*Pages 1--8 from Visio-471_10252002.vsd* FCC Form 471 Approval by OMB 3060- 0806 Schools and Libraries Universal Service Services Ordered and Certification Form 471 Estimated Average Burden Hours Per Response: 4 hours This form asks schools and libraries to list the eligible telecommunications- related serv ices they have ordered and estimate the annual charges for them so that the Fund Administrator can set aside sufficient support to reimburse providers for services. Do not writ e in t his area. Applicant's Form Identifier: (Create your own code to identify THIS Form 471) Block 1: Billed Entity Information (The "Billed Entity" is the entity paying the bills for the services listed on this form.) Name of Billed Entity 1 Funding Year: July 1, through June 30, Entity Number 2 3 4 a Street Address, P. O. Box, or Route Number City State b Telephone Number Ext Fax Number c E- mail Address d 5 Type of Application Form 471 Application # (To be inserted by Fund Administrator) b Street Address, P. O. Box, or Route Number City State Zip Code c Ext Fax d School District (LEA; public or non- public (e. g., diocesan) local district representing multiple schools) Library (library (i. e. outlet/ branch, system)) Consortium Check here if any members of this consortium are ineligible non- governmental entities. School (public or non- public school) E- mail Address Contact Person’s Name 6 a Telephone Number e Holiday/ vacation/ summer contact information: f First, fill in every item of the Contact Person's information below that is different from Item 4, above. Then check the box next to the preferred mode of contact. (At least one box MUST be checked.) FCC Form 471 - October 2002 Page 1 of 6 Zip Code Please read instructions before beginning this application. (You can also file online at www. sl. universalservice. org.) The instructions include information on the deadlines for filing this application. 1 Entity Number Applicant's Form Identifier Contact Person Phone Number Block 2: Minor Modification to Existing Contract? Check if this Form 471 represents a minor modification, such as a modification of services, to a Form 471 for which you already have a Receipt Acknowledgment Letter. Provide the data requested below, attach a Description of Services highlighting the modified service, and sign Block 6. 7 Form 471 Application #: Funding Request Number Minor modification requests can be filed MANUALLY only. Please see www. sl. universalservice. org for filing instructions. Block 3: Impact of Services Ordered in THIS Application Please provide your best estimate of the number of people who will be served by all of the services ordered in THIS Form 471. Schools/ school districts complete 8a. Libraries complete 8b. Consortia complete 8a and/ or 8b. 8 Number of students to be served Number of library patrons to be served a b The following questions seek summary outcome information based on the services ordered in this Form 471 application. Please complete only those rows that are relevant to THIS application. 9 IF THIS APPLICATION INCLUDES… BEFORE ORDER AFTER ORDER (Schools/ districts/ consortia only) Telephone service: How many classrooms had phone service before and after your order? a High- bandwidth voice/ data/ video service: How many buildings served before and after your order? b High- bandwidth voice/ data/ video service: Highest speed to a building before and after your order? c Dial- up Internet connections: How many before and after your order? d Dial- up Internet connections: Highest speed before and after your order? e f Direct connections to the Internet: Highest speed before and after your order? g Internet access (for schools): How many rooms have Internet access before and after your order? h Internet access (for libraries): How many buildings have Internet access before and after your order? i Internet access: How many computers (or other devices) with Internet access before and after your order? j Direct connections to the Internet: How many before and after your order? Other technology outcomes: (please specify): k Block 4: Discount Calculation Worksheets (pages 3a, 3b, and 3c) The following 3 pages (3a, 3b, and 3c) are Block 4 worksheets for use in calculating your discount for services. You will complete one or more depending on the type of application you are filing. Each worksheet has instructions. If you are filing as a consortium, use Worksheet C (page 3c), and include as many Worksheets A and B as you need for back- up documentation. If you are filing as a library (i. e. outlet/ branch, system), use Worksheet B (page 3b). If you are filing as a school or a school district, use Worksheet A (page 3a). FCC Form 471 - October 2002 Page 2 of 6 2 Block 4: Discount Calculation Worksheet A for Schools/ School Districts Instructions: If you are filing a School/ School District application, use this worksheet to calculate the discount rate for site- specific services and/ or to determine the weighted average discount calculations for shared services. (For Administrator's Use) 10a If you are: 1 2 3 4 5 8 Name of Eligible School Entity Number Urban or Rural U or R Total # of Students # of Students Eligible for NSLP Weighted Product for Calculating Shared Discount (Col. 4 x Col. 7) Totals for calculating Weighted Average Discount School District Name: ________________________________________ School District Entity Number: ________________________________________ l Applying for discounts ONLY for an individual school, or ONLY site- specific services: Complete columns 1- 7 only for each school. Add and number pages as needed. Then use each