FCC Form 470



Approval by OMB
3060-0806

Schools and Libraries Universal Service
Description of Services Requested and Certification Form 470

Estimated Average Burden Hours per Response: 3 hours
This form is designed to help you describe the eligible services you seek so that this data can be posted on the Fund Administrator Internet Site
and interested service providers can identify you as a potential customer and compete to serve you.
Please read instructions before beginning this form.
Form 470 Application Number: 920640001142839 Applicant's Form Identifier: MiCTA2013P2
Application Status: CERTIFIED Posting Date: 11/09/2013
Allowable Contract Date: 12/07/2013 Certification Received Date: 11/09/2013
Block 1: Applicant Address and Information
1 Name of Applicant:
MICTA
2 Funding Year: 2014 (Funding years run from July 1 through the following June 30)
3 Entity Number: 16024867
4a Street Address, P.O.Box, or Route Number:
4805 TOWNE CENTRE, SUITE 100
City: SAGINAW State: MI Zip Code: 48604 -0000
4b Telephone Number: (888)  964 -2227
4c Fax Number: (989)  753 -2655
5a Eligible Entities That Will Receive Services:
Check the ONE choice in 5a that best describes the eligible entities that will receive the services described in this form. You will then list in Item 15 the entity/entities that will pay the bills for these services.
Individual School (individual public or non-public school)
School District (LEA; public or non-public [e.g., diocesan] local district representing multiple schools)
Library (including library system, library outlet/branch or library consortium as definedunder LSTA)
Consortium (intermediate service agencies, states, state networks, consortia of schools and/or libraries)
Statewide application for (enter 2-letter state code)
representing (check all that apply)
All public schools/districts in the state
All non-public schools in the state
All libraries in the state
5b Recipient(s) of Services - Check all that apply:
 Private  Public  Charter
 Tribal  Head Start  State Agency
5c Number of eligible entities for which services are sought: 6805
Block 1: Applicant Address and Information (continued)
6a Contact Person's Name:
Gary Green
If the Contact Person’s Street Address is the same as Item 4a above, check here. If not, complete Item 6b.
6b Street Address, P.O.Box, or Route Number:
NOTE: USAC will use this address to mail correspondence
P.O. Box 303
City: Walloon lake State: MI Zip Code: 49796
Check the box next to your preferred mode of contact and provide your contact information. One box MUST be checked and an entry provided.
  6c Telephone Number: (231)  881 -6612
  6d Fax Number: (231)  535 -2993
  6e E-Mail Address: gary.green@mictatech.org 
Re-enter E-mail Address: gary.green@mictatech.org
If a consultant is assisting you with your application process, please complete Item 7 below:
7 Consultant Name:
Name of Consultant’s Employer:
Consultant’s Street Address:
 
City:  State:  Zip Code: 
Consultant’s Telephone Number: Ext. 
Consultant’s Fax Number:
Consultant’s E-mail Address:
Re-enter E-mail Address:
Consultant Registration Number:
Entity Number: 16024867 Applicant's Form Identifier: MiCTA2013P2
Contact Person: Gary Green Phone Number: (231) 881-6612
Block 2: Summary Description of Needs or Services Requested
8Telecommunication Services
If you check YES to indicate you have a Request for Proposals (RFP) that specifies the services you are seeking, your RFP must be available to all interested bidders for at least 28 days. If your RFP is not available to all interested bidders, or if you check NO and you have or intend to have an RFP, you risk denial of your funding requests.
a YES, I have released or intend to release an RFP for these services. It is available or will become available on the Internet at: 
or via (check one) the contact person in Item 6 or the contact person listed in Item 12

Your RFP Indentifier: 

bNO, I have not released and do not intend to release an RFP for these services.
 
9Internet Access
If you check YES to indicate you have a Request for Proposals (RFP) that specifies the services you are seeking, your RFP must be available to all interested bidders for at least 28 days. If your RFP is not available to all interested bidders, or if you check NO and you have or intend to have an RFP, you risk denial of your funding requests.
aYES, I have released or intend to release an RFP for these services. It is available or will become available on the Internet at: 
or via (check one) the contact person in Item 6 or the contact person listed in Item 12

Your RFP Indentifier: 

bNO, I have not released and do not intend to release an RFP for these services.

Whether you check YES or NO, you must list below the Internet Access services you seek. Specify each service (e.g., monthly Internet service) and quantity and/or capacity (e.g., for 500 users).

