Business or other for-profit

OMB 3060-xxxx

May 2021

Emergency Connectivity Fund Program

Post-Commitment Change Request (using FCC Form 471 and FCC Form 500 information collection requirements approved pursuant to OMB Control Nos. 3060-0806 and 3060-0853)

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, the order in which they will see information, or the exact wording or directions used to collect the information. Where possible, information already pre-filed in the system portal will be carried forward and auto-generated into the form.

Item #	Field Description	Purpose/Instructions
1	Applicant’s Nickname	Optional. To create a unique identifier for this request, the user simply enters a nickname (e.g., 2016 Funding Year ABC School FCC Form 471).
2	Applicant Name	Auto-generated by the system: This is the name of the applicant submitting the FCC Form 471.
3	Entity Number	Auto-generated by the system: This is the unique Universal Service Administrative Company (USAC) assigned identifier for BEN name.
4	BEN Contact Information	Auto-generated by the system: This is the BEN’s physical address, county, city, state, zip code, telephone, email address, website, and geolocation provided on the FCC Form 471
5	Consortium Name	Auto-generated by the system: This is the name the consortium submitting the FCC Form 471.
6	Consortium Contact Information	Auto-generated by the system: This is the consortium’s address, county, city, state, zip code, telephone, email address, website, contact name, contact employer and geolocation provided on the FCC Form 471.
7	FCC Registration Number	Auto-populated by the system: This is either the consortium or the applicant’s unique FCC registration number (FCC RN) submitted via the FCC Form 471.
8	Funding Year	Auto-populated by the system based on the funding year of the FRN line item(s) that are being adjusted.
9	Contact Person Name	The user must provide the name of the person who should be contacted with questions about this request. This could be the Primary Contact, Additional Contact(s) or another person qualified to answer questions relating to the request.
10	Contact Person Title	The user must provide the title of the person who should be contacted with questions about this request.
11	Contact Person Mailing Address	The user must provide the mailing address of the person who should be contacted with questions about this request.
12	Contact Person Telephone Number	The user must provide the telephone number of the person who should be contacted with questions about this request.
13	Contact Person Email Address	The user must provide the email address of the person who should be contacted with questions about this request.
14	Contact Person Fax Number	The user must provide the fax number of the person who should be contacted with questions about this request.
15	Type of Post-Commitment Request	Choices (choose all that apply; at least one is required): Service & Site Substitution; Service Provider Identification Number (SPIN) or Service Provider Change; Cancel Funding Request Number (FRN(s)); or Reduce Commitment Amount for FRN(s).
Site and Service Substitution
16	FRN Information	The applicant will select one or more line item(s) on a given FCC Form 471 application that requires this change.
17	FCC Form 471	The system will pre-populate this information based on the Funding Request Numbers (FRNs) selected by the applicant.
18	Site & Service Substitution Requirements	Applicants must meet the following requirements: The substitution is provided for in the contract, within the change clause, or constitutes a minor modification; The substitution does not violate any contract provision or local, state, or Tribal procurement laws; and Support is restricted to qualifying site and service substitutions that do not increase the total amount of support under the applicable funding commitment.
19	Site & Service Substitution Reason	The applicant will provide narrative of the substitution request and has option to upload supporting documents. The narrative should provide a brief explanation regarding the necessity of the change and why the request complies with the Site & Service Substitution Requirements.
SPIN or Service Provider Change
20	Service Provider Change Type	Select if you are requesting a service provider change. Check one that applies: □ Corrective service provider change: Correcting data entry errors; Updating a SPIN that has changed due to the merger of companies or the acquisition of one company by another; or Effectuating a change that was not initiated by the applicant. □ Operational SPIN change: The applicant has a legitimate reason to change services providers (e.g., breach of contract or the service provider is unable to perform).
21	Old Service Provider Information	The system will pre-populate this information based on the FRN(s) selected by the applicant.
22	New Service Provider Information	The applicant will provide information for the new service provider. Name and address will need to be provided if the service provider does not have a SPIN. If the service provider has a SPIN, the applicant will enter the SPIN and the system will pre-populate the contact information for the service provider.
23	SPIN Change Reason	The applicant will provide narrative for such change and has option to upload supporting documents.
