FCC Form 471 Do not write in this area. Approval by OMB

Transcription

1 FCC Form 471 Do not write in this area. Approval by OMB Shools an Libraries Universal Servie Desription of Servies Orere an Certifiation Form 471 Estimate Average Buren Hours per Response: 4 hours This form asks shools an libraries to list the eligible teleommuniations-relate servies they have orere an estimate the annual harges for them so that the Fun Aministrator an set asie suffiient support to reimburse proviers for servies. Please rea instrutions before beginning this appliation. (You an also file online at The instrutions inlue information on the ealines for filing this appliation. Appliant s Form Ientifier (Create your own oe to ientify THIS Form 471) Form 471 Appliation#: (To be assigne by aministrator) Blok 1: Bille Entity Information (The Bille Entity is the entity paying the bills for the servies liste on this form.) Name of 1 a Bille Entity 2 a 4 a Funing Year: July 1, through June 30, 3 Bille Entity Street Aress, P.O. Box, or Route City State Telephone b 5 a Type of Appliation Zip Coe Iniviual Shool Shool Distrit Library Consortium (iniviual publi or non-publi shool) Fax (LEA; publi or non-publi [e.g. ioesan] loal istrit representing multiple shools) (inluing library system, library outlet/branh or library onsortium as efine uner LSTA) Chek here if any members of this onsortium are ineligible or non-governmental entities. 6 Contat Person s Name First, if the Contat Person s Street Aress is the same as in Item 4, hek this box. for the Street Aress below. b Street Aress, P.O. Box, or Route If not, please omplete the entries City State Zip Coe Chek the box next to your preferre moe of ontat an provie your ontat information. One box MUST be heke an an entry provie. Telephone Fax e Aress f Holiay/vaation/summer ontat information: Page 1 of 7 FCC Form November 2004

2 Entity Appliant s Form Ientifier Contat Person Phone This information will failitate the proessing of your appliations. Please omplete all rows that apply to servies for whih you are requesting isounts. Complete this information on the FIRST Form 471 you file, to enompass this an all other Forms 471 you will file for this funing year. You nee not omplete this information on subsequent Forms 471. Provie your best estimates for the servies orere aross ALL of your Forms 471. Shools/shool istrits omplete Item 7. Libraries omplete Item 8. Consortia omplete Item 7 an/or Item 8. Blok 2: Impat of Servies Orere on Shools IF THIS APPLICATION INCLUDES SCHOOLS BEFORE ORDER AFTER ORDER 7a of stuents to be serve b Telephone servie: of lassrooms with phone servie Dial-up Internet aess: of onnetions (up to 56kbps) Diret broaban servies: of builings serve at the following spees: Less than 10 mbps Between 10 mbps an 200 mbps Greater than 200 mbps e Diret onnetions to the Internet: of rops f of lassrooms with Internet aess g of omputers or other evies with Internet aess Blok 3: Impat of Servies Orere on Libraries IF THIS APPLICATION INCLUDES LIBRARIES BEFORE ORDER AFTER ORDER 8a of library patrons to be serve b Telephone servie: of rooms with phone servie Dial-up Internet aess: of onnetions (up to 56kbps) Diret broaban servies: of builings serve at the following spees: Less than 10 mbps Between 10 mbps an 200 mbps Greater than 200 mbps e Diret onnetions to the Internet: of rops f of builings with Internet aess g of omputers or other evies with Internet aess Blok 4: Disount Calulation Worksheets You must omplete a separate worksheet for eah group of entities sharing one or more servies. If you are filing as a onsortium an your members inlue shool istrits or library systems, you must omplete a separate worksheet for eah of those members. In aition, if you are applying for isounts for aministrative builings or other non-instrutional failities, you must omplete a worksheet for all shools in the shool istrit or all library outlets/branhes in the library system in orer to alulate the appropriate isount for those failities. In general, the following olumns must be omplete: INDIVIDUAL SCHOOLS: Columns 1 7 an Columns 9 10 SCHOOLS IN ONE SCHOOL DISTRICT (SHARED SERVICES): Columns 1 10 an Item 9b, Line 1 SCHOOL DISTRICTS: Columns 1 10 an Item 9b, Line 1 LIBRARY OUTLETS/BRANCHES Columns 1 7 an Column 11 LIBRARY OUTLETS/BRANCHES IN ONE LIBRARY SYSTEM (SHARED SERVICES): Columns 1 7, Column 11, an Item 9b, Line 2 LIBRARY SYSTEMS: Columns 1 7, Column 11, an Item 9b, Line 2 CONSORTIA (after ompleting a worksheet or worksheet entry for eah member entity as neee): Columns 1 2, Column 12, an Item 9b, Line 3 Please refer to the Form 471 Instrutions for speifi information on eah Item in the worksheet. Page 2 of 7 FCC Form 471 November 2004