school's Entity Number and its discount from Column 7 to complete Block 5 site- specific service to that school. l Applying for discounts on services shared by ALL schools in the district (with or without site- specific services as well): Complete all columns 1- 8 for all schools in the district. Then use the Weighted Average Discount in 10c (below) to complete Block 5 for shared services. l Applying for discounts on different shared services shared by different groups of schools (with or without site- specific services as well): Complete one worksheet, columns 1- 8 PLUS 10c, for EACH different group of schools sharing a service. Designate this worksheet A- 1, A- 2, A- 3, etc. 10b List entities and calculate discount( s). Page ______ of ______ Worksheet #A-______ 6 % Students Eligible for NSLP (Col. 5 ÷ Col. 4) 10c Weighted Average Discount % for Shared Services (Col. 8 total divided by Col. 4 total. Round to nearest %) 7 Discount % from Discount Matrix Entity Number _________________________________________________________ Applicant's Form Identifier ________________________________________________________ Contact Person ________________________________________________________ Phone Number ___________________________________________________________________ Page 3a of 6 FCC Form 471 -- November 2002 October 3 Entity Number Applicant's Form Identifier Contact Person Phone Number Block 5: Discount Funding Request( s) Block 5, page of Instructions: Use one Block 5 page for EACH service (Funding Request Number) for which you are requesting discounts. Make as many copies of this page as necessary, and number the completed pages to assure that they are all processed correctly. 11 Category of Service (only ONE category should be checked) Telecommunications Service Internet Access Internal Connections 12 Form 470 Application Number (15 digits) 13 SPIN - Service Provider Identification Number (9 digits) 14 Service Provider Name 15 Contract Number 16 Billing Account Number (e. g., billed telephone number) 17 Allowable Vendor Selection/ Contract Date (mm/ dd/ yyyy) (based on Form 470 filing) Y D M M D Y Y Y 18 Contract Award Date (mm/ dd/ yyyy) Y D M M D Y Y Y 19a Service Start Date (mm/ dd/ yyyy) Y D M M D Y Y Y 19b Service End Date (mm/ dd/ yyyy) (use only for "T" or "MTM" services) Y D M M D Y Y Y 20 Contract Expiration Date (mm/ dd/ yyyy) Y D M M D Y Y Y 21 Description of This Service: You MUST attach a description of the service, including a breakdown of components and costs, plus any relevant brand names. Label this description with an Attachment #, and note number in space provided. Attachment # 22 Entity/ Entities Receiving This Service: If the service is site- specific (provided to one site and not shared by others), list the Entity Number of the entity from Block 4 receiving this service : a. If the service is shared by all entities on a Block 4 worksheet, list the worksheet number (e. g., A- 1): b. 23 Calculations Recurring Charges Monthly $ charges (total amount per month for service) A. How much of the $ amount in (A) is ineligible? B. Eligible monthly pre- discount amount (A minus B) C. # of months service provided in program year D. Annual pre- discount $ amount for eligible recurring charges (C x D) E. Non- Recurring Charges Annual non- recurring (one- time) $ charges F. How much of the $ amount in (F) is ineligible? G. Annual eligible pre- discount $ amount for one- time charges (F minus G) H. Total program year pre- discount $ amount (E + H) I. % discount (from Block 4 Worksheet) J. Total Charges FRN # (to be assigned by administrator) Funding Commitment $ Request ( I x J ) K. (if available; use "T" if tariffed services, "MTM" if month- to- month services as described in Instructions) FCC Form 471 - October 2002 Page 4 of 6 % . ,,, $ . ,,, $ . ,,, $ . ,,, $ . ,,, $ . ,,, $ . ,,, $ . ,,, $ . ,,, $ 6 Block 6: Certifications and Signature 24 The entities listed in Block 4 of this application are eligible for support because they are: (Check one or both.) Do not write in this area 25 The eligible schools and libraries listed in Block 4 of this application have secured access to all of the resources, including computers, training, software, maintenance, and electrical connections necessary to make effective use of the services purchased as well as to pay the discounted charges for eligible services. 26 All of the schools and libraries or library consortia listed in Block 4 of this application are covered by: an individual technology plan for using the services requested in this application; and/ or a higher- level technology plan( s) for using the services requested in this application; or b no technology plan needed; applying for basic local and long distance telephone service only. c 27 Status of technology plans (if representing multiple entities with mixed technology plan status, check both a and b): technology plan( s) has/ have been approved; and/ or a technology plan( s) will be approved by a state or other authorized body; or b no technology plan needed; applying for basic local and long distance telephone service only. c 28 I certify that the entities eligible for support that I am representing have complied with all applicable state and local laws regarding procurement of services for which support is being sought. 29 I certify that the services the applicant purchases at discounts provided by 47 U. S. C. Sec. 254 will be used solely for educational purposes and will not be sold, resold, or transferred in consideration for money or any other thing of value. 