Form FCC 471 FCC 471 Services Ordered and Certification

OMB 3060-0806
FCC 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.
FCC Form 471 Application #:

Applicant’s Form Identifier (Create an identifier for your own reference)

(To be assigned by administrator)

Block 1: Billed Entity Address and Information
1 Name of Billed Entity

(Funding years run from July 1 through the following June 30)

2 Funding Year

3a Billed Entity Number

3b FCC Registration Number
4a Street Address, P.O. Box, or Route Number

City

Zip Code

State

4b Telephone Number

Ext

4c 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:

Page 1 of 12

Private

Public

Charter

Tribal

Head Start

State Agency

FCC Form 471 – October 2014

OMB 3060-0806
Block 1: Billed Entity Address and Information (continued)
6a 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
Re-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:
6g Consultant Registration Number:
Consultant Name :
Name of Consultant’s Employer
Consultant’s Street Address
City
Consultant’s Telephone Number

State

Zip Code
Ext.

Consultant’s Fax Number
Consultant’s E-mail Address
Re-enter E-mail Address

Block 2 and 3 [Reserved]

Page 2 of 12

FCC Form 471 – October 2014

OMB 3060-0806

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

Total Square
Footage of
library outlet

NCES
or
FSCS
Code

Main
Branch?
(Y/N)

Urban
or
Rural

NIF

SCHOOLS ONLY
State
LEA ID

LIBRARIES ONLY
School
Library
District Billed
Attributes
Entity
Number

State
School
ID

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

Pre-discount
Entity Category
Two Budget

Alternative
Discount?

Student
count
based on
estimate

School
Attributes:

Pre-discount
Entity
Category
Two Budget

Postdiscount
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

Page 3 of 12

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

FCC Form 471 – October 2014

OMB 3060-0806
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. Equipment too costly
2. Installation too costly
3. Broadband connection speed to building is too slow
Page 4 of 12

FCC Form 471 – October 2014

OMB 3060-0806
4. Inadequate local area network (LAN) services/internal networks and wiring
5. Outdated equipment
6. Lack of training and technical support
7. Inconsistent service/frequent outages and down time
8. Physical structure or layout of building(s)
9. Other: 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

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

10

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:
Service Type (check only ONE box )

11

20

Calculations

CATEGORY ONE
Telecommunications
Services

Voice Services

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

Internet Access

CATEGORY TWO
Internal Connections and
Managed Internal Broadband Services

Establishing FCC Form 470 (check only ONE box )

12a

An FCC Form 470 was posted. Provide Application Number below:
________________________________________________

12b

This Funding Request is for an eligible commercially available
business-class Internet access service exempt from the requirement to
post an FCC Form 470.

Recurring Charges

Basic Maintenance of
Internal Connections

12c
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

Page 5 of 12

(A minus B)

FCC Form 471 – October 2014

OMB 3060-0806
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)

15b
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.

F. Annual non-recurring charges

Non-Recurring Charges

15a

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

____________________

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

Restriction that prevents information from becoming public:

16a
16b
17

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

H. Annual eligible pre-discount amount for non-recurring charges

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

(F minus G)

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

Contract Award Date (mm/dd/yyyy)

18
19a

I. Total funding year pre-discount amount (E + H) _______________
Service Start Date (mm/dd/yyyy)

Service End Date (mm/dd/yyyy)

19c

Contract Expiration Date
(mm/dd/yyyy)

19d

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

Total Charges

19b

J. Discount from Block 4 Worksheet
— voice phase out
(if applicable)

If Voice Services: FY 2015—subtract 20%
FY 2016—subtract 40%
K. Funding Commitment Request (I x J)

No

If yes:
Number of possible extensions remaining
_________
Total length of contract if all extensions are exercised: _________

Page 6 of 12

FCC Form 471 – October 2014

OMB 3060-0806

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

FRN ___________________________________

Narrative 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

Item 21b – Internal Connections

Monthly
Recurring
Eligible
Cost

Monthly
Recurring
Ineligible
Cost

Onetime
Eligible
Cost

Onetime Ineligible
Cost

Extended
Line item
Cost

FRN ___________________________________

Narrative Description
of this FRN

Services Requested
FRN Line Item

Type of Internal
Connections
(drop down)

FRN line item
(system generated)

Recipients of Service (Entity Number)

Page 7 of 12

Type of
Product
(drop down)

Quantity and
unit

Make

Model

Lease or
NonPurchase
Arrangement
(Yes/No)

Monthly
Recurring
Eligible Cost

Monthly
Recurring
Ineligible
Cost

One-time
Eligible
Cost

One-time
Ineligible
Cost

Cost-Allocation

FCC Form 471 – October 2014

Extended Eligible Line
Item Cost
(calculated)

OMB 3060-0806
Item 21c –Managed Internal Broadband Services

FRN ___________________________________

Narrative Description
of this FRN

Services Requested
FRN line item
(system generated)

Type of Managed Service
Agreement

Monthly Recurring
Eligible Cost

FRN line item
(system generated)

Recipients of Service (Entity Numbers)

Monthly Recurring
Ineligible Cost

One-time
Eligible Cost

One-time Ineligible
Cost

Extended Eligible Line Item
Cost
(calculated)

Cost-Allocation

Item 21d – Basic Maintenance of Internal Connections

FRN ___________________________________

Narrative Description
of this FRN

Services Requested
FRN line item
(system
generated)

Type of
Internal
Connections
being
maintained
(function drop
down)

FRN line item
(system generated)

Page 8 of 12

Type of
Product being
maintained
(product type
dropdown)

Quantity and
unit

Recipients of Service (Entity Numbers)

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)

Cost-Allocation

FCC Form 471 – October 2014

OMB 3060-0806

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

Page 9 of 12

Entity Number

Total Category Two Pre-discount Request on this
Application

Category Two Pre-discount Budget

Difference

FCC Form 471 – October 2014

OMB 3060-0806

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.)

23

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.

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

Total funding year pre-discount amount on this FCC Form 471
(Add the entries from Items 20I on all Block 5 Discount Funding Requests.)

b

Total funding commitment request amount on this FCC Form 471
(Add the entries from Items 20K on all Block 5 Discount Funding Requests.)

c

Total applicant non-discount share
(Subtract Item 23b from Item 23a.)

d

Total budgeted amount allocated to resources not eligible for E-rate support

e

Total 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

Check 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.

24

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.

25

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.

27

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.

28

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.

29

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.

Page 10 of 12

FCC Form 471 – October 2014

OMB 3060-0806

Entity Number __________________________________ Applicant’s Form Identifier __________________________________
Contact Person __________________________________ Phone Number __________________________________

Block 6: Certification and Signature (Continued)
30

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.

31

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.

32

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.

33

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.

34

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.

35

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

38
39

37

Signature of
authorized
person
Printed name
of authorized
person

Date

Title or position
of authorized
person
Check here if the consultant in Item 6g is the Authorized Person.

40a

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

City

State

Page 11 of 12

Zip Code

FCC Form 471 – October 2014

OMB 3060-0806
Entity Number __________________________________ Applicant’s Form Identifier __________________________________
Contact Person __________________________________ Contact Telephone Number __________________________________

40b
40c

40d

Telephone Number
of Authorized
Person

Ext.

.

Fax Number of Authorized Person

E-mail Address
of Authorized
Person
Re-enter E-mail Address

40e

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 12 of 12

FCC Form 471 – October 2014