Business or other for-profit

OMB Control No. 3060-xxxx

May 2021

Emergency Connectivity Fund Program

Emergency Connectivity Fund Program Request for Reimbursement (using FCC Form 472 and FCC Form 474 information collection requirements approved pursuant to OMB Control No. 3060-0856)

(Note: This is a representative description of the information to be collected via the online portal and is not intended to be a visual representation of what each applicant will see. Where possible, information already pre-filed in the system portal can be carried forward and auto-populated into the form. Also, where the system has the input to automatically generate calculations and other information for the form, it will provide that information).

Item Number	Field Description	Purpose/Instructions
1	Obligation Number	This is included in the purchase order that is integrated into the system and will include the FCC Form 471 Number.
2	Applicant Name	This will be pre-populated.
3	BEN Number	This will be pre-populated.
4	Service Provider Name	This is the name of the service provider providing the equipment or services. This will be pre-populated.
5	Total Reimbursement Request	The system will populate the total committed for this purchase order.
6	FCC Form 471 Application Number	This is the number that is assigned to the form when the FCC Form 471 was submitted.
7	Funding Request Number (FRN)	This is the number that is assigned to the funding request on the FCC Form 471. This will appear in the system.
8	Billing Frequency/Monthly Quantity	This field captures whether it is a monthly, quarterly, or one-time billing.
9	Customer Billed Date/Delivery Date	Use this field for providing date of customer bill for monthly recurring services or delivery date for one-time charge for equipment or other non-recurring costs.
10	Total Amount for Committed Equipment or Services	Enter the total amount for equipment or services that are being invoiced.
11	Required documentation for the request for reimbursement.	Applicants and service providers will be required to upload invoices and/or customer bills to support the Emergency Connectivity Fund request for reimbursements. Applicants who certify that they will pay their service provider(s) within 30 days of receipt of funds will also be required to upload payment verification documentation to demonstrate that the applicant paid their service provider(s) within 30 days of receipt of funds.
For applicants, the following certification will be required:
12	I am authorized to submit this request for reimbursement on behalf of the above-named school, library or consortium and that based on information known to me or provided to me by employees responsible for the data being submitted, I hereby certify that the data set forth in this request for reimbursement has been examined and is true, accurate and complete. I acknowledge that any false statement on this request for reimbursement or on other documents submitted by this school, library or consortium 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), or can lead to liability under the False Claims Act (31 U.S.C. §§ 3729 – 3733).	The authorized person will be required to make the following certifications to be able to submit the request for reimbursement. The certifications are necessary to ensure the applicant is compliant with the Emergency Connectivity Fund Program rules and to protect the Program from waste, fraud, and abuse.
13	In addition to the foregoing, the school, library or consortium is in compliance with the rules and orders governing the Emergency Connectivity Fund 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 funding, cancellation of funding commitments, and/or recoupment of past disbursements. I acknowledge that failure to comply with the rules and orders governing the Emergency Connectivity Fund Program could result in civil or criminal prosecution by law enforcement authorities.	See number 12.
14	By signing this request for reimbursement, I certify that the information contained in this request for reimbursement is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, sections 1001, 286-287 and 1341 and Title 31, sections 3729–3730 and 3801–3812).	See number 12.
15	The funds sought in the request for reimbursement are for eligible equipment and/or services that were purchased or ordered in accordance with the Emergency Connectivity Fund Program rules and requirements and received by either the school, library, or consortium, or the students, school staff, or library patrons as appropriate.	See number 12.
16	The portion of the costs eligible for reimbursement and not already paid for by another source was either: paid for in full; or will be paid to the service provider within 30 days of receipt of funds by the school, library, or consortium.	See number 12.
17	The amount for which the school, library, or consortium is seeking reimbursement from the Emergency Connectivity Fund consistent with the requirements set out in § 54.1707.	See number 12.
18	The school, library, or consortium is not seeking Emergency Connectivity Fund reimbursement for eligible equipment and/or services that have been purchased and reimbursed in full with other pandemic relief federal funding (e.g., CARES Act, Emergency Broadband Benefit Program or other provisions of the American Rescue Plan), targeted state funding, other external sources of targeted funding, or targeted gifts or eligible for discounts from the schools and libraries universal service support mechanism or other universal service support mechanism.	See number 12.
19	The equipment and services the school, library, or consortium purchased using Emergency Connectivity Fund support will be used primarily for educational purposes as defined in § 54.1700 and that the authorized person is not willfully or knowingly requesting reimbursement for equipment or services that are not being used.	See number 12.
20	The equipment and services the school, library, or consortium purchased will not be sold, resold, or transferred in consideration for money or any other thing of value, except as allowed by § 54.1713.	See number 12.
