FCC Forms 479, 486 and 500 (state, local or tribal entities)

N on-Public Draft – For Internal Use Only Pending Approval

OMB 3060-0853

Universal Service for Schools and Libraries

Funding Commitment Adjustment Request Form (FCC Form 500)

(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 500. 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
		Applicant Form Identifier (Nickname)	To create a unique identifier for this submission, the applicant simply enters a nickname.
		FCC Form 500 Application Number	(To be assigned by administrator) Auto-generated by the system: This is a USAC-assigned unique identifier for this submission.
1	Applicant Information	Name of Billed Entity	This is the name of the organization submitting this form—school, school district, library (outlet/branch or system) or a consortium of those entities (schools, libraries, or schools and libraries) and will be pre-populated into this submission.
2	Applicant Information	Billed Entity Number	Auto-populated by the system based on the applicant. This is the Unique identifier assigned by USAC to the organization listed in Applicant Name.
2	Applicant Information	FCC Registration Number	Auto-populated by the system based on the applicant. This is the identifier assigned by the FCC associated with the Tax Payer Identification Number for the organization listed in Applicant Name.
3	Applicant Information	Funding Year	Auto- populated by the system based on the funding year of the FRN line item(s) that is being adjusted
4	Applicant Information	Complete Mailing Address of Billed Entity Street Address, P.O. Box or Route Number; City; State; Zip Code	These fields include the complete mailing address for the applicant, it will be pre-populated into this submission.
4	Applicant Information	Telephone Number	This is the main telephone line for the applicant, it will be pre-populated into this submission.
4	Applicant Information	Email Address	E-mail Address of the Contact Person for the applicant, it will be pre-populated into this submission.
5	Applicant Information	Contact Person Information Contact Person Name	Provide the name of the person who should be contacted with questions about this application. This information should have already been entered into the applicant’s profile, it will be pre-populated into this submission.
5	Applicant Information	Contact Person Mailing Address Street Address, P.O. Box or Route Number; City; State; Zip Code	These fields include the complete mailing address of the Contact Person. This information should have already been entered into the applicant’s profile, it will be pre-populated into this submission.
5	Applicant Information	Telephone Number	Telephone Number of the Contact Person. This information should have already been entered into the applicant’s profile, it will be pre-populated into this submission.
5	Applicant Information	Email Address	Email Address of the Contact Person. This information should have already been entered into the applicant’s profile, it will be pre-populated into this submission.
	Type of Adjustment	Type of Adjustment	Choices (choose all that apply; at least one is required): Services Adjustment; Cancellation or Reduction of an FRN; Equipment Transfer Notification
	Service Start Date
6	Services Adjustment Information	Service Start Date FCC Form 471	The system will pre-populate this information based on the FRNs selected by the applicant.
6	Services Adjustment Information	FRN(s)	User will select one or more FRNs on a given FCC Form 471 application that require this change.
6	Services Adjustment Information	Original Service Start Date (mm/dd/yyyy)	System should pre-populate this field with the start based on the FRNs.
6	Services Adjustment Information	New Service Start Date (mm/dd/yyyy)	User will need to fill this out; date field (mm/dd/yyyy)
	Contract Expiration Date
7	Services Adjustment Information	FCC Form 471	The system will pre-populate this information based on the FRNs selected by the applicant.
7	Services Adjustment Information	FRN(s)	User will select one or more FRNs on a given FCC Form 471 application that require this change.
7	Services Adjustment Information	Original Contract Expiration Date (mm/dd/yyyy)	System will pre-populate this field with the Contract Expiration Date as entered on the FRNs.
7	Services Adjustment Information	New Contract Expiration Date (mm/dd/yyyy)	User will need to fill this out; date field (mm/dd/yyyy)
	Service Delivery Extension Request
8	Services Adjustment Information	FCC Form 471	The system will pre-populate this information based on the FRNs selected by the applicant.
8	Services Adjustment Information	FRN	User will select one or more FRNs on a given FCC Form 471 application that require this change.
8	Services Adjustment Information	Non-Recurring Service Delivery Extension: Select if you are requesting an extension of the deadline for delivery and installation of non-recurring services. Certify the reason for the non-recurring service delivery and installation extension request:	Check one that applies: □ The service provider was unable to complete delivery and installation for reasons beyond the service provider’s control. □ The service provider has been unwilling to complete delivery and installation after USAC withheld payment for those services on a properly-submitted invoice for more than 60 days after submission of the invoice.
8	Services Adjustment Information	Extension request reason	User will provide narrative and has option to upload supporting documents. User will have option to input invoice number(s) being held to assist in review for approval.
	Cancel FRN
9	Cancellation of an FRN	FCC Form 471	The system will pre-populate this information based on the FRNs selected by the applicant.
9	Cancellation of an FRN	FRN(s)	User will select one or more FRNs on a given FCC Form 471 application that require this change.
	Reduce FRN
10	Reduction of an FRN	FCC Form 471	The system will pre-populate this information based on the FRNs selected by the applicant.
10	Reduction of an FRN	FRN(s)	User will select one or more FRNs on a given FCC Form 471 application that require this change.
10	Reduction of an FRN	FRN Line #	NEW FIELD; user entered; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	New Number of Lines	NEW Field; user entered
10	Reduction of an FRN	Monthly Quantity	NEW Field; user entered; This would be filled out for reduction for Internal Connections FRNs and Basic Maintenance of Internal Connections FRNs.
10	Reduction of an FRN	Unit	NEW FIELD; user entered; This would be filled out for reduction for Internal Connections FRNs and Basic Maintenance of Internal Connections FRNs.