3 Entity Appliant s Form Ientifier Contat Person Contat Telephone Blok 4: Disount Calulation Worksheet Worksheet Page of The Blok 4 worksheet is use to alulate your isount for servies. You will omplete one or more worksheets epening on the type of appliation you are filing. If you file more than one worksheet, please number the omplete worksheets to assure that they are all proesse orretly. Please refer to the instrutions for information speifi to the Type of Appliation you iniate in Blok 1, Item 5. 9a List entities an alulate isount(s): Shool Distrit or Library System Name: Shool Distrit or Library System Entity : (For Aministrator s Use) 1 Name of Eligible Entity ALL ENTITIES Entity AND NCES Coe (for Shools) or FSCS Coe (for Libraries) Urban or Rural U or R Total of Stuents of Stuents Eligible for NSLP SCHOOLS AND LIBRARIES Perent of Stuents Eligible for NSLP (Col. 5 / Col 4) Disount from Disount Matrix Weighte Prout for Calulating Share Disount (Col. 4 x Col. 7) Shools with Share Servies Pre-K Ault E Or Juvenile Justie Shools Alt Dis Meh Entity of Shool Distrit in whih Library Outlet/Branh is Loate Library Outlets/Branhes Disount of Member Entity Consortia Share Disount 9b Share Servies SCHOOL DISTRICTS: (Inluing groups of shools within shool istrits.) Calulate the totals of Columns 4 an 8. Divie the total of Column 8 by the total of Column 4. Enter the result in Column 13. LIBRARY SYSTEMS: Calulate the total of Column 7. Divie this total by the number of outlets/branhes. Enter the result in Column 13. CONSORTIA: Calulate the total of Column 12. Divie this total by the number of member entities. Enter the result in Column 13. Page 3 of 7 FCC Form 471 November 2004

4 Entity Appliant s Form Ientifier Contat Person Phone Blok 5: Disount Funing Request(s) Instrutions: Use one Blok 5 page for EACH servie (Funing Request ) Blok 5, page of for whih you are requesting isounts. Make as many opies of this page as neee, an number the omplete pages to assure that they are all proesse orretly. FRN (to be assigne by aministrator) 10 If this is a upliate Funing Request (e.g., of an FRN that is not yet approve, uner appeal, et.), hek this box an enter the original FRN in the spae provie: 11 Category of Servie ( only ONE ategory shoul be heke) PRIORITY 1 Teleommuniations Servie PRIORITY 2 Internal Connetions Other than Basi Maintenane Basi Maintenane of Internal Internet Aess Connetions 12 Form 470 Appliation 13 SPIN Servie Provier Ientifiation 14 Servie Provier Name Reurring Charges 23 Calulations A. Monthly harges (total amount per month for servie) B. How muh of the amount in A is ineligible? C. Eligible monthly pre-isount amount (A minus B) D. of months servie provie in funing year E. Annual pre-isount amount for eligible reurring harges (C x D) 15a 15b Chek this box if this Funing Request is for non-ontrate tariffe or month-to-month servies. Contrat Chek this box if this Funing Request is overe uner a master ontrat (a ontrat negotiate by a thir party, the terms an onitions of whih are then mae available to an eligible entity that purhases iretly from the servie provier). Chek this box if this Funing Request is a ontinuation of an FRN from a previous funing year base on a multi-year ontrat. If so, provie that FRN here: Non-Reurring Charges F. Annual non-reurring harges G. How muh of the amount in F is ineligible? 