Form FCC Form 472 and F FCC Form 472 and F FCC Form 472 – Billed Entity Applicant Reimbursement For

OMB Control No. 3060-0856 Estimated Time per Response

[Month] 2025 1.5 hours

Not Yet Approved By OMB

Schools and Libraries Universal Service Program

Schools and Libraries Universal Service Request for Reimbursement Forms:

FCC Form 472 – Billed Entity Applicant Reimbursement Form and FCC Form 474 – Service Provider Invoice Form:

(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. 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	Obligation Number	This is included in the purchase order that is integrated into the system and will include the FCC Form 471 Number.
2	Applicant Name	This will be pre-populated.
3	BEN Number	This will be pre-populated.
4	Service Provider Name	This is the name of the service provider providing the equipment or services. This will be pre-populated.
5	Total Reimbursement Request	The system will populate the total committed for this purchase order.
6	FCC Form 471 Application Number	This is the number that is assigned to the form when the FCC Form 471 was submitted.
7	Funding Request Number (FRN)	This is the number that is assigned to the funding request on the FCC Form 471. This will appear in the system.
8	Billing Frequency/Monthly Quantity	This field captures whether it is a monthly, quarterly, or one-time billing.
9	Customer Billed Date/Delivery Date	Use this field for providing date of customer bill for monthly recurring services or delivery date for one-time charge for equipment or other non-recurring costs.
10	Total Amount for Committed Equipment or Services	Enter the total amount for equipment or services that are being invoiced.
11	Required documentation for the request for reimbursement.	Applicants and service providers will be required to upload invoices and/or customer bills to support the Schools and Libraries Universal Service request for reimbursements.
For applicants, the following certification will be required:
12	I declare under penalty of perjury that the foregoing is true and correct: I am authorized to submit this Billed Entity Applicant Reimbursement Form on behalf of the above-named Billed Entity Applicant, 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 Form has been examined and reviewed and is true, accurate and complete. I acknowledge that any false statement on this Form 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.	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 Universal Service Program rules and to protect the Program from waste, fraud, and abuse
13	The discount amounts listed in this Billed Entity Applicant Reimbursement Form are accurate and represent charges for eligible services and/or equipment delivered to and used by eligible schools, libraries, or consortia of those entities for educational purposes, on or after the service start date reported on the associated Form 486.	See number 12.
14	The amounts listed in this Billed Entity Applicant Reimbursement Form were already billed by the Service Provider and paid for by the Billed Entity Applicant on behalf of eligible schools, libraries and consortia of those entities.	See number 12.
15	The discount amounts listed in this Billed Entity Applicant Reimbursement Form are for eligible services and/or equipment approved by the Fund Administrator pursuant to a Funding Commitment Decision Letter (FCDL).	See number 12.
16	I acknowledge that I may be audited pursuant to this application and will retain for at least 10 years (or whatever retention period is required by the rules in effect at the time of this certification), after the latter of the last day of the applicable funding year or the service delivery deadline for the funding request any and all records that I rely upon to complete this form.	See number 12.
17	I certify that this Billed Entity/Applicant will make all documents requested available to the Administrator as required by 47 C.F.R. § 54.516 (b).	See number 12.
18	The school, library, or consortium is not seeking duplicative funding or support from the schools and libraries universal service program for eligible equipment and/or services that have been funded by other sources.	See number 12.
19	I certify that, in addition to the foregoing, this Billed Entity Applicant is in compliance with the rules and orders governing the schools and libraries universal service 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 discount funding and/or cancellation of funding commitments. I acknowledge that failure to comply with the rules and orders governing the schools and libraries universal service program could result in civil or criminal prosecution by law enforcement authorities.	See number 12.
For Service Providers, the following certifications will be required:
20	I declare under penalty of perjury that the foregoing is true and correct: I am authorized to submit this Service Provider Invoice Form on behalf of the above-named Service Provider, which has been assigned the above-referenced Service Provider Identification Number, 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 Form has been examined and reviewed and is true, accurate and complete. I acknowledge that any false statement on this Form 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.	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 the Schools and Libraries Universal Service Program rules and to protect the Program from waste, fraud, and abuse.
21	I certify that this Service Provider is in compliance with the rules and orders governing the schools and libraries universal service 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 discount funding and/or cancellation of funding commitments.	See number 20.
22	I certify that the certifications made on the Service Provider Annual Certification Form (FCC Form 473) by this Service Provider are true and correct.	See number 20.
23	I acknowledge that failure to comply with the rules and orders governing the schools and libraries universal service program could result in civil or criminal prosecution by law enforcement authorities.	See number 20.
24	Signature of Authorized Person	The form must be signed by an authorized person.
25	Date Signed	Auto generated by system.
26	Name of Authorized Person	This is the name of the authorized person signing the form.
27	Title or Position of Authorized Person	This is the title of the authorized person signing the form.
28	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.
29	Telephone Number of Authorized Person	This is the telephone number of the authorized person signing the form.
30	Email address of Authorized Person	This is the email address of the authorized person signing the form.
31	Name of Authorized Person’s Employer	This is the name of the employer of the authorized person signing the form.

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