Universal Service - Schools and Libraries Universal Service Program Reimbursement Forms

Approved by OMB

OMB Control No. 3060-0856

Estimated Average Burden Hours Per Response: 1.0 hour

FCC Form 473

Universal Service for Schools and Libraries

Service Provider Annual Certification Form

Instructions for Completing the

Universal Service for Schools and Libraries

Service Provider Annual Certification Form (FCC Form 473)

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT

Part 54 of the Commission’s Rules authorizes the Federal Communications Commission (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.

PURPOSE OF FORM

An FCC Form 473, Service Provider Annual Certification Form, is required to be submitted each Funding Year to the fund administrator in order for a service provider to complete the procedure for submitting an invoice form. The FCC Form 473 must be completed by each service provider, for each separate Service Provider Identification Number (SPIN), to confirm that the invoice forms submitted by each service provider are in compliance with the FCC’s rules governing the schools and libraries universal service support mechanism (Program). The FCC Form 473 can be found on the USAC website at http://www.usac.org.

Throughout these instructions, the service provider may be referred to as “you.” A service provider is any provider of eligible services or products to an eligible entity – a school, school district, library, library consortium or consortia of multiple entities. A service provider must obtain a SPIN by completing FCC Form 498, Service Provider Identification Number and General Contact Information Form, and submitting the completed FCC Form 498 to the Universal Service Administrative Company (USAC). For more information about SPINs, please contact the USAC’s Customer Resource Center 1-888-641-8722.

Universal service support will not be paid to a service provider on an approved funding commitment prior to the fund administrator’s receipt of the properly completed FCC Form 473.

FILING REQUIREMENTS AND GENERAL INSTRUCTIONS

Who must file the FCC Form 473?

An FCC Form 473 is required to be completed by each service provider, for each separate SPIN, to confirm that the invoices submitted by each service provider are in compliance with the FCC’s rules governing Universal Service for Schools and Libraries. An FCC Form 473 must be completed and submitted separately for each distinct SPIN assigned to a service provider that intends to submit invoices, pursuant to FCC Form 474, or approve applicant invoices, pursuant to FCC Form 472, for reimbursement of universal service support under the Program.

When to File?

An FCC Form 473 should be submitted once each year. The FCC Form 473 must be submitted prior to the fund administrator’s payment of invoices (FCC Form 472 or 474) for payment of universal service support under the Program.

A service provider is required to file an FCC Form 473 once each year for each SPIN.

Where to File?

Submit the FCC Form 473 by filing a paper copy of the completed form, including the completed and signed certification page, to USAC. The signed form must be filed with USAC at the address listed at the bottom of the FCC Form 473: SLD FCC Form 473, P.O. Box 7026, Lawrence, KS 66044-7026. For those applicants using express delivery services or U.S. Postal Service Return Receipt Requested, send to: SLD Forms, ATTN: SLD FCC Form 473, 3833 Greenway Drive, Lawrence, KS 66046, phone 1-888-203-8100. DO NOT FILE THIS OR ANY OTHER UNIVERSAL SERVICE FORM WITH THE FCC.

Compliance

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.

All of the required information in the FCC Form 473 must be completed, in order for this form to be accepted by the fund administrator for processing. A valid entry must be submitted on the FCC Form 473 for each component of required information. These instructions set forth the requirements for a valid entry. If you have any questions about completing this form, please visit the Forms section of the USAC website. You may also contact the SLD Client Service Bureau at 1-888-203-8100, before submitting the form. If the form is not properly completed, the form may be rejected and returned to you.

Where to Get More Information?

You may call the SLD Client Service Bureau at 1-888-203-8100, send an email using the “Submit a Question” feature on the website or send a fax to 1-888-276-8736 for more information on how to complete this or other universal service forms. Information and detailed guidance is also available on the website.

SPECIFIC INSTRUCTIONS

Type or clearly print in the spaces provided. Do not staple the FCC Form 473.

A. Block 1: Service Provider Information

Block 1 of FCC Form 473 asks you for your basic identification information and contact person data. "You" refers hereinafter to the service provider. A service provider is any provider of eligible services to an eligible entity – a school, school district, library, library consortium or consortium of multiple entities.

Item (1) - Provide the name of the service provider as indicated on FCC Form 498.

Item (2) - Provide the SPIN as it appears on the FCC Form 471 FCDLs for the Funding Request Numbers (FRNs) for which you will be seeking payment of the discount from the fund administrator. One form must be completed for each SPIN assigned by USAC. All entries in Item (1) must have a corresponding entry in Item (2).

Item (3) - Provide the Funding Year for which your funds were approved, e.g., "2012." The funding year you supply here must be the same as the funding year contained in the FCDL for the corresponding FCC Form 471. Funding Years begin on July 1 and end on the following June 30. For example, the 2012 Funding Year runs from July 1, 2012, through June 30, 2013.

