Schools and Libraries Universal Service Description of Services Requested and Certification Form 470

OMB 3060-0806

Schools and Libraries Universal Service

Description of Services Requested and Certification Form 470

Estimated Average Burden Hours per Response: 3 hours

This form is designed to help you describe the eligible services you seek so that this data can be posted on the Fund Administrator Internet Site

and interested service providers can identify you as a potential customer and compete to serve you.

Please read instructions before beginning this form. (You can also file online at www.usac.org/sl)

Applicant’s Form Identifier (Optional: Create an identifier for your own reference) X	Form 470 Application #: (To be assigned by administrator)
Block 1: Applicant Address and Information
Name of Applicant X XX X F unding Year (Funding years run from July 1 through the following June 30)
3 Entity Number 4a Street Address, P.O. Box, or Route Number City State Zip Code 4 b Telephone Number Ext 4 c Fax Number 5a Eligible Entities That Will Receive Services: Check the ONE choice in 5a that best describes the eligible entities that will receive the services described in this form. You will then list in Item 15 the entity/entities that will pay the bills for these services. Individual School (individual public or non-public school) School District (LEA; public or non-public [e.g. diocesan] local district representing multiple schools) Library (including library system, library outlet/branch or library consortium as defined under LSTA) Consortium (intermediate service agencies, non-statewide or regional consortia of schools and/or libraries) Statewide application for (enter 2-letter state code) representing (check all that apply) All public schools/districts in the state All non-public schools in the state All libraries in the state 5b Recipient(s) of Services - Check all that apply:
P rivate Public Charter
T ribal Head Start State Agency
5c Number of eligible entities for which services are sought

Entity Number __________________________________ Applicant’s Form Identifier __________________________________

Contact Person __________________________________ Contact Telephone Number __________________________________

Block 1: Applicant Address and Information (continued)

6a Contact Person’s Name

If the Contact Person’s Street Address is the same as Item 4a above, check here. If not, complete Item 6b.

6b Street Address, P.O. Box, or Route Number

NOTE: USAC will use this address to mail correspondence about this form.

City State Zip Code

Check the box next to your preferred mode of contact and provide your contact information. One box MUST be checked and an entry provided.

6c Telephone Number Ext.

6d Fax Number

6e E-mail Address

R e-enter E-mail Address

If a consultant is assisting you with your application process, please complete Item 7 below:

7 Consultant Name

N ame of Consultant’s Employer

C onsultant’s Street Address

C ity State Zip Code

Consultant’s Telephone Number Ext.

Consultant’s Fax Number

C onsultant’s E-mail Address

R e-enter E-mail Address

C onsultant Registration Number

Entity Number __________________________________ Applicant’s Form Identifier __________________________________ Contact Person __________________________________ Contact Telephone Number __________________________________
Block 2: Summary Description of Needs or Services Requested (Attach additional pages if needed)
8 Priority One Services (Telecommunications and/or Internet Access)
If you check YES to indicate you have a Request for Proposals (RFP) that specifies the services you are seeking, your RFP must be available to all interested bidders for at least 28 days. If your RFP is not available to all interested bidders, or if you check NO and you have or intend to have an RFP, you risk denial of your funding requests.
a	Y ES, I have released or intend to release an RFP for one or more of these services. It is available or will become available on the Internet at:
	o Your RFP Identifier: r via (check one) the contact person in Item 6 or	t he contact person listed in Item 12
b	N O, I have not released and do not intend to release an RFP for any of these services.
	Whether you check YES or NO, you must list below the Priority One Services you seek. Specify each service (e.g., voice service, monthly Internet access service, etc) and quantity and/or capacity (e.g., for voice service, 20 existing lines plus 10 new ones, or for monthly Internet access service, for 500 users).
S ervice Quantity and/or Capacity
9 [Reserved]