30 I certify that the entity( ies) I represent has complied with all program rules and I acknowledge that failure to do so may result in denial of discount funding and/ or cancellation of funding commitments. 31 I understand that the discount level used for shared services is conditional, for future years, upon ensuring that the most disadvantaged schools and libraries that are treated as sharing in the service, receive an appropriate share of benefits from those services. 32 I recognize that I may be audited pursuant to this application. I will retain for five years any and all worksheets and other records that I rely upon to fill out this application, and, if audited, will make available to the Administrator such records. 33 I certify that I am authorized to submit this request on behalf of the above- named entities, that I have examined this request, and to the best of my knowledge, information, and belief, all statements of fact contained herein are true. 34 Signature of authorized person 35 Date 36 Printed name of authorized person 37 Title or position of authorized person 38 Telephone number of authorized person Extension Persons willfully making false statements on this form can be punished by fine or forfeiture, under the Communications Act, 47 U. S. C. Secs. 502, 503( b), or fine or imprisonment under Title 18 of the United States Code, 18 U. S. C. Sec. 1001. The Americans with Disabilities Act, the Individuals with Disabilities Education Act and the Rehabilitation Act may impose obligations on entities to make the services purchased with these discounts accessible to and usable by people with disabilities. schools under the statutory definitions of elementary and secondary schools found in the No Child Left Behind Act of 2001, 20 U. S. C. Secs. 7801( 18) and (38), that do not operate as for- profit businesses and do not have endowments exceeding $50 million; and/ or a libraries or library consortia eligible for assistance from a State library administrative agency under the Library Services and Technology Act of 1996 that do not operate as for- profit businesses and whose budgets are completely separate from any schools, including, but not limited to, elementary and secondary schools, colleges, or universities. b Entity Number Applicant's Form Identifier Contact Person Phone Number Y D M M D Y Y Y FCC Form 471 - October 2002 Page 5 of 6 7 NOTICE: Section 54. 504 of the Federal Communications Commission's rules requires all schools and libraries ordering services that are eligible for and seeking universal service discounts to file this Description of Services Requested and Certification Form (FCC Form 470) with the Universal Service Administrator. 47 C. F. R. § 54.504. The collection of information stems from the Commission's authority under Section 254 of the Communications Act of 1934, as amended. 47 U. S. C. § 254. The data in the report will be used to ensure that schools and libraries comply with the competitive bidding requirement contained in 47 C. F. R. § 54.504. All schools and libraries planning to order services eligible for universal service discounts must file this form themselves or as part of a consortium. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The FCC is authorized under the Communications Act of 1934, as amended, to collect the information we request in this form. We will use the information you provide to determine whether approving this application is in the public interest. If we believe there may be a violation or a potential violation of a FCC statute, regulation, rule or order, your application may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing the statute, rule, regulation or order. In certain cases, the information in your application may be disclosed to the Department of Justice or a court or adjudicative body when (a) the FCC; or (b) any employee of the FCC; or (c) the United States Government is a party of a proceeding before the body or has an interest in the proceeding. In addition, consistent with the Communications Act of 1934, FCC regulations and orders, the Freedom of Information Act, 5 U. S. C. § 552, or other applicable law, information provided in or submitted with this form or in response to subsequent inquiries may be disclosed to the public. If you owe a past due debt to the federal government, the information you provide may also be disclosed to the Department of the Treasury Financial Management Service, other Federal agencies and/ or your employer to offset your salary, IRS tax refund or other payments to collect that debt. The FCC may also provide the information to these agencies through the matching of computer records when authorized. If you do not provide the information we request on the form, the FCC may delay processing of your application or may return your application without action. The foregoing Notice is required by the Paperwork Reduction Act of 1995, Pub. L. No. 104- 13, 44 U. S. C. § 3501, et seq. Public reporting burden for this collection of information is estimated to average 46 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing, and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the reporting burden to the Federal Communications Commission, Performance Evaluation and Records Management, Washington, DC 20554. FCC Form 471 - October 2002 Page 6 of 6 Entity Number Applicant's Form Identifier Contact Person Phone Number SLD- Form 471 P. O. Box 7026 Lawrence, Kansas 66044- 7026 SLD- Form 471 c/ o Ms. Smith 3833 Greenway Drive Lawrence, Kansas 66046 (888) 203- 8100 Please submit this form to: For express delivery services or U. S. Postal Service, Return Receipt Requested, mail this form to: 8