Form FCC Form 472 FCC Form 472 Billed Entitiy Applicant Reimbursement Form

FCC Form 472 Do not write in this space Approved by OMB DO NOT STAPLE THIS FORM OMB Control No. 3060 – 0856 Estimated time per response: 1.0 hour 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.
Applicant Form Identifier (Create an identifier for your own reference)	FCC Form 472 Invoice # (To be inserted by administrator)
BLOCK 1: HEADER INFORMATION
Billed Entity Name
Billed Entity Number
Service Provider Identification Number (SPIN)
Contact Name
Contact Telephone Number
Total Reimbursement Amount (total from Block 2, Column 14)

Billed Entity Applicant Reimbursement Form For reimbursement of discounts on approved services already paid for by the Billed Entity Applicant. Billed Entity Name ___________________________________________________ Billed Entity Number ______________ Contact Name______________________________________________ Contact Telephone Number_______________________________ Applicant Form Identifier_____________________
		BLOCK 2: LINE ITEM INFORMATION PER FUNDING REQUEST NUMBER
	(7)		(8)	(9)	(10)	(11)	(12)	(13)	(14)
	FCC Form 471 Application Number (from Funding Commitment Decision Letter)		Funding Request Number (FRN) (from Funding Commitment Decision Letter)	Bill Frequency	Customer Billed Date (mm/yyyy)	Shipping Date to Customer or Last Day of Work Performed (mm/dd/yyyy)	Total (Undiscounted) Amount for Service	Discount Rate	Amount Billed to USAC (Column 12 multiplied by Column 13)
				DO NOT WRITE IN THIS COLUMN.	For each FRN, complete either Column (10) or Column (11), but not both Columns
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TOTAL REIMBURSEMENT AMOUNT TO BE ENTERED INTO ITEM (6)

BILLED ENTITY APPLICANT Reimbursement Form Billed Entity Name ___________________________________________________ Billed Entity Number ___________ Contact Name____________________________________________________________________ Applicant Form Identifier_____________________
Block 3: Billed Entity Certification
I declare under penalty of perjury that the foregoing is true and correct and 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 I certify to the best of my knowledge, information and belief, as follows: The discount amounts listed in Column (14) 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 FCC Form 486. The discount amounts listed in Column (14) 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. The discount amounts listed in Column (14) of this Billed Entity Applicant Reimbursement Form are for eligible services approved by the fund administrator pursuant to a Funding Commitment Decision Letter. I recognize that I may be audited pursuant to this application and will retain for at least five years (or whatever retention period is required by the rules in effect at the time of this certification), after the last day of service delivered in this funding year any and all records that I rely upon to fill in this form. I certify that, in addition to the foregoing, this Billed Entity Applicant is in compliance with the rules and orders governing the schools and libraries universal service support program, and I acknowledge that failure to be in compliance and remain in compliance with those rules and orders may result in the denial of discount funding and/or cancellation of funding commitments. I acknowledge that failure to comply with the rules and orders governing the schools and libraries universal service support program could result in civil or criminal prosecution by law enforcement authorities.
15. Signature of authorized person	16. Date
17. Printed name of authorized person
18. Title or position of authorized person
19. Telephone number of authorized person
20. Address of authorized person

BILLED ENTITY APPLICANT Reimbursement Form Billed Entity Name ___________________________________________________ Billed Entity Number ___________ Contact Name____________________________________________________________________ Applicant Form Identifier_____________________
Block 4: Service Provider Acknowledgment
I declare under penalty of perjury that the foregoing is true and correct and 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: 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. 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. I certify that, in addition to the foregoing, this Service Provider is in compliance with the rules and orders governing the schools and libraries universal service support program, and I acknowledge that failure to be in compliance and remain in compliance with those rules and orders may result in the denial of discount funding and/or cancellation of funding commitments. I acknowledge that failure to comply with the rules and orders governing the schools and libraries universal service support program could result in civil or criminal prosecution by law enforcement authorities.
21. Signature of authorized person (fax, copy or original signature)	22. Date
23. Printed name of authorized person
24. Title or position of authorized person
25. Telephone number of authorized person
26. Address of authorized person

27. Applicant Remittance Information

Name

Title

Street Address

A paper copy of this Form (pages 1-4) should be mailed to:

SLD BEAR FCC Form 472

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 FCC Form 472

3833 Greenway Drive

Lawrence, KS 66046

Phone: 1-888-203-8100