Item (4) - Provide the name of a contact person who should be contacted with questions about this form. The contact person must be able to answer questions in a timely manner regarding the information included in this form.

Item (5) - Provide the mailing address for the contact person.

Item (6) - Provide the telephone number with area code (containing 10 digits) for the contact person identified in Item (5).

Item (7) - Provide the fax telephone number with area code (containing 10 digits) for the contact person identified in Item (5).

Item (8) - Provide the email address of the contact person identified in Item (5).

2. Block 2: Certification

This Block requests that person who is authorized to submit the Service Provider Annual Certification Form on behalf of the service provider, which has been assigned the above-referenced Service Provider Identification Number, and declares under penalty of perjury that based on information known to me or provided to the authorized person by employees responsible for the data being submitted, the authorized person certifies that the data set forth in the FCC Form 473 has been examined and reviewed and is true, accurate and complete. The authorized person acknowledges that any false statement of this Form or on the Service Provider Invoice Form can be punished by fine or forfeiture under the Communications Act, 47 U.S.C. § 502, 503 (b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. § 1001, and that any such false statement could subject the service provider to liability under the False Claims Act. The authorized person certifies to the following statements.

Item (9) - I certify that the Service Provider Invoice Forms (FCC Form 474) 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.

Item (10) - I certify that the Service Provider Invoice Forms (FCC Form 474) 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.

Item (11) - I certify that any requests for reimbursement that are sought under a Service Provider Invoice Form (FCC Form 474) for discounts for products or services that contain both eligible and ineligible components are properly allocated as required by the Commission’s rules at 47 C.F.R. § 54.504(e) (1) and (2).

Item (12) - I certify that 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.

Item (13) - I certify that no non-discount portion of the costs for eligible services will be waived, paid, or promised to be paid by this Service Provider. I acknowledge that the provision by any service provider of a supported service, or of free services or products unrelated to the supported service or product constitutes a rebate of the non-discount portion of the supported services as stated in 47 C.F.R. § 54.523.

Item (14) - I certify that no kickbacks, as defined in 41 U.S.C. § 8701, were paid by this Service Provider to anyone in connection with the schools and libraries universal support program.

Item (15) - I certify that this Service Provider is in compliance with the Commission’s rule and orders regarding gifts and this Service Provider and has not directly or indirectly offered or provided any gifts, gratuities, favors, entertainment, loans, or any other thing of value to any eligible schools, libraries, or consortium that includes eligible schools or libraries, except as permitted by the Commission’s rule at 47 C.F.R. § 54.503(d).

Item (16) - I certify that if the Fund Administrator, as necessary, requests additional supporting information, this Service Provider will make all documents requested available to the Fund Administrator as required by 47 C.F.R. § 54.516(b). I certify that this Service Provider 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 delivery of discounted services, (1) any and all records that I rely upon to complete this form and each Service Provider Invoice Form (FCC Form 474) that is submitted by this Service Provider during the present funding year and (2) all documents necessary to demonstrate compliance with the statutory or regulatory requirements for the schools and libraries universal service support program as required by 47 C.F.R. § 54.516(a)(2) I recognize that this Service Provider may be audited pursuant to 47 C.F.R. § 54.516(c), and that the Service Provider must provide such records as required by 47 C.F.R. § 54.516(b)

Item (17) - I certify that 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.

Item (18) - I certify that 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.

Item (19) - I certify that 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.

Item (20) - I certify that this Service Provider is not suspended or debarred from participating in Federal programs.

Item (21) - 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 acknowledges 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.

Item (22) - The signature of an authorized person certifying to the accuracy of the information contained in FCC Form 473 on behalf of the service provider is required in this block. Please note that it is essential that the signature be provided to the fund administrator. A person authorized to sign this form must be responsible for the service provider’s preparation and submission of invoice forms to seek reimbursement from the schools and libraries universal service support mechanism. This person must be able to certify to the accuracy of the invoice forms and their compliance with FCC Rules.

Item (23) - Enter the date the FCC Form 473 was signed. This date must include the month, day and year. This information is required to be provided.

Item (24) - Print the name of the authorized person certifying the information contained in FCC Form 473 on behalf of the service provider. This information is required to be provided.

Item (25) - Provide the title or position of the authorized person certifying the information contained in FCC Form 473 on behalf of the service provider. This information is required to be provided.

Item (26) - Provide the telephone number of the authorized person certifying the information contained in FCC Form 473 on behalf of the service provider. This information is required to be provided.

Item (27) - Provide the address of the authorized person certifying the information contained in FCC Form 473 on behalf of the service provider. This information is required to be provided.

Submit completed forms to:

SLD FCC Form 473

P.O. Box 7026

Lawrence, Kansas 66044-7026

For express delivery services or U.S. Postal Service, Return Receipt Requested:

SLD Forms

ATTN: SLD FCC Form 473

3833 Greenway Drive

Lawrence, Kansas 66046

Phone: 1-888-203-8100