FCC Form 479 Schools and Librabies Universal Service Certification by

FCC Form 479 Approval by OMB 3060-0853 Estimated time per response: 1 hour DO NOT SEND THIS FORM TO THE UNIVERSAL SERVICE ADMINSTRATIVE COMPANY OR TO THE FEDERAL COMMUNICATIONS COMMISSION Schools and Libraries Universal Service Certification by Administrative Authority to Billed Entity of Compliance with the Children’s Internet Protection Act Please read instructions before completing. (To be completed by the Administrative Authority and provided to your Billed Entity) This form is required only for funding years beginning July 1, 2001 and later.
Administrative Authority’s Form Identifier: __________________________________________ Create your own code to identify THIS Form 479.
Block 1: Administrative Authority Information
1. Name of Administrative Authority	2. Funding Year
3. Mailing Address and Contact Information for Administrative Authority
Street Address, P. O. Box or Route Number
City State Zip Code
Name of Contact Person
10-Digit Telephone Number Fax Number Email Address
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.
Block 2: Certifications and Signature
I am the Administrative Authority for one or more schools or libraries for which Universal Service Support Mechanism discounts have been requested or approved for eligible services. The Administrative Authority must make the required certification(s) for the purposes of the Children’s Internet Protection Act (CIPA) in order to receive discounted services. I recognize that I may be audited pursuant to this form and will retain for five years any and all records that I rely upon to complete this form.

Name of Administrative Authority _________________________________________________________________ Administrative Authority’s Form Identifier __________________________________________________________ Contact Person _________________________________________________________________________ Telephone Number______________________________________________________________________________
Block 2: Certifications and Signature (Continued)
I certify that as of the date of the start of discounted services: a the recipient(s) of service under my administrative authority and represented in the Funding Request Number(s) for which you have requested or received Funding Commitments has (have) complied with the requirements of the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l). b pursuant to the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), the recipient(s) of service under my administrative authority and represented in the Funding Request Number(s) for which you have requested or received Funding Commitments: (FOR SCHOOLS and FOR LIBRARIES IN THE FIRST FUNDING YEAR FOR PURPOSES OF CIPA) is (are) undertaking such actions, including any necessary procurement procedures, to comply with the requirements of CIPA for the next funding year, but has (have) not completed all requirements of CIPA for this funding year. (FOR FUNDING YEAR 2003 ONLY: FOR LIBRARIES IN THE SECOND OR THIRD FUNDING YEAR FOR PURPOSES OF CIPA) is (are) in compliance with the requirements of CIPA under at 47 U.S.C. § 254(l) and undertaking such actions, including any necessary procurement procedures, to comply with the requirements of CIPA under 47 U.S.C. § 254(h) for the next funding year. c the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), does not apply because the recipient(s) of service under my administrative authority and represented in the Funding Request Number(s) for which you have requested or received Funding Commitments is (are) receiving discount services only for telecommunications services. CIPA Waiver. Check the box below if you are requesting a waiver of CIPA requirements for the Second Funding Year after April 20, 2001 in which the recipients of service under your administrative authority have applied for discounts: d I am providing notification that, as of the date of the start of discounted services, I am unable to make the certifications required by the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), because my state or local procurement rules or regulations or competitive bidding requirements prevent the making of the certification(s) otherwise required. I certify that the recipient(s) of service under my administrative authority and represented in the Funding Request Number(s) for which you have requested or received Funding Commitments will be brought into compliance with the CIPA requirements before the start of the Third Funding Year after April 20, 2001 in which they apply for discounts. CIPA WAIVER FOR LIBRARIES FOR FUNDING YEAR 2004. Check the box below if you are requesting a waiver of CIPA requirements for Funding Year 2004 for the library(ies) under your administrative authority that have applied for discounts for Funding Year 2004: e I am providing notification that, as of the date of the start of discounted services in Funding Year 2004, I am unable to make the certifications required by the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), because my state or local procurement rules or regulations or competitive bidding requirements prevent the making of the certification(s) otherwise required. I certify that the library(ies) under my administrative authority and represented in the Funding Request Number(s) for which you have requested or received Funding Commitments will be brought into compliance with the CIPA requirements before the start of Funding Year 2005. The certification language above is not intended to fully set forth or explain all the requirements of the statute.
Signature of authorized person	Date
Printed name of authorized person
Title or position of authorized person
Telephone number 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 (3060-0853), 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.

A paper copy of this form, with a signature in Block 2, Item 7, must be mailed or delivered to your Billed Entity.

Page 3 of 3 FCC Form 479 April 2007