FCC Form 472 Billed Entity Applicant Reimbursement Form

FCC Form 472 Table

OMB Control No. 3060-0856

FCC Form 472

Schools and Libraries Universal Service

Billed Entity Applicant Reimbursement Form 472

(Note: This is a representative description of the information to be collected electronically. This table is not a visual representation of what applicants will see when they use the online version of the FCC Form 472.)

Form 472	Field	Rules
Billed Entity Applicant Reimbursement Form
Invoice# (To be inserted by administrator)		This field populates from system once form is saved and/or completed
Created on:		This field populates from system once form is saved and/or completed
Last updated on:		This field populates from system once form is saved and/or completed
Applicant Form Identifier		Must be entered using alphanumeric characters; if the online form is converted to a printable format, this information will auto-populate on each page.
Block 1: Header information
Billed Entity Name	1	This line is auto-populated with the Billed Entity Name matching the Billed Entity Number associated with the user that was identified at login; if the online form is converted to a printable format, this information will auto-populate on each page.
Billed Entity Number	2	This line is auto-populated with the Billed Entity Number or BEN associated with the user that was identified at login; if the online form is converted to a printable format, this information will auto-populate on each page.
FCC Form 498 ID (New Field)	3	This item will be a drop down menu of available selections. Also, a link to the FCC Form 498 will be provided.
Service Provider Identification Number (SPIN)		Must be entered using a valid nine digit SPIN number (1430XXXX)
Service Provider Name		Populates based on the SPIN number provided
Contact Name	4	This line is auto-populated with the Contact Name of the user associated with the user that was identified at login; if the online form is converted to a printable format, this information will auto-populate on each page.
Contact Telephone Number	5	This line is auto-populated with the Contact telephone number of the user associated with the user identified at login
Contact Fax		This line is auto-populated with the Contact Fax Number of the user associated with the User identified at login
Contact Email		This line is auto-populated with the Contact Email Address of the user associated with the User identified at login
Total Reimbursement Amount (total from Block 2)	6	Populates based on totals found in Block 2
Review and add		This allows the user to review line item requests or add new line items to the invoice in Block 2.
BLOCK 2: LINE ITEM INFORMATION PER FUNDING REQUEST NUMBER
FCC Form 471 Application Number (from Funding Commitment Decision Letter)	7	Must be entered using valid six digit application number
Funding Request Number (FRN)	8	Must be entered using valid seven digit Funding Request Number. A new line will be added for each FRN.
Bill Frequency (New field)	9	Must be entered.
Customer Billed Date	10	Must be entered in valid date format (MM/DD/YYYY). This field will be visible for reimbursement requests for FRNs with recurring services or multiple installments of non-recurring services.
Shipping Date to Customer or Last Day of Work Performed	11	Must be entered in valid date format (MM/DD/YYYY). This field will be visible for reimbursement requests for FRNs for non-recurring services (such as Internal Connections).
Total (Undiscounted) Amount for Service	12	Must be entered in numeric characters
Discount Rate	13	Populates once FRN data has been entered
Discount Amount Billed to USAC	14	Populates once numeric data has been entered
TOTAL REIMBURSEMENT AMOUNT		Numeric entry calculated by the system based on previous entries.
Block 3: Billed Entity Certification
Contact Information for Billed Entity Authorized Person:
Signature of authorized person	15	Check box to sign electronically (once checked, printed information will populate based on Applicant login credentials)
Date	16	Automatically populates from system when form is created.
Name	17	This line is auto-populated based on data entered on the most recent 471.
Title/Position	18	This line is auto-populated based on data entered on the most recent 471.
Phone Number	19	This line is auto-populated based on data entered on the most recent 471.
Fax Number	19a	If provided, must be 10 digits (xxx-xxx-xxxx)
Email	19b	This line is auto-populated based on data entered on the most recent 471.
BILLED ENTITY CERTIFICATIONS: I declare under penalty of perjury that the foregoing is true and correct and that I am authorized to submit this Billed Entity Applicant Reimbursement Form on behalf of the eligible schools, libraries, or consortia of those entities represented on this Form, and I certify to the best of my knowledge, information and belief, as follows: The discount amounts listed in this Billed Entity Applicant Reimbursement Form 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 FCC Form 486. The discount 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. 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). 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. 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 support 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 support program could result in civil or criminal prosecution by law enforcement authorities.