Entity Number __________________________________ Applicant’s Form Identifier __________________________________ Contact Person __________________________________ Contact Telephone Number __________________________________
Block 2: Summary Description of Needs or Services Requested (Attach additional pages if needed)
10 Internal Connections Other Than Basic Maintenance
If you check YES to indicate you have a Request for Proposals (RFP) that specifies the services you are seeking, your RFP must be available to all interested bidders for at least 28 days. If your RFP is not available to all interested bidders, or if you check NO and you have or intend to have an RFP, you risk denial of your funding requests.
a	Y ES, I have released or intend to release an RFP for one or more of these services. It is available or will become available on the Internet at:
	o Your RFP Identifier: r via (check one) the contact person in Item 6 or	t he contact person listed in Item 12.
b	N O, I have not released and do not intend to release an RFP for any of these services.
	Whether you check YES or NO, you must list below the Internal Connections services you seek. Specify each service (e.g., a router, hub and cabling) and quantity and/or capacity (e.g., connecting 1 classroom of 30 students).
S ervice Quantity and/or Capacity
11 Basic Maintenance of Internal Connections
If you check YES to indicate you have a Request for Proposals (RFP) that specifies the services you are seeking, your RFP must be available to all interested bidders for at least 28 days. If your RFP is not available to all interested bidders, or if you check NO and you have or intend to have an RFP, you risk denial of your funding requests.
a	Y ES, I have released or intend to release an RFP for one or more of these services. It is available or will become available on the Internet at:
	o Your RFP Identifier: r via (check one) the contact person in Item 6 or	t he contact person listed in Item 12.
b	N O, I have not released and do not intend to release an RFP for any of these services.
	Whether you check YES or NO, you must list below the Basic Maintenance services you seek. Specify each service (e.g., basic maintenance of routers) and quantity and/or capacity (e.g., for 10 routers).
Service Quantity and/or Capacity

Entity Number __________________________________ Applicant’s Form Identifier __________________________________ Contact Person __________________________________ Contact Telephone Number __________________________________
Block 2: Summary Description of Needs or Services Requested (Continued)
12 (Optional) Please name the person on your staff or project who can provide additional technical details or answer specific questions from service providers about the services you are seeking. This person does not need to be the contact person(s) listed in Item 6 nor the Authorized Person who signs this form. Name Title T elephone Number Ext. F ax Number E mail Address Re-enter E-mail Address
13	C heck this box if there are any restrictions imposed by state or local laws or regulations on how or when service providers may contact you or on other bidding procedures. Please describe below any such restrictions or procedures and/or provide an Internet address where they are posted and a contact name and telephone number. C heck this box if no state and local procurement/competitive bidding requirements apply to the procurement of services sought on this Form 470. If you are requesting services for a funding year for which a Form 470 cannot yet be filed online, include that information here.
Block 3:
14		[Reserved]

Entity Number __________________________________ Applicant’s Form Identifier __________________________________ Contact Person __________________________________ Contact Telephone Number __________________________________
Block 4: Recipients of Service
15	Billed Entities List the entity/entities that will be paying the bills directly to the provider for the services requested in this form. These are known as Billed Entities. At least one line of this item must be completed. If a Billed Entity cited on your Form 471 is not listed below, funding may be denied for the funding requests associated with this Form 470. Attach additional pages if needed. Entity Number Entity Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

Do not write in this area.

Entity Number __________________________________ Applicant’s Form Identifier __________________________________ Contact Person __________________________________ Contact Telephone Number __________________________________
Block 5: Certifications and Signature
16	I certify that the applicant includes: (Check one or both.)
	a		schools under the statutory definitions of elementary and secondary schools found in the No Child Left Behind Act of 2001, 20 U.S.C. §§ 7801 (18) and (38), that do not operate as for-profit businesses, and do not have endowments exceeding $50 million; and/or
	b		libraries or library consortia eligible for assistance from a State library administrative agency under the Library Services and Technology Act of 1996 that do not operate as for-profit businesses and whose budgets are completely separate from any schools (including, but not limited to elementary and secondary schools, colleges, and universities).
17	I certify that, if required by Commission rules, all of the individual schools and libraries receiving services under this form are covered by technology plans that do or will cover all 12 months of the funding year, and that have been or will be approved by a state or other authorized body, or an SLD-certified technology plan approver, prior to the commencement of service.
			Or I certify that no technology plan is required by Commission rules.
18	I certify that I will post my Form 470 and (if applicable) make my RFP available for at least 28 days before considering all bids received and selecting a service provider. I certify that all bids submitted will be carefully considered and the bid selected will be for the most cost-effective service or equipment offering, with price being the primary factor, and will be the most cost-effective means of meeting educational needs and technology plan goals.
19	I certify that I will retain required documents for a period of 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. I certify that I will retain all documents necessary to demonstrate compliance with the statute and Commission rules regarding the form for, receipt of, and delivery of services receiving schools and libraries discounts. I acknowledge that I may be audited pursuant to participation in the schools and libraries program.
20	I certify that the services the applicant purchases at discounts provided by 47 U.S.C. § 254 will be used primarily for educational purposes and will not be sold, resold or transferred in consideration for money or any other thing of value, except as permitted by the Commission’s rules at 47 C.F.R. §§ 54.500, 54.513. Additionally, I certify that the entity or entities listed on this form have not received anything of value or a promise of anything of value, other than services and equipment sought by means of this form, from the service provider, or any representative or agent thereof or any consultant in connection with this request for services.
21	I acknowledge that support under this support mechanism is conditional upon the school(s) and/or library(ies) I represent securing access, separately or through this program, to all of the resources, including computers, training, software, internal connections, maintenance, and electrical capacity necessary to use the services purchased effectively. I recognize that some of the aforementioned resources are not eligible for support. I certify that I have considered what financial resources should be available to cover these costs.
22	I certify that I am authorized to procure eligible services for the eligible entity(ies). I certify that I am authorized to submit this request on behalf of the eligible entity(ies) listed on this form, that I have examined this request, and to the best of my knowledge, information, and belief, all statements of fact contained herein are true.
23	I certify that I have reviewed all applicable FCC, state, and local procurement/competitive bidding requirements and that I have complied with them. I acknowledge that persons willfully making false statements on this 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.
24	I acknowledge that FCC rules provide that persons who have been convicted of criminal violations or held civilly liable for certain acts arising from their participation in the schools and libraries support mechanism are subject to suspension and debarment from the program.

