(Note: This is a representative
description of the information to be collected electronically. This
table is not a visual representation of what service providers will
see when they use the online FCC Form 473).
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Form 473
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Field
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Rules
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Service
Provider Annual Certification Form
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Block
1: Service Provider Information
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Name
of Service Provider
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1
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Must
be entered using alphabetic characters
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Service
Provider Identification Number (SPIN)
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2
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Must
be entered using a valid nine digit SPIN number (1430XXXX)
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Funding
Year:
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3
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Must
be entered using numeric character in the year format (YYYY)
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Contact
Name
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4
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Must
be entered using alphabetic characters
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Complete
Mailing Address of Contact Person
Street Address, P. O. Box
or Route Number
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5
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Must
be entered using alphanumeric characters
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City
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Must
be entered using alphabetic characters
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State
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Must
be entered using alphabetic characters
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Zip
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Must
be entered using alphabetic characters
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Telephone
Number with Area Code
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6
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Must
be entered using numeric characters, must be nine digits
(xxx-xxx-xxxx)
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Fax
Number with Area Code
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7
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Must
be entered using numeric characters, must be nine digits
(xxx-xxx-xxxx)
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Email
Address
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8
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Valid
email address must be entered. Email must be composed of a
username and domain name (username@domain.extension)
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Block
2: Certification
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Signature
of authorized person
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9
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Must
be entered using alphabetic characters
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Date
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10
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Must
be entered using numeric characters in the dd/yyyy format.
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Printed
name of authorized person
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11
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Must
be entered using alphabetic characters
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Title
or position of authorized person
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12
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Must
be entered using alphabetic characters
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Telephone
number of authorized person
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13
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Must
be entered using numeric characters, must be nine digits
(xxx-xxx-xxxx)
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Address
of authorized person
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14
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Must
be entered using alphanumeric characters
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CERTIFICATIONS:
I
declare under penalty of perjury that the foregoing is true and
correct: I am authorized to submit this Service Provider Annual
Certification 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 or on the
Service Provider Invoice Form (FCC Form 474) 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, and that any such false
statement could subject this Service Provider to liability under
the False Claims Act.
I
certify that the Service Provider Invoice Forms (FCC Form 474)
that are submitted by this Service Provider contain requests for
universal service support for services which have been billed to
the Service Provider’s customers on behalf of schools,
libraries, and consortia of those entities, as deemed eligible
for universal service support by the fund administrator.
I
certify that the Service Provider Invoice Forms (FCC Form 474)
that are submitted by this Service Provider are based on bills or
invoices issued by the Service Provider to the Service Provider’s
customers on behalf of schools, libraries, and consortia of those
entities as deemed eligible for universal service support by the
fund administrator, and exclude any charges previously invoiced
to the fund administrator for which the fund administrator has
not yet issued a reimbursement decision.
I
certify that the bills or invoices issued by this Service
Provider to the Billed Entity are for equipment and services
eligible for universal service support by the Administrator, and
exclude any charges previously invoiced to the Administrator by
the Service Provider.
I
certify that any requests for reimbursement that are sought under
a Service Provider Invoice Form (FCC Form 474) for discounts for
products or services that contain both eligible and ineligible
components are properly allocated as required by the Commission’s
rules at 47 C.F.R. § 54.504(e).
I
certify that the invoices that are submitted by this Service
Provider to the Billed Entity for reimbursement pursuant to
Billed Entity Applicant Reimbursement Forms (FCC Form 472) are
accurate and represent payments from the Billed Entity to the
Service Provider for equipment and services provided pursuant to
E-rate program rules.
I
certify that this Service Provider makes available to customers,
upon their request, separate prices for distinct services to
assist Billed Entity Applicants in identifying the portions of
their bills that represent the costs of services provided to
eligible entities for eligible purposes.
I
certify that no non-discount portion of the costs for eligible
services will be waived, paid, or promised to be paid by this
Service Provider. I acknowledge that the provision by any
service provider of a supported service, or of free services or
products unrelated to the supported service or product
constitutes a rebate of the non-discount portion of the supported
services as stated in 47 C.F.R. § 54.523.
I
certify that no kickbacks, as defined in 41 U.S.C. § 8701,
were paid by this Service Provider to anyone in connection with
the schools and libraries universal support program.
I
certify that this Service Provider is in compliance with the
Commission’s rule and orders regarding gifts and this
Service Provider and has not directly or indirectly offered or
provided any gifts, gratuities, favors, entertainment, loans, or
any other thing of value to any eligible schools, libraries, or
consortium that includes eligible schools or libraries, except as
permitted by the Commission’s rule at 47 C.F.R. §
54.503(d).
I
certify that if the fund administrator, as necessary, requests
additional supporting information, this Service Provider will
make all documents requested available to the Fund Administrator
as required by 47 C.F.R. § 54.516(b). I certify that this
Service Provider 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 requests, (1) any and all records that I rely upon to
complete this form and each Service Provider Invoice Form (FCC
Form 474) that is submitted by this Service Provider during the
present funding year, (2) any and all records issued by this
Service Provider to the Billed Entity for reimbursement pursuant
to Billed Entity Applicant Reimbursement Forms (FCC Form 472),
and (3) all documents necessary to demonstrate compliance with
the statutory or regulatory requirements for the schools and
libraries universal service support program as required by 47
C.F.R. § 54.516(a)(2) I acknowledge that this Service
Provider may be audited pursuant to 47 C.F.R. § 54.516(c),
and that the Service Provider must provide such records as
required by 47 C.F.R. § 54.516(b)
I
certify that the prices in any offer that this Service Provider
makes pursuant to the schools and libraries universal service
support program have been arrived at independently, without, for
the purpose of restricting competition, any consultation,
communication, or agreement with any other offeror or competitor
relating to (i) those prices, (ii) the intention to submit an
offer, or (iii) the methods or factors used to calculate the
prices offered.
I
certify that the prices in any offer that this Service Provider
makes pursuant to the schools and libraries universal service
support program will not be knowingly disclosed by this Service
Provider, directly or indirectly, to any other offeror or
competitor before bid opening (in the case of a sealed bid
solicitation) or contract award (in the case of a negotiated
solicitation) unless otherwise required by law.
I
certify that no attempt will be made by this Service Provider to
induce any other concern to submit or not to submit an offer for
the purpose of restricting competition.
I
certify that this Service Provider is not suspended or debarred
from participating in Federal programs.
I certify that,
in addition to the foregoing, this Service Provider is in
compliance with the rules and orders governing the schools and
libraries universal service support program, and acknowledges
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 support
program could result in civil or criminal prosecution by law
enforcement authorities.
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