FCC Forms 479, 486 and 500 (business entities)

N on-Public – For Internal Use Only Pending Approval by OMB

3060-0853

Schools and Libraries Universal Service

Receipt of Service Confirmation and Children’s Internet Protection Certification Form (FCC Form 486)

[Applicable to Funding Years 2016 and Later]

(Note: This is a representative description of the information to be collected in USAC’s online portal for the E-rate program. This table is not a visual representation of exactly what applicants will see when they use the online version of the FCC Form 486. Where possible, information already provided by applicants in the system portal will be auto-populated into this form. The language below is not intended to fully set forth or explain all the requirements of the Communications Act.)

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT

Part 54 of the Federal Communications Commission’s (FCC) rules authorize the FCC to collect the information requested in this form. Responses to the questions herein are required to obtain the benefits sought by this application. Failure to provide all requested information will delay processing or result in the form being returned without action. Information requested by this form will be available for public inspection. The information provided will be used to determine whether approving this request is in the public interest. We have estimated that each response to this collection of information will take 1 hour. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Paperwork Reduction Project (3060-0853), Washington, DC 20554. We will also accept your comments via the Internet if you send them to [email protected]. Please DO NOT SEND COMPLETED APPLICATIONS 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 PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. 3507

#	Section	Field Description	Purpose/Instructions
		Form Nickname	Create an identifier for your own reference. User entered.
		FCC Form 486 Application #	Auto-generated by the system: This is a USAC-assigned unique identifier for this submission.
1	Billed Entity Information	Name of Billed Entity	System will auto-populate based on the user’s profile.
2	Billed Entity Information	Billed Entity Number	System will auto-populate based on the user’s profile.
	Billed Entity Information	FCC Registration Number	Auto-populated by the system.
3	Billed Entity Information	Funding Year	System should auto-populate based on the present funding year when the form is completed.
4	Billed Entity Information	Complete Mailing Address of Billed Entity Street Address, P.O. Box or Route Number, City State, Zip Code	System will auto-populate based on the user’s profile.
4	Billed Entity Information	Telephone Number	System will auto-populate based on the user’s profile.
5	Billed Entity Information	Contact Person Information Contact Person Name	System will auto-populate based on the user logged into the system or allow them to change to another user in their organization.
5	Billed Entity Information	Contact Person’s Street Address, P.O. Box or Route Number, City, State, Zip Code	System will auto-populate based on the user’s profile.
5	Billed Entity Information	Telephone Number	System will auto-populate based on the user’s profile.
5	Billed Entity Information	Email Address	System will auto-populate based on the user’s profile.
6a.	Early Filing Information and CIPA Waiver Request	Early Filing	Applicants will check this box if the funding requests on this Form 486 are for services starting on or before July 31 of the funding year. Checking this box confirms the following: “The Funding Requests listed in the Service Information section of this form have been approved by USAC as showing 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.” (This is only an option if services will start within the month of July of the relevant Funding Year, all relevant certifications in the Certifications and Signatures section can be accurately made, and the FCC Form 486 is postmarked on or before July 31 of the Funding Year.)
6b.	Early Filing Information and CIPA Waiver Request	CIPA Waiver – Second Funding Year	Applicants will check this box to request a waiver of Children’s Internet Protection Act (CIPA) requirements for the Second Funding Year in which they have applied for discounts as the administrative authority for the billed entity. Checking this box confirms and certifies the following: (check box) CHECK THE BOX BELOW IF YOU ARE REQUSTING 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 (I), 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 can 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).
7	Service Information	Service Start Dates	System will auto-populate based on the commitments made in the Funding Commitment Decision Letter associated with the Billed Entity. System will provide the following information for each FCC Form 471 funding request: (1) FCC Form 471 Application Number; (2) Funding Request Number (system will allow the user to select from a list of FRNs that are associated with that Billed Entity); (3) Service Provider Identification Number (SPIN); (3) Service Provider Name. The applicant will indicate, by checking off, the funding requests for which the billed entity or the named service provider may begin submitting invoices to USAC. The Funding Year Service Start Date for each funding request will default to July 1 of the current funding year but applicants will have the option to manually enter a different date if needed.
9	Certifications and Signatures	Receipt of Service Certification	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.
10	Certifications and Signature	Shared Discounts/ Audits	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 acknowledge that I may be audited pursuant to this application and will retain for ten years (or whatever retention period is required by the rules in effect at the time of this certification) after the later of the last day of the applicable funding year or the service delivery deadline for the funding request 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.
11	Certifications and Signatures	Children’s Internet Protection Act – Billed Entity Who is the Administrative Authority	The Billed Entity who is the Administrative Authority must certify by checking off ONE of the following certifications: “I certify that as the date of the start of discounted services 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 (I).” [ONLY APPLICABLE TO SCHOOLS and LIBRARIES IN THE FIRST FUNDING YEAR FOR PURPOSES OF CIPA] “I certify that as the date of the start of discounted services, pursuant to the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (I), the recipient(s) of service represented in the Funding Request Number(s) on this Form 486 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.” “I certify that as the date of the start of discounted services the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (I), 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.”
12	Certifications and Signature	Children’s Internet Protection Act – Billed Entity Who Represents One or More Administrative Authorities	The Billed Entity who represents one or more Administrative Authorities must check off the certifications that apply: “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.” “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 telecommunication services, and therefore, the requirements of the Children’s Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (I), do not apply.”
11	Certifications and Signatures	Children’s Internet Protection Act – Billed Entity Who Represents One or More Administrative Authorities - CIPA Waivers	If the Billed Entity who represents one or more the Administrative Authorities certified that it collected duly completed and signed FCC Forms 479 from all eligible members of the consortium above, it needs to certify to only one of the following: “I certify that some or all of the eligible consortium members checked the applicable box on the FCC Form 479 to seek a CIPA Waiver, and upon request from the Administrator I can provide this information.” “I certify that no eligible consortium members checked the applicable box on the FCC Form 479 to seek a CIPA Waiver.”
12	Certifications and Signature	Signature of authorized person	System will auto-populate based on the profile of the user who is certifying the form. [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].
13	Certifications and Signature	Date	Date and Time field; system provided as time that certify button is pushed
14	Certifications and Signature	Printed Name of authorized person	System provided from user profile of certifying person’s account
15	Certifications and Signature	Title or position of authorized person	System provided from user profile of certifying person’s account
16a	Certifications and Signature	Street Address, P.O. Box or Route Number of authorized person including City, State, Zip Code	System will auto-populate based on the profile of the user who is certifying the form.
16b	Certifications and Signature	Telephone number of authorized person	System will auto-populate based on the profile of the user who is certifying the form.
16c	Certifications and Signature	Email address of authorized person	System will auto-populate based on the profile of the user who is certifying the form.
16d	Certifications and Signature	Name of authorized person’s employer	System will auto-populate based on the profile of the user who is certifying the form.

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