Do not write in this area.

Entity Number __________________________________ Applicant’s Form Identifier __________________________________ Contact Person __________________________________ Contact Telephone Number __________________________________
Block 5: Certifications and Signature (Continued)
25	Signature of authorized person		26	D ate
27a	P rinted name of authorized person
27b	Title or position of authorized person Check here if the consultant in Item 7 is the Authorized Person.
27c	Street Street Address, P.O. Box, or Route Number City State Zip Code
27d 27e	Telephone Number of Authorized Ext. Person Fax Number of Authorized Person
27f 27g	E -mail Address of Authorized Person R e-enter E-mail Address Name of Authorized Person’s Employer
Service provider involvement with preparation or certification of a Form 470 can taint the competitive bidding process and result in the denial of funding requests. For more information, refer to the Schools and Libraries area of the USAC web site at www.usac.org/sl or call the SLD Client Service Bureau at 1-888-203-8100.

Entity Number _________________________Applicant’s Form Identifier __________________________________

Contact Person ________________________Contact Telephone Number __________________________________

Block 5: Certifications and Signature (Continued)

NOTICE: In accordance with Section 54.504 of the Federal Communications Commission’s rules, certain schools and libraries ordering

services that are eligible for and seeking universal service discounts must file this Description of Services Requested and Certification

Form (FCC Form 470) with the Universal Service Administrator. 47 C.F.R. § 54.504(b). The collection of information stems from the

Commission’s authority under Section 254 of the Communications Act of 1934, as amended. 47 U.S.C. § 254. The data in the

report will be used to ensure that schools and libraries comply with the competitive bidding requirement contained in 47 C.F.R. §

54.504. Schools and libraries must file this form themselves or as part of a consortium.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a

currently valid OMB control number.

The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. We

will use the information you provide to determine whether approving this application is in the public interest. If we believe there

may be a violation or a potential violation of any applicable statute, regulation, rule or order, your application may be referred to

the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation or

order. In certain cases, the information in your application may be disclosed to the Department of Justice or a court or adjudicative

body when (a) the FCC; or (b) any employee of the FCC; or (c) the United States Government is a party of a proceeding before the

body or has an interest in the proceeding. In addition, information provided in or submitted with this form or in response to

subsequent inquiries may also be subject to disclosure consistent with the Communications Act of 1934, FCC regulations, the

Freedom of Information Act, 5 U.S.C. § 552, or other applicable law.

If you owe a past due debt to the federal government, the information you provide may also be disclosed to the Department of the

Treasury Financial Management Service, other Federal agencies and/or your employer to offset your salary, IRS tax refund or other

payments to collect that debt. The FCC may also provide the information to these agencies through the matching of computer

records when authorized.

If you do not provide the information we request on the form, the FCC may delay processing of your application or may return your

form without action.

The foregoing Notice is required by the Paperwork Reduction Act of 1995, Pub. L. No. 104-13, 44 U.S.C. § 3501, et seq.

Public reporting burden for this collection of information is estimated to average 3 hours per response, including the time for

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing, and reviewing the

collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,

including suggestions for reducing the reporting burden to the Federal Communications Commission, Performance Evaluation and

Records Management, Washington, DC 20554.

Please submit this form to:

SLD-Form 470

P.O. Box 7026

Lawrence, Kansas 66044-7026

1-888-203-8100

For express delivery services or U.S. Postal Service, Return Receipt Requested, mail this form to:

SLD Forms

ATTN: SLD Form 470

3833 Greenway Drive

Lawrence, Kansas 66046

1-888-203-8100

Page 10 of 10 Draft FCC Form 470 – [month] 2013