FCC Form 486

F CC Form 486 Do Not Write in this Area OMB Control No. DO NOT STAPLE 3060-0853 Estimated time per response: 1.5 hours Schools and Libraries Universal Service Receipt of Service Confirmation and Children’s Internet Protection Act and Technology Plan Certification Form To be completed by the Billed Entity Please read instructions before completing. (You can also file online.)
Applicant’s Form Identifier (Create your own code to identify THIS FCC Form 486)			FCC Form 486 Application#: ______________ (To be assigned by administrator)
Block 1: Billed Entity Information
1. Name of Billed Entity
2.aBilled Entity Number
3. Funding Year July 1, ________ through June 30, __________
4. Complete Mailing Address of Billed Entity Street Address, P.O. Box, or Route Number
City State Zip Code
Telephone Number Extension		Fax Number
5. Contact Person Information Contact Person Name
Street Address, P.O. Box or Route Number
City
State Zip Code
Check the box next to the preferred mode of contact. (At least one box MUST be checked.) Telephone Number Extension Fax Number
E mail Address

DO NOT STAPLE OMB Control No. 3060-0853 Entity Number __________________ Applicant’s Form Identifier ___________________________ Contact Person __________________________________ Phone Number _________________________
Block 2: Early Filing Information and CIPA Waiver Request
6a.	Early Filing
CHECK THE BOX BELOW IF THE FRNS ON THIS FCC FORM 486 ARE FOR SERVICES STARTING ON OR BEFORE JULY 31 OF THE FUNDING YEAR. T he Funding Requests listed in Block 3 have been approved by USAC as shown in my Funding Commitment Decision Letter (FCDL). I have confirmed with the service provider(s) featured in those Funding Requests that these services will start on or before July 31 of the Funding Year. Remember: Early filing using Item 6a is an option if and ONLY if services will start within the month of July of the relevant Funding Year, all relevant certifications in Block 4 can be accurately made, and the FCC Form 486 is postmarked on or before July 31 of the Funding Year.
6b.	CIPA Waiver
CHECK THE BOX BELOW IF YOU ARE REQUESTING A WAIVER OF CIPA REQUIREMENTS FOR THE SECOND FUNDING YEAR IN WHICH YOU HAVE APPLIED FOR DISCOUNTS IF YOU AS THE BILLED ENTITY ARE THE ADMINISTRATIVE AUTHORITY. I am providing notification that, as of the date of the start of discounted services, I am unable to make the certifications required by the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), because my state or local procurement rules or regulations or competitive bidding requirements prevent the making of the certification(s) otherwise required. I certify that the schools or libraries represented in the Funding Request Number(s) on this FCC Form 486 will be brought into compliance with the CIPA requirements before the start of the Third Funding Year in which they apply for discounts. (For Libraries for Funding Year 2004: You may also request this waiver for FY2004 if you as the Billed Entity are the Administrative Authority for the library(ies) represented on this FCC Form 486. By checking this box, you are certifying that the library(ies) represented in the Funding Request Number(s) on this FCC Form 486 will be brought into compliance with the CIPA requirements before the start of Funding Year 2005.)

DO NOT STAPLE OMB Control No. 3060-0853 Entity Number __________________ Applicant’s Form Identifier ___________________________ Contact Person __________________________________ Phone Number _________________________
Block 3: Service Information
7.	Please provide the following information for each FCC Form 471 Block 5 (Discount Funding Request) for which the Billed Entity is indicating that the named service provider may begin submitting invoices to USAC. You will need your FCDL for some of the information required below. Remember: The FRNs listed below must be from the same Funding Year as is listed in Block 1, Item 3. If you need additional pages, please label them 3A, 3B, 3C, etc. and indicate the number in the space provided here: Page 3_____
	(A) FCC Form 471 Application Number From FCDL	(B) Funding Request Number (FRN) From FCDL	(C) Service Provider Identification Number (SPIN) From FCDL	(D) Service Provider Name From FCDL	(E) Funding Year Service Start Date (Earliest Date that Discounted Services Will Begin)
1
2
3
4
5
6
7
8
9
10
11
1 2

DO NOT STAPLE OMB Control No. 3060-0853

Entity Number ________________________ Applicant’s Form Identifier ________________

Contact Person __________________________________ Phone Number _________________________

Block 4:Certifications and Signature

8 . I certify that, if required by program rules, the entity(ies) receiving discounted services as indicated on this FCC Form 486 are covered by technology plan(s) that have been approved by a state or other authorized body (i.e., a USAC-certified technology plan approver) prior to the commencement of service and that cover all 12 months of the funding year. Provide the name(s) of the organization(s) that approved a technology plan for any eligible entity that is receiving services covered under this FCC Form 486 or, if EVERY FRN listed in this FCC Form 486 is for services that do not require a technology plan, enter "NONE" here.

