FCC Form 472 and F Request for Reimbursement

OMB Control No. 3060-xxxx Estimated Time per Response

Month 2023 1.75 hours

Not Yet Approved by OMB

Schools and Libraries Cybersecurity Pilot Program

Request for Reimbursement (using FCC Form 472 and FCC Form 474, and ECF FCC Form 472 and ECF FCC Form 474 information collection requirements approved pursuant to OMB Control Nos. 3060-0856 and 3060-1286)

(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 or service provider 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	Billed Entity Name	Name of the entity that pays the Service Provider for the equipment and/or services. This will be pre-populated.
2	Billed Entity Number (BEN)	The Administrator assigns a billed entity number (BEN) to the entity who pays the Service Provider for equipment and/or services delivered to eligible schools and libraries. This will be pre-populated.
3	Service Provider Name	This is the name of the Service Provider providing the cybersecurity equipment or services. This will be pre-populated.
4	Service Provider Identification Number (SPIN)	The Administrator assigned a unique identifier to the Service Provider. Will be pre-populated.
5	Applicant FCC Form 498 ID Number	The FCC Form 498 is used to collect remittance, payment, and contact information for service providers and applicants that will be receiving direct payments. This is the unique identifier assigned to the applicant who will be submitting the request for reimbursement. Will be pre-populated.
6	Total Reimbursement Request	The system will populate the total amount available for this funding request.
7	FCC Form 471 Application Number	This is the number that was assigned to the FCC Form 471 when it was submitted.
8	Funding Request Number (FRN)	This is the number that was assigned to the specific FRN on the FCC Form 471. This will be pre-populated.
9	Billing Frequency/Monthly Quantity	This field captures whether the invoice is for a monthly, quarterly, or one-time billing.
10	Customer Billed Date/Delivery Date	Use this field to provide the date of the customer bill for monthly recurring cybersecurity services or the delivery date for a one-time charge for cybersecurity equipment or other non-recurring cybersecurity costs.
11	Total Undiscounted Amount for Equipment or Service	Enter total amount for the cybersecurity equipment or services that are being invoiced.
12	Discount Rate	This is the applicant’s calculated discount rate. Will be pre-populated.
13	Total Amount Being Invoiced to the Cybersecurity Pilot Program.	Will be system generated based on line items 11 and 12.
14	Required documentation for the request for reimbursement.	Applicants selected to participate in, or Service Providers seeking reimbursement from, the Schools and Libraries Cybersecurity Pilot Program must submit invoices to the Administrator detailing the cybersecurity equipment and services purchased when they submit their FCC Form 472 or FCC Form 474.
For Applicants, the following certifications will be required:
15	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 Schools and Libraries Cybersecurity Pilot Program rules and to protect the Program from waste, fraud, and abuse.
16	In addition to the foregoing, the school, library, or consortium is in compliance with the rules and orders governing the Schools and Libraries Cybersecurity Pilot 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 Schools and Libraries Cybersecurity Pilot Program could result in civil or criminal prosecution by law enforcement authorities.	See number 15.
17	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 15.
18	The funds sought in the request for reimbursement are for eligible services and/or equipment that were purchased in accordance with the Schools and Libraries Cybersecurity Pilot Program rules and requirements in this subpart and received by the school, library, or consortium. The equipment and/or services being requested for reimbursement were determined to be eligible and approved by the Administrator.	See number 15.
19	The non-discounted share of costs amount(s) were billed by the Service Provider and paid for by the Billed Entity Applicant on behalf of the eligible schools, libraries, and consortia of those entities.	See number 15.
20	The school, library, or consortium is not seeking Schools and Libraries Cybersecurity Pilot Program reimbursement for eligible services and/or equipment that have been purchased and reimbursed in full with other federal, targeted state funding, other external sources of targeted funding, or targeted gifts or are eligible for discounts from the schools and libraries universal service support mechanism or other universal service support mechanisms.	See number 15.
21	The school, library, or consortium acknowledges that it must submit invoices detailing the items purchased along with the submission of its request for reimbursement as required by § 54.2008(b).	See number 15.
22	The equipment and/or 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 § 54.2003(c).	See number 15.
23	The school, library, or consortium acknowledges 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 Schools and Libraries Cybersecurity Pilot Program 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 15.
24	No kickbacks, as defined in 41 U.S.C. 8701, were paid to or received by the applicant from anyone in connection with the Schools and Libraries Cybersecurity Pilot Program or the schools and libraries universal service support mechanism.	See number 15.