21	The school, library, or consortium recognizes that it may be subject to an audit, inspection or investigation pursuant to its request for reimbursement, that it will retain for ten years any and all records related to its request for reimbursement, and will make such records and equipment purchased with Emergency Connectivity Fund reimbursement available at the request of any representative (including any auditor) appointed by a state education department, the Administrator, the Commission and its Office of Inspector General, or any local, state or federal agency with jurisdiction over the entity.	See number 12.
22	No kickbacks, as defined in 41 U.S.C. § 8701 and/or 42 U.S.C. § 1320a-7b, were paid or received by the applicant to anyone in connection with the Emergency Connectivity Fund.	See number 12.
23	I certify that no Federal subsidy made available through a program administered by the Commission that provides funds to be used for the capital expenditures necessary for the provision of advanced communications services has been or will be used to purchase, rent, lease, or otherwise obtain, any covered communications equipment or service, or maintain any covered communications equipment or service previously purchased, rented, leased, or otherwise obtained, as required by 47 C.F.R. § 54.10.	See number 12.
For service providers, the following certifications will be required:
24	I am authorized to submit this request for reimbursement on behalf of the above-named service provider and that based on information known to me or provided to me by employees responsible for the data being submitted, I hereby certify that the data set forth in this request for reimbursement has been examined and is true, accurate and complete. I acknowledge that any false statement on this request for reimbursement or on other documents submitted by this school, library or consortium 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), or can lead to liability under the False Claims Act (31 U.S.C. §§ 3729 – 3733).	The authorized person will be required to make the following certifications to be able to submit the request for reimbursement. The certifications are necessary to ensure the service provider is compliant with the Emergency Connectivity Fund Program rules and to protect the Program from waste, fraud, and abuse.
25	In addition to the foregoing, the service provider is in compliance with the rules and orders governing the Emergency Connectivity Fund 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 funding, cancellation of funding commitments, and/or recoupment of past disbursements. I acknowledge that failure to comply with the rules and orders governing the Emergency Connectivity Fund Program could result in civil or criminal prosecution by law enforcement authorities.	See number 24.
26	By signing this request for reimbursement, I certify that the information contained in this request for reimbursement is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, sections 1001, 286-287 and 1341 and Title 31, sections 3729–3730 and 3801–3812).	See number 24.
27	The funds sought in the request for reimbursement are for eligible equipment and/or services that were purchased or ordered in accordance with the Emergency Connectivity Fund Program rules and requirements and received by either the school, library, or consortium, or the students, school staff, or library patrons as appropriate.	See number 24.
28	The amount for which service provider is seeking reimbursement from the Emergency Connectivity Fund consistent with the requirements set out in § 54.1707.	See number 24.
29	The service provider is not willfully or knowingly requesting reimbursement for equipment or services that are not being used.	See number 24.
30	The service provider is not seeking Emergency Connectivity Fund reimbursement for eligible equipment and/or services for which it has already been paid.	See number 24.
31	The service provider recognizes that it may be subject to an audit, inspection or investigation pursuant to its request for reimbursement, that it will retain for ten years any and all records related to its request for reimbursement, and will make such records and equipment purchased with Emergency Connectivity Fund reimbursement available at the request of any representative (including any auditor) appointed by a state education department, the Administrator, the Commission and its Office of Inspector General, or any local, state or federal agency with jurisdiction over the entity.	See number 24.
32	No kickbacks, as defined in 41 U.S.C. § 8701 and/or 42 U.S.C. § 1320a-7b, were paid or received by the applicant to anyone in connection with the Emergency Connectivity Fund.	See number 24.
33	I certify that no Federal subsidy made available through a program administered by the Commission that provides funds to be used for the capital expenditures necessary for the provision of advanced communications services has been or will be used to purchase, rent, lease, or otherwise obtain, any covered communications equipment or service, or maintain any covered communications equipment or service previously purchased, rented, leased, or otherwise obtained, as required by 47 C.F.R. § 54.10.	See number 24.
34	Signature of Authorized Person	The form must be signed by an authorized person.
35	Date Signed	Auto generated by system.
36	Name of Authorized Person	This is the name of the authorized person signing the form.
37	Title or Position of Authorized Person	This is the title of the authorized person signing the form.
38	Physical or mailing address of Authorized Person	This is the address (can be physical address or mailing address) of the authorized person signing the form.
39	Telephone Number of Authorized Person	This is the telephone number of the authorized person signing the form.
40	Email address of Authorized Person	This is the email address of the authorized person signing the form.
41	Name of Authorized Person’s Employer	This is the name of the employer of the authorized person signing the form.

10