 
Entity Number: 16024867 Applicant's Form Identifier: MiCTA2013P2
Contact Person: Gary Green Phone Number: (231) 881-6612
10Internal Connections Other Than Basic Maintenance
If you check YES to indicate you have a Request for Proposals (RFP) that specifies the services you are seeking, your RFP must be available to all interested bidders for at least 28 days. If your RFP is not available to all interested bidders, or if you check NO and you have or intend to have an RFP, you risk denial of your funding requests.
aYES, I have released or intend to release an RFP for these services. It is available or will become available on the Internet at: www.mictatech.org
or via (check one) the contact person in Item 6 or the contact person listed in Item 12

Your RFP Indentifier: MT-TISA 2013

bNO, I have not released and do not intend to release an RFP for these services.

Whether you check YES or NO, you must list below the Internal Connections services you seek. Specify each service (e.g., a router,hub and cabling) and quantity and/or capacity (e.g., connecting 1 classroom of 30 students).

Service Quantity and/or Capacity
Internal Connections 6805
 
11Basic Maintenance of Internal Connections
If you check YES to indicate you have a Request for Proposals (RFP) that specifies the services you are seeking, your RFP must be available to all interested bidders for at least 28 days. If your RFP is not available to all interested bidders, or if you check NO and you have or intend to have an RFP, you risk denial of your funding requests.
aYES, I have released or intend to release an RFP for these services. It is available or will become available on the Internet at: www.mictatech.org
or via (check one) the contact person in Item 6 or the contact person listed in Item 12

Your RFP Indentifier: MT-TISA 2013

bNO, I have not released and do not intend to release an RFP for these services.

Whether you check YES or NO, you must list below the Basic Maintenance services you seek. Specify each service (e.g., basic maintenance of routers) and quantity and/or capacity (e.g., for 10 routers).

