FCC Form 474 Schools and Libraries Universal Service - Service Provid

F CC Form 474 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 Schools and Libraries Universal Service Service Provider Invoice FCC Form 474 Please read instructions before completing This form can be filed online or by mail.
Service Provider Form Identifier (Create an identifier for your own reference)	FCC Form 474 Invoice # ________________________________________ (To be inserted by administrator)
BLOCK 1: Service Provider Information
1. Service Provider Name
2. Service Provider Identification Number (SPIN)
3. Contact Person’s Name
4. Contact Telephone Number Area Code: Phone Number: Ext.
Contact Fax Number Area Code: Fax Number:
Contact Email Address
5. Total Invoice Amount (total of Block 2, Column 13)

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
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	FCC Form 471 Application Number (from Funding Commitment Decision Letter)		Funding Request Number (FRN) (from Funding Commitment Decision Letter)	Bill Frequency (e.g., Monthly, Quarterly, Annually, One-time, Other)	Customer Billed Date (mm/yyyy)		Shipping Date to Customer or Last Day of Work Performed (mm/dd/yyyy)	Total (Undiscounted) Amount for Service per FRN	Discount Rate		Amount Billed to USAC (Column 11 multiplied by Column 12)
					For each FRN, there should be an entry in Column 9 or Column 10 but NOT BOTH
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	TOTAL REIMBURSEMENT AMOUNT TO BE ENTERED INTO ITEM 5

Service Provider Invoice FCC Form 474 Service Provider Form Identifier ______________________________________________________ Contact Person ____________________________________________________________________ Contact Telephone Number ___________________________________________________________
Block 3: Service Provider Certifications & Signature
I declare under penalty of perjury that the foregoing is true and correct and that I am authorized to submit this Service Provider Invoice Form (FCC Form 474) and acknowledge to the best of my knowledge, information and belief, as follows: I certify that 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 certify that the certifications made on the Service Provider Annual Certification Form (FCC Form 473) by this Service Provider are true and correct. 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.
14. Signature of authorized person	15. Date
16. Printed name of authorized person
17. Title or position of authorized person
18. Telephone number of authorized person
19. Address of authorized person

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.

Do not staple the FCC Form 474.

Please submit this form to:

SLD SPI FCC 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 FCC Form 474

3833 Greenway Drive

Lawrence, KS 66046

888-203-8100