Form FCC 471 FCC 471 Services Ordered and Certification

OMB 3060-0806 DRAFT VERSION

F CC Form 471 Approval by OMB 3060-0806 Schools and Libraries Universal Service Description of Services Ordered and Certification Form 471 Estimated Average Burden Hours per Response: 4 hours This form is designed to help schools and libraries to list the eligible services they have ordered and estimate the annual charges for them so that the Fund Administrator can determine the appropriate amount of Universal service support for those services. Please read instructions before beginning this application. The instructions include information on the deadlines for filing this application.
Applicant’s Form Identifier (Create an identifier for your own reference)	FCC Form 471 Application #: (To be assigned by administrator)
Block 1: Billed Entity Address and Information
Name of Billed Entity 2 Funding Year (Funding years run from July 1 through the following June 30) 3a Billed Entity Number
3b FCC Registration Number 4a Street Address, P.O. Box, or Route Number City State Zip Code 4b Telephone Number Ext 4 c Fax Number 5a Type of Application (check only one) 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, consortia of schools and/or libraries) Statewide application for 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:
P rivate Public Charter
T ribal Head Start State Agency

OMB 3060-0806

Block 1: Billed Entity Address and Information (continued)

6 a Contact Person’s Name

6b Correspondence Address. NOTE: USAC will use THIS address to mail correspondence about this form.

City State Zip Code

Email will be the required mode of contact for all questions about this application.

6c E-mail Address

R e-enter E-mail Address

The following alternate contact information is required.

6d Telephone Number Ext.

6e Fax Number

6f Holiday/vacation/summer contact information: please include name of alternate contact (if applicable) and alternate phone, fax or E-mail address

If a consultant is assisting you with your E-rate process, please complete Item 6g below:

6 g Consultant Registration Number:

C onsultant 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

Block 2 and 3 [Reserved]

Block 4: Discount Calculations and Recipients of Service

7. School District or Library System Name

School District or Library System Billed Entity Number _______________________________ School District or Library System Name _____________________________

7a. Enter all of the schools or libraries, as well as NIFs, that are part of your school district or library system, regardless of whether they are receiving service as part of this application or not.

Entity #

Individual School or Library Outlet/ Branch Name

NCES or FSCS Code

Urban or Rural

NIF

SCHOOLS ONLY

State LEA ID

State School ID

# of Students that attend this school full time or part time

Student count based on estimate

Alternative Discount?

School Attributes:

Pre-discount Entity Category Two Budget

Post-discount Entity Category Two Budget

LIBRARIES ONLY
Total Square Footage of library outlet	Main Branch? (Y/N)	School District Billed Entity Number	Library Attributes	Pre-discount Entity Category Two Budget	Post-discount Entity Category Two Budget

7b. School District Discount Calculation (NOTE: Libraries provide the information for the public school district(s) in which the main branch of the library is located.)

Consortium Discount Calculation: Complete one line for each school district entity number that will be featured in the Consortium Discount Calculation.

School District Name	School District Entity Number	Total Number of Students Enrolled in School District	Total Number of Students in School District Eligible for NSLP	Percentage of Students in School District Eligible for NSLP	Category One Discount Rate	Category Two Discount Rate

8. Connectivity

Please complete the following information for the school, school district, library, or library system referenced in Block 8a. Complete only once for each school, school district, library, or library system.

Internet Access

8a. Schools and School Districts. Does the school district (or school, if not part of a district) referenced in Block 7a have Internet access of

less than 100 Mbps per 1,000 users (students and staff)

at least 100 Mbps per 1,000 users but less than 1Gbps per 1,000 users

at least 1 Gbps per 1,000 users

8b Libraries.

1 How many libraries that are part of the library system referenced in Block 7a serve a population of less than 50,000? _____

How many of these libraries serving populations less than 50,000 have Internet access of

less than 100 Mbps: _____

at least 100 Mbps but less than 1Gbps: _____

at least 1 Gbps: ____

2. How many libraries that are part of the library system referenced in Block 7a serve a population greater than or equal to 50,000? [integer]

How many of these libraries serving populations greater than or equal to 50,000 have Internet access of

less than 100 Mbps: _____

at least 100 Mbps but less than 1Gbps: _____

at least 1 Gbps: ____

Wide Area Networking

8c. Schools and School Districts.

How many of the schools in the school district referenced in Block 8a have Wide Area Networking connections that are scalable to 10 Gbps? _____

8d. Libraries.

How many of the libraries in the library system referenced in Block 8a have Wide Area Networking connections that are scalable to 10 Gbps? ____

8e. How many schools in your school district or libraries in your library system have LAN/WLAN capacity and coverage?

