FCC Form 474 Service Provider Invoice Form

FCC Form 474

FCC Form 474 Table

OMB Control No. 3060-0856

Schools and Libraries Universal Service

Service Provider Invoice Form 474

(Note: This is a representative description of the information to be collected electronically. This table is not a visual representation of what service providers will see when they use the online FCC Form 474).

Form 474 Service Provider Invoice FCC Form 474	Field	Rules
Service Provider Form Identifier (Create an identifier for your own reference)		Must be entered using alphanumeric characters; if the form is converted to a printable format, this information will populate on each page of the form.
FCC Form 474 Invoice# (To be inserted by Administrator)		Automatically populates from system once form is saved or completed
BLOCK 1: Service Provider Information
Service Provider Name	1	Must be entered using alphanumeric characters
Service Provider Identification Number (SPIN)	2	Must be entered using a valid nine digit SPIN number (1430XXXX); if the form is converted to a printable format, this information will populate on each page of the form.
Contact Person's Name	3	Must be entered using alphabetic characters; if the form is converted to a printable format, this information will populate on each page of the form.
Contact Telephone Number	4	Must be 10 digits (xxx-xxx-xxxx); if the form is converted to a printable format, this information will populate on each page of the form.
Contact Fax Number		Must be 10 digits (xxx-xxx-xxxx)
Ext.		Must be entered using numeric characters
Contact Email Address		Valid email address must be entered. Email must be composed of a username and domain name ([email protected])
Total Invoice Amount	5	System populated this field based numeric data entered into Block 2
BLOCK 2: Funding Request Number Information
FCC Form 471 Application Number (from Funding Commitment Decision Letter)	6	Must be entered using valid six digit application number
Funding Request Number (FRN) (FRN from funding Commitment Decision Letter)	7	Must be entered using valid seven digit Fund Request Number. A new line will be added for each FRN.
Bill Frequency (e.g., Monthly, Quarterly, Annually, One-time, Other)	8	Must be chosen from drop down menu
Customer Billed Date (mm/yyyy)	9	Must be entered in valid date format (MM/DD/YYYY). This field will be visible for reimbursement requests for FRNs for recurring services or multiple installments of non-recurring services.
Shipping Date to Customer or Last Day of Work Performed (mm/yyyy)	10	Must be entered in valid date format (MM/DD/YYYY). This field will be visible for reimbursement requests for FRNs for non-recurring services (such as Internal Connections).
Total (Undiscounted) Amount for Service	11	Must be entered in numeric characters
Discount Rate	12	Populates once FRN data has been entered
Amount Billed to USAC	13	Populates once numeric data has been entered
TOTAL REIMBURSEMENT AMOUNT		Populates once numeric data has been entered
Block 3: Service Provider Certifications & Signature
Signature of authorized person	14	Check box to sign electronically
Date	15	Populates once the Service Provider checks the signature box. This becomes the "Submitted to SLD on" date
Printed name of authorized person	16	Populates based on Service Provider login credentials
Title or position of authorized person	17	Populates based on Service Provider login credentials (alphanumeric data may be edited using correct format)
Telephone number of authorized person	18	Populates based on Service Provider login credentials (alphanumeric data may be edited using correct format)
Address of authorized person	19	Populates based on Service Provider login credentials (alphanumeric data may be edited using correct format)
CERTIFICATIONS: 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.