16a Billing Aount (e.g., bille telephone number) 16b 17 Chek this box if there are multiple Billing Aount s an attah a omplete list of those numbers to this page. Allowable Venor Seletion/Contrat Date (mm//yyyy) (base on Form 470 filing) H. Annual eligible pre-isount amount for non-reurring harges (F minus G) 18 Contrat Awar Date (mm//yyyy) I. Total funing year pre-isount amount (E + H) 19 20a 20b Servie Start Date (mm//yyyy) Servie En Date (mm//yyyy) Contrat Expiration Date (mm//yyyy) Total Charges J. Disount from Blok 4 Worksheet K. Funing Commitment Request (I x J) 21 Desription of This Servie: Attahment You MUST attah a esription of the servie, inluing a breakown of omponents, osts, manufaturer name, make an moel number. You must inlue any aitional aount or telephone numbers if the bille aount has multiple numbers. Label the esription with an Attahment, an note number in spae provie. a. If the servie is site-speifi (provie to one site 22 Entity/Entities Reeiving This Servie: an not share by others), list the Entity of the entity from Blok 4 reeiving this servie: b. If the servie is share by all entities on a Blok 4 worksheet, list the worksheet number (e.g., 1): Page 4 of 7 FCC Form 471- November 2004

5 Do not write in this area Entity Appliant s Form Ientifier Contat Person Phone Blok 6: Certifiations an Signature 24 I ertify that the entities liste in Blok 4 of this appliation are eligible for support beause they are: (Chek one or both.) a b shools uner the statutory efinitions of elementary an seonary shools foun in the No Chil Left Behin At of 2001, 20 U.S.C. Ses. 7801(18) an (38), that o not operate as for-profit businesses an o not have enowments exeeing $50 million; an/or libraries or library onsortia eligible for assistane from a State library aministrative ageny uner the Library Servies an Tehnology At of 1996 that o not operate as for-profit businesses an whose bugets are ompletely separate from any shools, inluing, but not limite to, elementary, seonary shools, olleges, or universities. 25 I ertify that the entity I represent or the entities liste on this appliation have seure aess, separately or through this program, to all of the resoures, inluing omputers, training, software, internal onnetions, maintenane, an eletrial apaity, neessary to use the servies purhase effetively. I reognize that some of the aforementione resoures are not eligible for support. I ertify that the entities I represent or the entities liste on this appliation have seure aess to all of the resoures to pay the isounte harges for eligible servies from funs to whih aess has been seure in the urrent funing year. I ertify that the Bille Entity will pay the non-isount portion of the ost of the goos an servies to the servie provier(s). a Total funing year pre-isount amount on this Form 471 (A the entries from Items 23I on all Blok 5 Disount Funing Requests.) b Total funing ommitment request amount on this Form 471 (A the entries from Items 23K on all Blok 5 Disount Funing Requests.) Total appliant non-isount share (Subtrat Item 25b from Item 25a.) Total bugete amount alloate to resoures not eligible for E-rate support e Total amount neessary for the appliant to pay the non-isount share of the servies requeste on this appliation AND to seure aess to the resoures neessary to make effetive use of the isounts. (A Items 25 an 25.) f Chek this box if you are reeiving any of the funs in Item 25e iretly from a servie provier liste on any of the Forms 471 file by this Bille Entity for this funing year, or if a servie provier liste on any of the Forms 471 file by this Bille Entity for this funing year assiste you in loating funs in Item 25e. 26 I ertify that all of the shools an libraries or library onsortia liste in Blok 4 of this appliation are overe by tehnology plans that are written, that over all 12 months of the funing year, an that have been or will be approve by a state or other authorize boy, an an SLD-ertifie tehnology plan approver, prior to the ommenement of servie. The plans were written at the following level(s): a b an iniviual tehnology plan for using the servies requeste in this appliation; an/or higher-level tehnology plan(s) for using the servies requeste in this appliation; or no tehnology plan neee; applying for basi loal, ellular, PCS, an/or long istane telephone servie an/or voie mail only. 27 I ertify that I poste my Form 470 an (if appliable) mae my RFP available for at least 28 ays before onsiering all bis reeive an seleting a servie provier. I ertify that all bis submitte were arefully onsiere an the most ost-effetive servie offering was selete, with prie being the primary fator onsiere, an is the most ost-effetive means of meeting euational nees an tehnology plan goals. 