FCC Form 5640 Final Certification and Updates, Section 1.50004(m)

OMB 3060-1270

September 2021

Secure and Trusted Communications Networks Reimbursement Program

FCC Form 5640: Final Certification and Updates, Section 1.50004(m)

Information Submitted Using Online Portal

Estimated Time Per Response: 0.5 hours

(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.)

Item Number	Field(s) Description	Purpose/Instructions
Applicant Information
1	Applicant FCC Registration Number (FRN)	An FRN is a 10-digit number that is assigned by the Commission Registration System (CORES) to a business or individual registering with the FCC. This unique FRN is used to identify the registrant’s business dealings with the FCC. This information will be auto-generated from the information provided in the Application Request for Funding Allocation.
2	Applicant Name	This is the name of the Applicant submitting this request. This information will be auto-generated from the information provided in the Application Request for Funding Allocation.
3	Applicant Information: Applicant Street Name; Applicant City; Applicant State; Applicant Zip Code; Applicant Phone Number; Applicant Email.	This information will be auto-generated from the information provided in the Application Request for Funding Allocation.
Contact Information
4	Contact different than Applicant: Contact Name; Contact Street Name; Contact City; Contact State; Contact Zip Code; Contact Phone #; Contact Email.	These items identify the contact representative, if different from the Applicant. This is usually the headquarters offices of a large company, the law firm or other representative of the Applicant, or the person or company that prepared or submitted the application on behalf of the Applicant. If there is a question about the application, an FCC representative will communicate with the Applicant’s contact representative. This information will be auto-generated from the information provided in the Application Request for Funding Allocation but filer will have the opportunity to change information to designate a different contact for the filing.
5	Contact same as Applicant: Contact Name; Contact Street Name; Contact City; Contact State; Contact Zip Code; Contact Phone #; Contact Email.	These items identify the contact representative. This is usually the headquarters offices of a large company, the law firm or other representative of the Applicant, or the person or company that prepared or submitted the application on behalf of the Applicant. If there is a question about the application, an FCC representative will communicate with the Applicant’s contact representative. This information will be auto-generated from the information provided in the Application Request for Funding Allocation but filer will have the opportunity to change information to designate a different contact for the filing.
Final Certification Selection
6	Indicate whether recipient has (1) fully complied with (or is in the process of complying with) all terms and conditions of the Reimbursement Program and commitments made in the application request for funding; (2) has permanently removed from the communications network of the recipient, replaced, and disposed of (or is in the process of permanently removing, replacing, and disposing of) all covered communications equipment or services that were in the network of the recipient as of the date of the submission of the application request for funding; and (3) has fully complied with (or is in the process of complying with) the timeline submitted by the recipient.	Statutorily required to obtain this information from recipient.
Certifications
7	By checking the box and providing the electronic signature where indicated below, the Certifying Official on behalf of the filer certifies under penalty of perjury that: The Certifying Official is authorized to submit this final certification on behalf of the above-named filer and, based on information known to me or provided to me by employees responsible for the information being submitted, the information set forth in this final certification has been examined and is true, accurate, and complete, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. The Certifying Official acknowledges that any false, fictitious, or fraudulent information or statement, or the omission of any material fact on this final certification or on other documents submitted by filer may subject the filer and the undersigned to punishment by fine or forfeiture under the Communications Act (47 U.S.C. §§ 502, 503(b), 1606), or fine or imprisonment under Title 18 of the United States Code (18 U.S.C. § 1001, §§ 286-287, and § 1343), or can lead to liability under the False Claims Act (31 U.S.C. §§ 3729-3733, and §§ 3801-3812). The filer has been throughout its participation in the Reimbursement Program, and is now in compliance with the statute, rules, and orders governing the Reimbursement Program, including but not limited to allocations, draw downs, payments, obligations and expenditures of money; the Certifying Official acknowledges that failure to be in compliance and remain in compliance with those statute, rules, and orders may result in the recoupment of past disbursements. The Certifying Official acknowledges that failure to comply with the statute, rules, and orders governing the Reimbursement Program could result in civil or criminal prosecution by law enforcement authorities. The filer has fully complied with (or is in the process of complying with) all terms and conditions of the Reimbursement Program. The filer has fully complied with (or is in the process of complying with) the commitments made in the application request for funding allocation, as modified, and reimbursement claim request. The filer has permanently removed from the communications network of the filer, replaced, and disposed of (or is in the process of permanently removing, replacing, and disposing of) all covered communications equipment or services that were in the network of the filer as of the date of the submission of the application request for funding, and the filer has fully complied with (or is in the process of complying with) the timeline submitted by the filer. The amounts claimed for reimbursement were limited to only the portion of the costs that were reasonably incurred for the removal, replacement, and disposal of covered communications equipment and services in accordance with the Secure and Trusted Communications Networks Act of 2019, as amended, Pub. L. 116-124 § 4 (47 U.S.C. § 1603) and the Commission’s rules (47 CFR § 1.50004). The filer did not use Reimbursement Program funds for any portion of expenses that have been or will be reimbursed by other sources of funding (e.g., Federal pandemic relief funding such as the Coronavirus Aid, Relief, and Economic Security (CARES) Act, Emergency Broadband Benefit Program, or other provisions of the American Rescue Plan; targeted state funding; other external sources of targeted funding; or other universal service support mechanisms). The filer recognizes that it may be subject to an audit, inspection or investigation pursuant to its participation in the Reimbursement program, that it will retain for ten years any and all records related to its participation in the program as required by 47 CFR § 1.50004(n), and will make such records and equipment purchased with Reimbursement Program reimbursement available at the request of any representative (including any auditor) appointed by the Administrator, the Commission and its Office of Inspector General, or any local, state, or Federal agency with jurisdiction over the entity. No kickbacks, as defined in 41 U.S.C. § 8701 and/or 42 U.S.C. § 1320a-7b, were paid or received by the filer to anyone in connection with the Reimbursement Program.	Certifications necessary to protect Reimbursement Program against waste, fraud, and abuse.
8	Certifying Official Name	Name of certifying official.
9	Certifying Official Title	Job title of certifying official.
10	Certifying Official Phone Number	Phone number of the certifying official.
11	Certifying Official Email Address	Email address of the certifying official.
12	Certifying Date Signed	The date on which the filing is certified will be auto-generated.

FCC Form 5640/ September 2021