____________________________________________________________________________________________

9 . I certify that the services listed on this FCC Form 486 have been, are planned to be, or are being provided to all or some of the eligible entities identified in the FCC Form 471 application(s) cited above. I certify that there are signed contracts covering all of the services listed on this FCC Form 486 except for those services provided under tariff or on a month-to-month basis. I certify that I am authorized to submit this receipt of service confirmation 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.

1 0. 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 recognize that I may be audited pursuant to this application and will retain for five years (or whatever retention period is required by the rules in effect at the time of this certification) any and all records, including FCC Forms 479 where required, that I rely upon to complete this form and, if audited, will make such records available to the Administrator.

NOTES FOR COMPLETING THE CERTIFICATIONS IN ITEM 11: A Billed Entity who is the Administrative Authority must check Item 11a or 11b or 11c. Check only ONE item. If the Billed Entity is not the Administrative Authority, skip to Item 11d. A Billed Entity who represents one or more Administrative Authorities must check Item 11d or 11e. A Billed Entity who represents one or more Administrative Authorities in Funding Years after Funding Year 2001 and who checks Item 11d must check Item 11f or 11g. See the FCC Form 486 Instructions for Item 11, "Special Notes for Billed Entities Who Represent One or More Administrative Authorities."

IF THIS FORM PERTAINS TO A FUNDING YEAR PRIOR TO FUNDING YEAR 2001 (THE FUNDING YEAR BEGINNING JULY 1, 2001), SKIP TO ITEM 12.

DO NOT STAPLE OMB Control No. 3060-0853

Entity Number ___________________ Applicant’s Form Identifier ______________________________________

Contact Person __________________________________ Phone Number ________________________________

11. FOR A BILLED ENTITY WHO IS THE ADMINISTRATIVE AUTHORITY:

I certify that as of the date of the start of discounted services:

a . the recipient(s) of service represented in the Funding Request Number(s) on this Form 486 has (have) complied with the requirements of the Children's Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l).

b . pursuant to the Children's Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), the recipient(s) of service represented in the Funding Request Number(s) on this Form 486:

(FOR SCHOOLS and FOR LIBRARIES IN THE FIRST FUNDING YEAR FOR PURPOSES OF CIPA) is (are) undertaking such actions, including any necessary procurement procedures, to comply with the requirements of CIPA for the next funding year, but has (have) not completed all requirements of CIPA for this funding year.

(FOR FUNDING YEAR 2003 ONLY: FOR LIBRARIES IN THE SECOND OR THIRD FUNDING YEAR FOR PURPOSES OF CIPA) is (are) in compliance with the requirements of CIPA under 47 U.S.C. § 254(l) and undertaking such actions, including any necessary procurement procedures, to comply with the requirements of CIPA under 47 U.S.C. § 254(h) for the next funding year.

c . the Children's Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), does not apply because the recipient(s) of service represented in the Funding Request Number(s) on this Form 486 is (are) receiving discount services only for telecommunications services.

FOR A BILLED ENTITY WHO REPRESENTS ONE OR MORE ADMINISTRATIVE AUTHORITIES:

d . I certify as the Billed Entity for the consortium that I have collected duly completed and signed FCC Forms 479 from all eligible members of the consortium.

e . I certify as the Billed Entity for the consortium that the only services that have been approved for discounts under the universal service support mechanism on behalf of eligible members of the consortium are telecommunications services, and therefore the requirements of the Children's Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), do not apply.

For Funding Years after Funding Year 2001: If you checked Item 11d above, check ONE of the boxes below:

f. I certify that some or all of the eligible consortium members checked FCC Form 479 Item 6d to seek a CIPA Waiver, and upon request from the Administrator I can provide this information; OR

g . I certify that no eligible consortium members checked FCC Form 479 Item 6d to seek a CIPA Waiver.

The certification language above is not intended to fully set forth or explain all the requirements of the statute.

0 4 8 6 0 1 0 6 0 3

FCC Form 486

DO NOT STAPLE Approval by OMB 3060-0853

Entity Number __________________ Applicant’s Form Identifier _______________________________________

Contact Person __________________________________ Phone Number _________________________________

Persons willfully making false statements on this form can be punished by fine or forfeiture under the Communications Act, 47 U.S.C. Secs. 502, 503(b), or fine or imprisonment under Title 18 of the United States Code, 18 U.S.C. Sec. 1001.

12. Signature of authorized person 13. Date

______________________________________________________________

14. Printed name of authorized person

15. Title or position of authorized person

16a. Street Address, P.O. Box, or Route Number

City

State Zip Code

16b. Telephone number of authorized person Extension 16c. Fax number of authorized person

16d. Email address of authorized person

16e. Name of authorized person’s employer

DO NOT STAPLE Approval by OMB 3060-0853

Entity Number _____________________ Applicant’s Form Identifier _______________________________

Contact Person __________________________________ Phone Number _______________________________

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.

Please submit this form to:

SLD Form 486

PO Box 7026

Lawrence, KS 66044-7026

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

SLD Forms

ATTN: SLD Form 486

3833 Greenway Dr

Lawrence, KS 66046

888-203-8100

Page 2 of 7 FCC Form 486 October 2013