28 I ertify that the entity responsible for seleting the servie provier(s) has reviewe all appliable FCC, state, an loal prourement/ompetitive biing requirements an that the entity or entities liste on this appliation have omplie with them. 29 I ertify that the servies the appliant purhases at isounts provie by 47 U.S.C. Se. 254 will be use solely for euational purposes an will not be sol, resol, or transferre in onsieration for money or any other thing of value, exept as permitte by the Commission s rules at 47 C.F.R. Se (k). Aitionally, I ertify that the Bille Entity has not reeive anything of value or a promise of anything of value, other than servies an equipment requeste uner this form, from the servie provier(s). or any representative or agent thereof or any onsultant in onnetion with this request for servies. 30 I ertify that I an the entity(ies) I represent have omplie with all program rules an I aknowlege that failure to o so may result in enial of isount funing an/or anellation of funing ommitments. There are signe ontrats overing all of the servies liste on this Form 471 exept for those servies provie uner non-ontrate tariffe or month-to-month arrangements. I aknowlege that failure to omply with program rules oul result in ivil or riminal proseution by the appropriate law enforement authorities. Page 5 of 7 FCC Form 471- November 2004

6 Do not write in this area Entity Appliant s Form Ientifier Contat Person Phone 31 I aknowlege that the isount level use for share servies is onitional, for future years, upon ensuring that the most isavantage shools an libraries that are treate as sharing in the servie, reeive an appropriate share of benefits from those servies. 32 I ertify that I will retain require ouments for a perio of at least five years after the last ay of servie elivere. I ertify that I will retain all ouments neessary to emonstrate ompliane with the statute an Commission rules regaring the appliation for, reeipt of, an elivery of servies reeiving shools an libraries isounts, an that if auite, I will make suh reors available to the Aministrator. I aknowlege that I may be auite pursuant to partiipation in the shools an libraries program. 33 I ertify that I am authorize to orer teleommuniations an other supporte servies for the eligible entity(ies) liste on this appliation. I ertify that I am authorize to submit this request on behalf of the eligible entity(ies) liste on this appliation, that I have examine this request, that all of the information on this form is true an orret to the best of my knowlege, that the entities that are reeiving isounts pursuant to this appliation have omplie with the terms, onitions an purposes of the program, that no kikbaks were pai to anyone an that false statements on this form an be punishe by fine or forfeiture uner the Communiations At, 47 U.S.C. Ses. 502, 503(b), or fine or imprisonment uner Title 18 of the Unite States Coe, 18 U.S.C. Se an ivil violations of the False Claims At. 34 I aknowlege that FCC rules provie that persons who have been onvite of riminal violations or hel ivilly liable for ertain ats arising from their partiipation in the shools an libraries support mehanism are subjet to suspension an ebarment from the program. I will institute reasonable measures to be informe, an will notify USAC shoul I be informe or beome aware that I or any of the entities liste on this appliation, or any person assoiate in any way with my entity an/or the entities liste on this appliation, is onvite of a riminal violation or hel ivilly liable for ats arising from their partiipation in the shools an libraries support mehanism. 35 I ertify that if any of the Funing Requests on this Form 471 are for isounts for prouts or servies that ontain both eligible an ineligible omponents, that I have alloate the ost of the ontrat to eligible an ineligible omponents as require by the Commission's rules at 47 C.F.R. Se (g)(1), (2). 36 I ertify that this funing request oes not onstitute a request for internal onnetions servies, exept basi maintenane servies, in violation of the Commission requirement that eligible entities are not eligible for suh support more than twie every five funing years beginning with Funing Year 2005 as require by the Commission's rules at 47 C.F.R. Se (). 