This action will NOT result in more funding.
Contract Expiration Date: If you wish to change the ending date for services. This action will not result in
more funding but you could combine it with a reduction in funding.
Cancel: If you wish to cancel a Funding Request Number. Please note: This action is irrevocable and the
FRN can NOT be reinstated later. This action would allow money to be put back into the Universal
Service fund for possible commitment to other applicants.
Reduce: If you wish to reduce the amount of your funding commitment for a particular FRN. This action is
irrevocable and the FRN can NOT be increased later. This action would allow money to be put back into the Universal
Service fund for possible commitment to other applicants.
The information required can be found in your Funding Commitment Decision Letter (FCDL) pertaining to the Funding
Request (FRN) being affected.
To launch the submission of invoices for payment, please file Form 486.
IDENTIFICATION OF THE FRN TO BE ADJUSTED
(A) Form 471 Application Number:
(B) Funding Request Number:
(C) Billing Account Number:
(D) Service Provider Name:
(E) Service Provider SPIN:

(F) Service Start Date

ADJUSTMENT TO FRN LISTED ABOVE:
Original Date (mm/dd/yyyy):
New Date (mm/dd/yyyy):

Change Date
(G) Contract Expiration Date

Original Date (mm/dd/yyyy):

New Date (mm/dd/yyyy):

Original Commitment Amount:

New Commitment Amount:

Change Date
(H) Cancel FRN
Please Cancel
(I) Reduce FRN

$0.00
Original Commitment Amount from
FCDL:

New Commitment Amount AFTER
Reduction:

Please Reduce

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FCC Form 500

November 2006

Do Not Write In This Area

Billed Entity Name _____________________________ Contact Name ____________________________________
Billed Entity Number __________________ Contact Telephone Number _________________________________
Block 3: Certification
7. I certify that I am authorized to submit this form on behalf of the above-named billed entity, that I have examined this
request, and that, to the best of my knowledge, information, and belief, all statements of fact contained herein are
true.
8. I understand 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 services receive an appropriate share of
benefits from those services.
9. 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.
10. Signature
11. Date
12. Printed name of authorized person
13. Title or position of authorized person
14. Telephone number of authorized person
15. E-Mail address of authorized person
16. Address of authorized person

A paper copy of this form, with an authorized signature in Block 3, Item 10 should be mailed to:
SLD Form 500
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: SLD Form 500
3833 Greenway Drive
Lawrence, Kansas 66046
888-203-8100

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FCC Form 500

November 2006