1. Completely sufficient to support the educational or library activities conducted there: ____

2. Mostly sufficient to support the educational or library activities conducted there: _____

3. Sometimes sufficient to support the educational or library activities conducted there: _____

4. Rarely sufficient to support the educational or library activities conducted there: _____

5. Not sufficient to support the educational or library activities conducted there: _____

8f. For those schools and libraries that do not have sufficient LAN/WLAN capacity and coverage to support the educational objectives or library activities conducted at that location, is the reason (check all that apply):

1. E quipment too costly

2. I nstallation too costly

3. B roadband connection speed to building is too slow

4. I nadequate local area network (LAN) services/internal networks and wiring

5. O utdated equipment

6. L ack of training and technical support

7. I nconsistent service/frequent outages and down time

8. P hysical structure or layout of building(s)

9. O ther: If so, please provide it here: ________________________________________________________________________

9. Consortium Discount Calculation

Name of Consortium Member	Billed Entity Number of Consortium Member	Category One Discount Rate	Category Two Discount Rate
Sum of Member Discounts
Number of Members
Category One Consortium Discount
Category Two Consortium Discount

B lock 5: Discount Funding Request(s) I FRN ______________________ (to be assigned by administrator) nstructions: Use one Block 5 for EACH service (Funding Request Number)for which you are requesting discounts. . Optional: Applicant FRN Identifier: ___________________________________

1 0

If this is a duplicate Funding Request (e.g., of an FRN that is not yet approved, under appeal, etc.), check this box and enter the original FRN in the space provided:

11

Service Type (check only ONE box ) CATEGORY ONE

20

Calculations

Telecommunications Services Internet Access CATEGORY TWO Basic Maintenance of Internal Connections

Voice Services Internal Connections and Managed Internal Broadband Services

Recurring Charges

A . Monthly charges (total amount per month for service)

1 2a 1 2b 1 2c

Establishing FCC Form 470 (check only ONE box ) An FCC Form 470 was posted. Provide Application Number below: ________________________________________________ This Funding Request is for an eligible commercially available business-class Internet access service exempt from the requirement to post an FCC Form 470. This Funding Request is for an eligible preferred master contract exempt from the requirement to post an FCC Form 470.

B. How much of the amount in A is ineligible?

13

SPIN – Service Provider Identification Number

C. Eligible monthly pre-discount amount (A minus B)

14

Service Provider Name

D . Number of months service provided in funding year

E . Annual pre-discount amount for eligible recurring charges (C x D)

15a

Check this box if this Funding Request is for non-contracted tariffed or month-to-month services.

Non-Recurring Charges

F. Annual non-recurring charges ____________________

15b

Contract Number

15c 15d 15e

Check this box if this Funding Request is covered under a master contract (a contract negotiated by a third party, the terms and conditions of which are then made available to an eligible entity that purchases directly from the service provider). Check this box if this Funding Request is a continuation of an FRN from a previous funding year based on a multi-year contract. If so, provide that FRN here: Check here to certify that there is a specific statute, rule or other restriction barring publication of the information provided in Item 21. Applicants making this certification shall retain the necessary documents to demonstrate this restriction and cite below to the statute, rule or other restriction that prevents this information from becoming public. Note that contracts and other agreements executed after September 18, 2014 may not prohibit pricing disclosure, and any such restrictions will have no effect. ­ Restriction that prevents information from becoming public:

G. How much of the amount in F is ineligible?

16a

Billing Account Number (e.g., billed telephone number)

16b

Check this box if there are multiple Billing Account Numbers and attach a complete list of those numbers to this page.

H . Annual eligible pre-discount amount for non-recurring charges (F minus G)

1 7

Allowable Vendor Selection/Contract Date (mm/dd/yyyy)

18

C ontract Award Date (mm/dd/yyyy)

Total Charges

I. Total funding year pre-discount amount (E + H) _______________

19a

S ervice Start Date (mm/dd/yyyy)

19b

Service End Date (mm/dd/yyyy)

J. Discount from Block 4 Worksheet — voice phase out (if applicable) If Voice Services: FY 2015—subtract 20% FY 2016—subtract 40%

19c 19d

Contract Expiration Date ( mm/dd/yyyy) Indicate whether the contract for this FRN contains a clause that permits the parties to extend or renew the agreement at the end of the initial contract period: Yes No If yes: Number of possible extensions remaining _________ Total length of contract if all extensions are exercised: _________

K. Funding Commitment Request (I x J)

Item 21a – Telecommunications (including Voice) and Internet Access FRN ___________________________________

N

arrative Description

of this FRN

Services Requested

FRN line Item number

Type of Service Requested

Type of Connection

Purpose (transport, Internet, both, voice)

Quantity or # of lines

Bandwidth Upload speed

Bandwidth Download speed (if different)

Burstable bandwidth? (Y/N/ Unknown) If yes, insert max speed.