37 I ertify that the non-isount portion of the osts for eligible servies will not be pai by the servie provier. The pre-isount osts of eligible servies feature on this Form 471 are net of any rebates or isounts offere by the servie provier. I aknowlege that, for the purpose of this rule, the provision, by the provier of a supporte servie, of free servies or prouts unrelate to the supporte servie or prout onstitutes a rebate of some or all of the ost of the supporte servies. 38 Signature of authorize person 40 Printe name of authorize person 39 Date 41 Title or position of authorize person 42a Street Aress, P.O. Box, or Route City State Zip Coe 42b Telephone number of authorize person 42 Fax number of authorize person 42 aress of authorize person 42e Name of authorize person s employer Page 6 of 7 FCC Form 471 November 2004

7 The Amerians with Disabilities At, the Iniviuals with Disabilities Euation At an the Rehabilitation At may impose obligations on entities to make the servies purhase with these isounts aessible to an usable by people with isabilities. NOTICE: Setion of the Feeral Communiations Commission's rules requires all shools an libraries orering servies that are eligible for an seeking universal servie isounts to file this Servies Orere an Certifiation Form (FCC Form 471) with the Universal Servie Aministrator. 47 C.F.R The olletion of information stems from the Commission's authority uner Setion 254 of the Communiations At of 1934, as amene. 47U.S.C The ata in the report will be use to ensure that shools an libraries omply with the ompetitive biing requirement ontaine in 47C.F.R All shools an libraries planning to orer servies eligible for universal servie isounts must file this form themselves or as part of a onsortium. An ageny may not onut or sponsor, an a person is not require to respon to, a olletion of information unless it isplays a urrently vali OMB ontrol number. The FCC is authorize uner the Communiations At of 1934, as amene, to ollet the information we request in this form. We will use the information you provie to etermine whether approving this appliation is in the publi interest. If we believe there may be a violation or a potential violation of any appliable statute, regulation, rule or orer, your appliation may be referre to the Feeral, state, or loal ageny responsible for investigating, proseuting, enforing, or implementing the statute, rule, regulation or orer. In ertain ases, the information in your appliation may be islose to the Department of Justie or a ourt or ajuiative boy when (a) the FCC; or (b) any employee of the FCC; or () the Unite States Government is a party of a proeeing before the boy or has an interest in the proeeing. In aition, onsistent with the Communiations At of 1934, FCC regulations an orers, the Freeom of Information At, 5 U.S.C. 552, or other appliable law, information provie in or submitte with this form or in response to subsequent inquiries may be islose to the publi. If you owe a past ue ebt to the Feeral government, the information you provie may also be islose to the Department of the Treasury Finanial Management Servie, other Feeral agenies an/or your employer to offset your salary, IRS tax refun or other payments to ollet that ebt. The FCC may also provie the information to these agenies through the mathing of omputer reors when authorize. If you o not provie the information we request on the form, the FCC may elay proessing of your appliation or may return your appliation without ation. The foregoing Notie is require by the Paperwork Reution At of 1995, Pub. L. No , 44 U.S.C. 3501, et seq. Publi reporting buren for this olletion of information is estimate to average 4 hours per response, inluing the time for reviewing instrutions, searhing existing ata soures, gathering an maintaining the ata neee, ompleting, an reviewing the olletion of information. Sen omments regaring this buren estimate or any other aspet of this olletion of information, inluing suggestions for reuing the reporting buren to the Feeral Communiations Commission, Performane Evaluation an Reors Management, Washington, DC Please submit this form to: SLD-Form 471 P.O. Box 7026 Lawrene, Kansas For express elivery servies or U.S. Postal Servie, Return Reeipt Requeste, mail this form to: SLD Forms ATTN: SLD Form Greenway Drive Lawrene, Kansas (888) Page 7 of 7 FCC Form 471 November 2004