Request to Cancel FRN(s)
24	FRN Information	The applicant will select one or more FRNs that it would like to be cancelled. This action is irrevocable and the FRN or FRNS cannot be reinstated later. This action will allow the requested funding to be returned to the Emergency Connectivity Fund Program for possible commitments to other applicants.
25	FCC Form 471	The system will pre-populate this information based on the FRNs selected by the applicant.
Request to Reduce Commitments for FRN(s)
26	FRN Information	The applicant will select one or more FRNs where it would like the amount of funding committed to be reduced.
27	FCC Form 471	The system will pre-populate this information based on the FRNs selected by the applicant.
FRN Information
28	Type of Service	The system will pre-populate this information based on the FRNs selected by the applicant.
29	Monthly Recurring Unit Cost	If there is a change in the monthly recurring unit cost, provide the updated cost.
30	Monthly Quantity	If there is a change in the monthly quantity, provide the updated monthly quantity.
31	Months of Service	If there is a change in the number of months of service, provide the updated number of months of service. t
32	Service Start Date	If the original service start date was delayed, please enter the actual start date here.
33	Service End/Termination Date	If the service was ended or terminated earlier than the original service end/termination date, please enter the actual end or termination date here.
34	Total Recurring Cost	The system will calculate the updated Total Recurring Cost based on the changes that were made.
35	One-Time Cost	If there is change in the one-time cost, provide the updated cost.
36	One-Time Quantity	If there was a change on the one-time quantity, provide the updated quantity amount.
37	Total One Time Cost	The system will calculate and display the updated total cost for updated non-recurring cost.
38	Type of Product/Make /Model	If the type of product, make or model changed, provide the updated type of product, make and model.
39	One-Time Cost	If the one-time coat has changed, provide the updated one-time cost.
40	One-Time Quantity	If the one-time quantity amount has changed, provide the updated one-time quantity amount.
41	One-Time Total Cost	The system will calculate and display the updated total undiscounted cost for eligible non-recurring cost.
Certifications
42	I certify under penalty of perjury that I am authorized to submit this application on behalf of the above-named applicant and that based on information known to me or provided to me by employees responsible for this data being submitted, I hereby certify that the data set forth in the application has been examined and is true, accurate, and complete. I acknowledge that any false statement on this application or on any other documents submitted by the applicant 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 representative of the applicant must provide this certification.
43	By signing this application, I certify that the information contained in this application is true, complete, and accurate, and the projected 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).	The authorized representative of the applicant must provide this certification.
44	The applicant recognizes that it may be audited pursuant to its application, that it will retain for [ten] years any and all records related to its application, and that, if audited, it shall produce shall records 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.	The authorized representative of the applicant must provide this certification.
45	Signature	The authorized representative of the applicant is required to provide all required certifications and signatures The Post-Commitment Change Request must be certified electronically.
46	Date Submitted	Auto generated by system.
47	Date Signed	Auto generated by system.
48	Authorized Person Name	This is the name of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant. This field will be auto-populated if the name of the Authorized Person is already within the system.
49	Authorized Person’s Employer	This is the name of the employer of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant. This field will be auto-populated if already within the system.
50	Authorized Person’s Employer FCC RN	This is the FCC RN of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant. This field will be auto-populated if already within the system.
51	Authorized Person’s Title/Position	This is the title of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant. This field will be auto-populated if already within the system.
52	Authorized Person’s Mailing Address	This is the address (can be physical address or mailing address) of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant. This field will be auto-populated if already within the system.
53	Authorized Person Telephone Number	This is the telephone number of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant. This field will be auto-populated if already within the system.
54	Authorized Person Email Address	This is the email address of the Authorized Person certifying the Post-Commitment Request Form on behalf of the applicant. This field will be auto-populated if already within the system.

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