Service Quantity and/or Capacity
Basic Maintenance 6805
 
Entity Number: 16024867 Applicant's Form Identifier: MiCTA2013P2
Contact Person: Gary Green Phone Number: (231) 881-6612
12(Optional) Please name the person on your staff or project who can provide additional technical details or answer specific questions from service providers about the services you are seeking. This person does not need to be the contact person(s) listed in Item 6 nor the Authorized Person who signs this form.
Name:
Gary Green
Title:
Consultant
Telephone Number: (231) 881 - 6612
Fax Number: (231) 535 - 2993
Email Address: gary.green@mictatech.org
Re-enter E-mail Address: gary.green@mictatech.org
13 Check this box if there are any restrictions imposed by state or local laws or regulations on how or when service providers may contact you or on other bidding procedures. Please describe below any such restrictions or procedures and/or provide an Internet address where they are posted and a contact name and telephone number.
Check this box if no state and local procurement/competitive bidding requirements apply to the procurement of services sought on this Form 470.
If you are requesting services for a funding year for which a Form 470 cannot yet be filed online, include that information here.
The Initial term of the resulting contracts will be for two(2) years with three (3) one year voluntary extensions. Any MiCTA K-12/Library member may use any of the MiCTA Contracts awarded thru this 470 process for filing current or future 471(s) through 2020. Also, due to evolving technology and potential price reductions, MiCTA reserves the right to amend the resulting contracts over their term.
Block 3:
14. [Reserved]
Entity Number: 16024867 Applicant's Form Identifier: MiCTA2013P2
Contact Person: Gary Green Contact Phone Number: (231) 881-6612
Block 4: Recipients of Service
15 Billed Entities
List the entity/entities that will be paying the bills directly to the provider for the services requested in this form.
These are known as Billed Entities. At least one line of this item must be completed. If a Billed Entity cited on your
FCC Form 471 is not listed below, funding may be denied for the funding requests associated with this FCC Form 470. Attach additional pages if needed.
Entity Number Entity Name
131424 LENAWEE I S D
Entity Number: 16024867 Applicant's Form Identifier: MiCTA2013P2
Contact Person: Gary Green Contact Phone Number: (231) 881-6612
Block 5: Certifications and Signature
16 I certify that the applicant includes: (Check one or both.)
a  schools under the statutory definitions of elementary and secondary schools found in the No Child Left Behind Act of 2001, 20 U.S.C. §§ 7801 (18) and (38), that do not operate as for-profit businesses, and do not have endowments exceeding $50 million; and/or
b  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, and universities).
17 I certify that, if required by Commission rules, all of the individual schools and libraries receiving services under this form are covered by technology plans that do or will cover all 12 months of the funding year, and that have been or will be approved by a state or other authorized body, or an SLD-certified technology plan approver, prior to the commencement of service.
      Or I certify that no technology plan is required by Commission rules.
18 I certify that I will post my FCC Form 470 and (if applicable) make any applicable RFP available for at least 28 days before considering all bids received and selecting a service provider. I certify that all bids submitted will be carefully considered and the bid selected will be for the most cost-effective service or equipment offering, with price being the primary factor, and will be the most cost-effective means of meeting educational needs and technology goals.
19 I certify that I will retain required documents for a period of at least five years after the last day of service delivered. I certify that I will retain all documents necessary to demonstrate compliance with the statute and Commission rules regarding the form for, receipt of, and delivery of services receiving schools and libraries discounts. I acknowledge that I may be audited pursuant to participation in the schools and libraries program.
20 I certify that the services the applicant purchases at discounts provided by 47 U.S.C. § 254 will be used primarily for educational purposes, see 47 C.F.R. § 54.500, and will not be sold, resold or transferred in consideration for money or any other thing of value, except as permitted by the Commission’s rules at 47 C.F.R. § 54.513. Additionally, I certify that the entity or entities listed on this form have not received anything of value or a promise of anything of value, other than services and equipment sought by means of this form, from the service provider, or any representative or agent thereof or any consultant in connection with this request for services.
21 I acknowledge that support under this support mechanism is conditional upon the school(s) and/or library(ies) I represent securing access, separately or through this program, to all of the resources, including computers, training, software, internal connections, maintenance, and electrical capacity necessary to use the services purchased effectively. I recognize that some of the aforementioned resources are not eligible for support. I certify that I have considered what financial resources should be available to cover these costs.
22 I certify that I am authorized to procure eligible services for the eligible entity(ies). I certify that I am authorized to submit this request on behalf of the eligible entity(ies) listed on this form, that I have examined this request, and to the best of my knowledge, information, and belief, all statements of fact contained herein are true.
23 I certify that I have reviewed all applicable FCC, state, and local procurement/competitive bidding requirements and that I have complied with them. I acknowledge that persons willfully making false statements on this form may 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.
24 I acknowledge that FCC rules provide that persons who have been convicted of criminal violations or held civilly liable for certain acts arising from their participation in the schools and libraries support mechanism are subject to suspension and debarment from the program.
Entity Number: 16024867 Applicant's Form Identifier: MiCTA2013P2
Contact Person: Gary Green Contact Phone Number: (231) 881-6612
25 Signature of authorized person:
26 Date: 11/09/2013
27a Printed name of authorized person:
Gary Green
27b Title or position of authorized person:
Consultant
Check here if the consultant in Item 7 is the Authorized Person.
27c Street Address, P.O. Box, Route Number, City, State, Zip Code:
P. O. Box 303
4695 High Oaks Dr
City: Walloon Lake
State: MI
Zip Code: 49796
27d Telephone Number of Authorized Person:
(231) 881-6612
27e Fax Number of Authorized Person:
(231) 535-2993
27f E-mail Address of Authorized Person:
gary.green@mictatech.org
Re-enter E-mail Address:
gary.green@mictatech.org
27g Name of Authorized Person's Employer:
MiCTA
Service provider involvement with preparation or certification of an FCC Form 470
can taint the competitive bidding process and result in the denial of funding requests.
For more information, refer to the Schools and Libraries area of the USAC web site at
www.usac.org/sl or call the SLD Client Service Bureau at 1-888-203-8100.
Entity Number: 16024867 Applicant's Form Identifier: MiCTA2013P2
Contact Person: Gary Green Phone Number: (231) 881-6612
NOTICE: In accordance with Section 54.503 of the Federal Communications Commission’s rules, certain schools and libraries ordering services that are eligible for and seeking universal service discounts must file this Description of Services Requested and Certification Form (FCC Form 470) with the Universal Service Administrator. 47 C.F.R. § 54.503(c). 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. § 54.503. Schools and libraries 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 any applicable 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, information provided in or submitted with this form or in response to subsequent inquiries may also be subject to disclosure consistent with the Communications Act of 1934, FCC regulations, the Freedom of Information Act, 5 U.S.C. § 552, or other applicable law.

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 form 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 3 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 470
October 2010