FCC Form 500

OMB Control No. 3060-0853

F CC Form 500 OMB Control No. 3060-0853 DO NOT STAPLE Estimated time per response: 1.5 hours Universal Service for Schools and Libraries Funding Commitment Adjustment Request Form Please read instructions before completing. (To be completed by schools, libraries or consortia.)
Applicant’s Form Identifier: (Create your own code to identify THIS FCC Form 500)	FCC Form 500 Application Number: (To be assigned by administrator.) ___________________
Block 1: Applicant Information
1. Name of Billed Entity	2. Billed Entity Number	3. Funding Year
4. Complete Mailing Address of Billed Entity Street Address, P. O. Box or Route Number City State Zip Code
Telephone Number Fax Number Email Address
5. Contact Person Information
Contact Person Name
Mailing Address Street Address, P. O. Box or Route Number City State Zip Code
Telephone Number Fax Number Email Address
Type of Adjustment (Check all that apply) ⧠ Block 2: Services Adjustment ⧠ Block 4: Equipment Transfer Notification ⧠ Block 3: Cancellation or Reduction of an FRN

DO NOT STAPLE

Billed Entity Name _____________________________ Contact Name ____________________________________

Billed Entity Number __________________ Contact Telephone Number ___________________________Page 2__

Block 2: Services Adjustment Remember: The Funding Request Number(s) (FRNs) listed on this form must be for the same Funding Year as listed in Block 1, Item 3. New Service Start Date: Complete if you wish to change the Service Start Date you listed on a previously filed FCC Form 486 in the funding year listed in Block 1, Item 3. This action will NOT increase funding. Contract Expiration Date: Complete if the contract expiration date has changed and you wish to report the change to USAC. This action will NOT increase funding but you could combine it with a funding reduction. Service Delivery Extension: Complete if you are requesting an extension of the deadline for delivery and installation of non-recurring services. You must submit this request to USAC on or before the September 30 following the close of the funding year. This action will NOT increase funding. Note: Complete the Contract Expiration Date (Item 7) also if your contract will expire prior to the installation or delivery of services.
Service Start Date
FCC Form 471	FRN(s)	Original Date (mm/dd/yyyy):	New Date (mm/dd/yyyy):
Contract Expiration Date
FCC Form 471	FRN(s)	Original Date (mm/dd/yyyy):	New Date (mm/dd/yyyy):
Make as many copies of this page as needed, and number the completed pages so that they are all processed correctly. Please number your pages 2A, 2B, 2C, etc. and provide the number in space provided in Block 2.

Service Delivery Extension Request
FCC Form 471	FRN
Certify the reason for the service delivery and installation request by checking one of the boxes below: ⧠ The service provider was unable to complete delivery and installation for reasons beyond the service provider's control. ⧠ The service provider has been unwilling to complete delivery and installation after USAC withheld payment for those services on a properly-submitted invoice for more than 60 days after submission of the invoice.

DO NOT STAPLE

Billed Entity Name _____________________________ Contact Name ____________________________________

Billed Entity Number __________________ Contact Telephone Number ___________________________Page 3__

Block 3: Cancellation or Reduction of an FRN Remember: The FRNs listed on this form must be for the same Funding Year as listed in Block 1, Item 3. Cancel: Complete if you wish to cancel an FRN. This action is irrevocable and the FRN cannot be reinstated later. This action would allow money to be put back into the Universal Service fund for possible commitment to other applicants. Reduce: Complete if you wish to reduce the amount of your funding commitment for a particular FRN. This action is irrevocable and the FRN cannot be increased later. This action would allow money to be put back into the Universal Service Fund for possible commitment to other applicants.
Make as many copies of this page as needed, and number the completed pages so that they are all processed correctly. Please number your pages 3A, 3B, 3C, etc. and provide the number in space provided in Block 3
Cancel FRN
FCC Form 471	FRN (s) (list individually)				Write in “CANCEL ALL” below if you wish to cancel all FRNs on FCC Form 471
Reduce FRN
FCC Form 471		FRN(s)	Original Commitment Amount from FCDL	New Commitment Amount AFTER Reduction

Block 4: Equipment Transfer Notification Remember: The FRNs listed on this form must be for the same Funding Year as listed in Block 1, Item 3. Equipment Transfer: Complete this section if you are transferring equipment from a closed entity to other eligible entities within three years of the date of purchase. Both the transferring and receiving entities must maintain detailed records documenting the transfer and the reason for the transfer for at least five years (or whatever retention period is required by the rules in effect at the time of this certification).
Make as many copies of this page as needed, and number the completed pages so that they are all processed correctly. Please number your pages 4A, 4B, 4C, etc. and provide the number in space provided in Block 4
FCC Form 471		FRN
Closed Entity Number		Closed Entity Name
Purchase Date	Transfer Date	Transfer Reason
⧠ Check here if transfer is temporary. Enter projected return date __________________________
List all entities receiving the equipment. Receiving Entity(s) Number(s)		Receiving Entity Name (s)	Equipment Received Equipment name, make and model

DO NOT STAPLE

Billed Entity Name _____________________________ Contact Name ____________________________________

Billed Entity Number __________________ Contact Telephone Number __________________________Page 4__

DO NOT STAPLE Billed Entity Name _____________________________ Contact Name ____________________________________ Billed Entity Number __________________ Contact Telephone Number _________________________________
Block 5: Certification
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. 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. I 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 discount services (or after the date of transfer for equipment transfers), (1) any and all records that I rely upon to complete this form and (2) all documents necessary to demonstrate compliance with the statutory or regulatory requirements for the schools and libraries universal service support program. I recognize that I may be audited pursuant to this application and the applicant must produce such records as required by 47 C.F.R. § 54.516.
Signature	Date
Printed name of authorized person
Title or position of authorized person
Telephone number of authorized person
Email address of authorized person
Address of authorized person
Name of Authorized Person’s Employer

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 1.5 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.

A paper copy of this form, with an authorized signature in Block 5, Item 15 should be mailed to:

SLD Form 500

P. O. Box 7026

Lawrence, KS 66044-7026

If sent by express delivery services or U.S. Postal Service, Return Receipt Requested, the form should be mailed to: SLD-Forms

SLD Forms

ATTN: Form 500

3833 Greenway Dr.

Lawrence, KS 66046

888-203-8100

FCC Form 500 Page 6 of 6 October 2013