Basic firewall protection included? Y/N

Recipient of Service [Entity Numbers]

Last Mile connection? (Y/N)

WAN

Monthly Re-curring Eligible Cost

Monthly Re-curring Ineligible Cost

One-time Eligible Cost

One-time In-eligible Cost

Extended Line item Cost

Item 21b – Internal Connections FRN ___________________________________

N

arrative Description

of this FRN

Services Requested

FRN Line Item	Type of Internal Connections (drop down)	Type of Product (drop down)	Quantity and unit	Make	Model	Lease or Non-Purchase Arrangement (Yes/No)	Monthly Recurring Eligible Cost	Monthly Recurring Ineligible Cost	One-time Eligible Cost	One-time Ineligible Cost	Extended Eligible Line Item Cost (calculated)

FRN line item (system generated)	Recipients of Service (Entity Number)	Cost-Allocation

Item 21c –Managed Internal Broadband Services FRN ___________________________________

N

arrative Description

of this FRN

Services Requested

FRN line item (system generated)	Type of Managed Service Agreement	Monthly Recurring Eligible Cost	Monthly Recurring Ineligible Cost	One-time Eligible Cost	One-time Ineligible Cost	Extended Eligible Line Item Cost (calculated)

FRN line item (system generated)	Recipients of Service (Entity Numbers)	Cost-Allocation

Item 21d – Basic Maintenance of Internal Connections FRN ___________________________________

N

arrative Description

of this FRN

Services Requested

FRN line item (system generated)	Type of Internal Connections being maintained (function drop down)	Type of Product being maintained (product type dropdown)	Quantity and unit	Make of Covered Equipment	Model of Covered Equipment	Cost Allocation % (if not 100% eligible)	Monthly Recurring Eligible Cost	Monthly Recurring Ineligible Cost	One-time Eligible Cost	One-time Ineligible Cost	Pre-Discount Extended Eligible Line Item Cost (calculated)

FRN line item (system generated)	Recipients of Service (Entity Numbers)	Cost-Allocation

Category Two Funding Requested By Entity

The table below shows the Category Two funds that you have requested for each of the entities you listed in Block 4. This table does not include any funding requested on other FCC Forms 471 that includes these entities. To determine if any of the entities are over their Category Two budget, you must review all of the Category Two applications filed that include your entities. This may include applications filed by other applicants, such as consortia. If the total dollars requested by, and on behalf of, any of your entities in this funding year exceeds its Category Two budget for this funding year, processing of your application may be delayed.

Entity Name	Entity Number	Total Category Two Pre-discount Request on this Application	Category Two Pre-discount Budget	Difference

Entity Number __________________________________ Applicant’s Form Identifier _________________________________

Contact Person __________________________________ Phone Number _________________________________

Block 6: Certifications and Signature

22 I certify that the entities listed in Block 4 of this application are eligible for support because they are: (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, secondary schools, colleges, or universities.

2 3 I certify that the entity I represent or the entities listed on this application have secured 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 the entities I represent or the entities listed on this application have secured access to all of the resources to pay the discounted charges for eligible services from funds to which access has been secured in the current funding year. I certify that the Billed Entity will pay the non-discount portion of the cost of the goods and services to the service provider(s).

a	T otal funding year pre-discount amount on this FCC Form 471 (Add the entries from Items 20I on all Block 5 Discount Funding Requests.)
b	T otal funding commitment request amount on this FCC Form 471 (Add the entries from Items 20K on all Block 5 Discount Funding Requests.)
c	T otal applicant non-discount share (Subtract Item 23b from Item 23a.)
d	T otal budgeted amount allocated to resources not eligible for E-rate support
e	T otal amount necessary for the applicant to pay the non-discount share of the services requested on this application AND to secure access to the resources necessary to make effective use of the discounts. (Add Items 23c and 23d.)
f	C heck this box if you are receiving any of the funds in Item 23e directly from a service provider listed on any of the FCC Forms 471 filed by this Billed Entity for this funding year, or if a service provider listed on any of the FCC Forms 471 filed by this Billed Entity for this funding year assisted you in locating funds in Item 23e.