25	The school, library, or consortium acknowledges that Commission rules provide that persons who have been convicted of criminal violations or held civilly liable for certain acts arising from their participation in the universal service support mechanisms are subject to suspension and debarment from the program. The school, library, or consortium will institute reasonable measures to be informed, and will notify the Administrator should it be informed or become aware that any of the entities listed on this application, or any person associated in any way with this entity and/or the entities listed on this application, is convicted of a criminal violation or held civilly liable for acts arising from their participation in the universal service support mechanisms.	See number 15.
26	No universal service support has been or will be used to purchase, obtain, maintain, improve, modify, or otherwise support any equipment or services produced or provided by any company designated by the Federal Communications Commission as posing a national security threat to the integrity of communications networks or the communications supply chain since the effective date of the designations.	See number 15.
27	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, or maintain any covered communications equipment or service previously purchased, rented, leased, or otherwise obtained, as required by § 54.10.	See number 15.
For Service Providers, the following certifications will be required:
28	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 Schools and Libraries Cybersecurity Pilot Program rules and to protect the Program from waste, fraud, and abuse.
29	In addition to the foregoing, the Service Provider is in compliance with the rules and orders governing the Schools and Libraries Cybersecurity Pilot 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 Schools and Libraries Cybersecurity Pilot Program could result in civil or criminal prosecution by law enforcement authorities.	See number 28.
30	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 28.
31	The funds sought in the request for reimbursement are for eligible services and/or equipment that were purchased or ordered in accordance with the Schools and Libraries Cybersecurity Pilot Program rules and requirements in this subpart and received by the school, library, or consortium.	See number 28.
32	The Service Provider is not seeking Schools and Libraries Cybersecurity Pilot Program reimbursement for eligible equipment and/or services for which it has already been paid.	See number 28.
33	The Service Provider certifies that the school’s, library’s, or consortium’s non-discount portion of costs for the eligible equipment and services has not been waived, paid, or promised to be paid by this Service Provider. The Service Provider acknowledges that the provision of a supported service or free services or equipment unrelated to the supported equipment or services constitutes a rebate of the non-discount portion of the costs as stated in § 54.2007(e).	See number 28.
34	The Service Provider acknowledges that it must submit invoices detailing the items purchased along with the submission of its request for reimbursement as required by § 54.2008(b).	See number 28.
35	The Service Provider certifies that it is compliant with the Commission’s rules and orders regarding gifts and this Service Provider has not directly or indirectly offered or provided any gifts, gratuities, favors, entertainment, loans, or any other thing of value to any eligible school, library, or consortium, except as provided for at § 54.2005(d).	See number 28.
36	The Service Provider acknowledges 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 Schools and Libraries Cybersecurity Pilot Program 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 28.
37	No kickbacks, as defined in 41 U.S.C. 8701, were paid by the Service Provider to anyone in connection with the Schools and Libraries Cybersecurity Pilot Program or the schools and libraries universal service support mechanism.	See number 28.
38	The Service Provider is not debarred or suspended from any Federal programs, including the universal service support mechanisms.	See number 28.
39	No universal service support has been or will be used to purchase, obtain, maintain, improve, modify, or otherwise support any equipment or services produced or provided by any company designated by the Federal Communications Commission as posing a national security threat to the integrity of communications networks or the communications supply chain since the effective date of the designations.	See number 28.
40	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, or maintain any covered communications equipment or service previously purchased, rented, leased, or otherwise obtained, as required by § 54.10.	See number 28.
41	Signature of Authorized Person	The form must be signed by an authorized person.
42	Date Signed	Auto generated by system.
43	Name of Authorized Person	This is the name of the authorized person signing the form.
44	Title or Position of Authorized Person	This is the title or position of the authorized person signing the form.
45	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.
46	Telephone Number of Authorized Person	This is the telephone number of the authorized person signing the form.
47	Email Address of Authorized Person	This is the email address of the authorized person signing the form.
48	Name of Authorized Person’s Employer	This is the name of the employer of the authorized person signing the form.

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