10	Reduction of an FRN	New Monthly Unit Cost	NEW FIELD; user entered; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	New Monthly Ineligible Cost	NEW FIELD; user entered; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	New Monthly Eligible Cost	NEW FIELD; calculated; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	Pre-discount New Monthly Cost	NEW FIELD; calculated; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	Pre-discount New Monthly Ineligible Cost	NEW FIELD; calculated; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	Pre-discount New Monthly Eligible Cost	NEW FIELD; calculated; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Cancellation or Reduction of an FRN	One time Quantity	NEW Field; user entered; This would be filled out for reduction for Internal Connections FRNs and Basic Maintenance of Internal Connections FRNs.
10	Reduction of an FRN	Pre-discount New One-time Unit Cost	NEW FIELD; user entered; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	Pre-discount New One-time Unit Ineligible Cost	NEW FIELD; user entered; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	Pre-discount New One-time Unit Eligible Cost	NEW FIELD; user entered; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	Pre-discount New One-time Cost	NEW FIELD; calculated; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	Pre-discount New One-time Ineligible Cost	NEW FIELD; calculated; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	Pre-discount New One-time Eligible Cost	NEW FIELD; calculated; This would be filled out for reduction for Category One FRNs, Internal Connections FRNs, Basic Maintenance of Internal Connections FRNs, and Managed Internal Broadband Service FRNs.
10	Reduction of an FRN	Entity Number	NEW FIELD; user entered; This field is required if the Category One modification includes # of Lines per Entity for a Last Mile Connection, if it is an Internal Connection modification, if it’s a Basic Maintenance of Internal Connection modification, and if it is a Managed Internal Broadband Services modification.
10	Reduction of an FRN	New Number of Lines per Entity	NEW FIELD; user entered; This field is required if the modification includes # of Lines per Entity for a Last Mile Connection.
10	Reduction of an FRN	New Eligible Cost per Entity	NEW FIELD; user entered; This field is required if it is an Internal Connection modification, if it’s a Basic Maintenance of Internal Connection modification, and if it is a Managed Internal Broadband Services modification.
10	Reduction of an FRN	Original Commitment Amount from FCDL	Prepopulated from FCDL for the FRN chosen above.
10	Reduction of an FRN	New Commitment Amount AFTER Reduction	If not auto-populated, user will need to provide.
	Equipment Transfer
11	Equipment Transfer Notification	FCC Form 471	The system will pre-populate this information based on the FRNs selected by the applicant.
11	Equipment Transfer Notification	FRN	User will select one or more FRNs on a given FCC Form 471 application that require this change.
11	Equipment Transfer Notification	Closed Entity Number	Choose from a list of related entities for this entity. System-populated dropdown list; choose only 1
11	Equipment Transfer Notification	Closed Entity Name	System populated based on the Entity Number chosen above
11	Equipment Transfer Notification	Purchase Date	User must enter information
11	Equipment Transfer Notification	Transfer Date	User must enter information
11	Equipment Transfer Notification	Transfer Reason	User must enter information
11	Equipment Transfer Notification	Transfer Temporary?	Yes/No field if the transfer of equipment is temporary
11	Equipment Transfer Notification	Project Return Date	If the transfer is temporary, a project return date is required.
11	Equipment Transfer Notification	Entities Receiving Equipment Entity Number	Choose from list of related entity numbers for this entity; be able to choose multiple
11	Equipment Transfer Notification	Entity Name	Name should populate once an entity number is chosen from above
11	Equipment Transfer Notification	Equipment Received Equipment Name	System Pre-Populated list based on the 471 and FRN’s chosen
11	Equipment Transfer Notification	Equipment Make	System Pre-Populated list based on the 471 and FRN’s chosen
11	Equipment Transfer Notification	Equipment Model	System Pre-Populated list based on the 471 and FRN’s chosen
12	Certification		I certify that I am authorized to submit this form 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.
13	Certification		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.
14	Certification		I will retain for at least 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 (1) any and all records that I rely upon to complete this form and (2) all documents necessary to demonstrate compliance with the statutory or regulatory requirements for the schools and libraries universal service support program. I recognize that I may be audited pursuant to this application and the applicant must produce such records as required by 47 C.F.R. § 54.516.
15	Certification	Signature of Authorized Person	The form must be certified electronically with the authorized person’s applicant name and password.
16	Certification	Date of Certification	Auto generated by system.
17	Certification	Name of Person Certifying	This is the name of the authorized person signing the form. This will be prepopulated based on the profile of the applicant signing the form electronically.
18	Certification	Position of Person Certifying	This is the position of the authorized person signing the form. This will be prepopulated based on the profile of the applicant signing the form electronically.
19	Certification	Telephone Number of Person Certifying	This is the telephone number of the authorized person signing the form. This will be prepopulated based on the profile of the applicant signing the form electronically.
20	Certification	Email Address of Person Certifying	This is the email address of the authorized person signing the form. This will be prepopulated based on the profile of the applicant signing the form electronically.
21	Certification	Address of Person Certifying	This is the address of the authorized person signing the form. This will be prepopulated based on the profile of the applicant signing the form electronically.
22	Certification	Name of Employer of Person Certifying	This is the employer of the authorized person signing the form. This will be prepopulated based on the profile of the applicant signing the form electronically.

6