2 4 If I did not check either item 12b or 12c on any block 5 worksheet, I certify an FCC Form 470 was posted and that any related RFP was made available for at least 28 days before considering all bids received and selecting a service provider. I certify that all bids submitted were carefully considered and the most cost-effective service offering was selected, with price being the primary factor considered, and is the most cost-effective means of meeting educational needs and technology goals.

2 5 I certify that if I checked item 12b on any Block 5 worksheet on this form that I selected an eligible commercially available business-class Internet access service exempt from the requirement to post an FCC Form 470.

26 I certify that if I checked item 12c on any Block 5 worksheet on this form the services ordered were from an eligible preferred master contract exempt from the requirement to post an FCC Form 470.

2 7 I certify that the entity responsible for selecting the service provider(s) has reviewed all applicable FCC, state, and local procurement/competitive bidding requirements and that the entity or entities listed on this application have complied with them.

2 8 I certify that the services the applicant purchases at discounts provided by 47 U.S.C. § 254 will be used primarily for educational purposes, see 47 C.F.R. § 54.500 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. § 54.513. Additionally, I certify that the entity or entities listed on this application 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.

2 9 I certify that I and the entity(ies) I represent have complied with all program rules, including recordkeeping requirements, and I acknowledge that failure to do so may result in denial of discount funding and/or cancellation of funding commitments. There are signed contracts or other legally binding agreements covering all of the services listed on this FCC Form 471 except for those services provided under non-contracted tariffed or month-to-month arrangements. I acknowledge that failure to comply with program rules could result in civil or criminal prosecution by the appropriate law enforcement authorities.

Entity Number __________________________________ Applicant’s Form Identifier __________________________________

Contact Person __________________________________ Phone Number __________________________________

Block 6: Certification and Signature (Continued)

3 0 I acknowledge 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 service, receive an appropriate share of benefits from those services.

3 1 I certify that I will retain required documents for a period of at least 10 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 application for, receipt of, and delivery of services receiving schools and libraries discounts, and that if audited, I will make such records available to the Administrator. I acknowledge that I may be audited pursuant to participation in the schools and libraries program.

3 2 I certify that I am authorized to order telecommunications and other supported services for the eligible entity(ies) listed on this application. I certify that I am authorized to submit this request on behalf of the eligible entity(ies) listed on this application, that I have examined this request, that all of the information on this form is true and correct to the best of my knowledge, that the entities that are receiving discounts pursuant to this application have complied with the terms, conditions and purposes of the program, that no kickbacks were paid to anyone and that 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 and civil violations of the False Claims Act.

3 3 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. I will institute reasonable measures to be informed, and will notify USAC should I be informed or become aware that I or any of the entities listed on this application, or any person associated in any way with my entity and/or the entities listed on this application, is convicted of a criminal violation or held civilly liable for acts arising from their participation in the schools and libraries support mechanism.

3 4 I certify that if any of the Funding Requests on this FCC Form 471 are for discounts for products or services that contain both eligible and ineligible components, that I have allocated the eligible and ineligible components as required by the Commission's rules at 47 C.F.R. § 54.504.

3 5 I certify that the non-discount portion of the costs for eligible services will not be paid by the service provider. The pre-discount costs of eligible services featured on this FCC Form 471 are net of any rebates or discounts offered by the service provider. I acknowledge that, for the purpose of this rule, the provision, by the provider of a supported service, of free services or products unrelated to the supported service or product constitutes a rebate of some or all of the cost of the supported services.

36	Signature of authorized person		37	D ate
38	P rinted name of authorized person
39	T itle or position of authorized person Check here if the consultant in Item 6g is the Authorized Person.
40a	S treet Street Address, P.O. Box, or Route Number City State Zip Code

Entity Number __________________________________ Applicant’s Form Identifier __________________________________ Contact Person __________________________________ Contact Telephone Number __________________________________
40b 40c	T elephone Number Ext.. of Authorized Person Fax Number of Authorized Person
40d 40e	E -mail Address of Authorized Person Re-enter E-mail Address Name of Authorized Person’s Employer

NOTICE: Section 54.504 of the Federal Communications Commission's rules requires all schools and libraries ordering services that are eligible for and seeking universal service discounts to file this Services Ordered and Certification Form (FCC Form 471) with the Universal Service Administrator. 47 C.F.R.§ 54.504(a). 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 47C.F.R. § 54.503. All schools and libraries planning to order services eligible for universal service discounts 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, consistent with the Communications Act of 1934, FCC regulations and orders, the Freedom of Information Act, 5 U.S.C. § 552, or other applicable law, information provided in or submitted with this form or in response to subsequent inquiries may be disclosed to the public.

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 application 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 4 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.

Page 3 of 13 Draft FCC Form 471 – Date 2014