FCC Form 471
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Approval by OMB
3060-0806
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Schools and Libraries Universal Service
Description of Services Ordered and Certification Form 471
Estimated Average Burden Hours per Response: 4 hours
This form is designed to help schools and libraries to list the eligible services 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.
Please read instructions before beginning this application. (You can also file online at www.usac.org/sl.)
The instructions include information on the deadlines for filing this application.
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Applicant’s Form Identifier (Create an identifier for your own reference)
TPL 471 P1 14
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Form 471 Application #:
938652
(To be assigned by administrator)
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Block 1: Billed Entity Address and Identifications
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1 Name
of Billed Entity
TACOMA PUBLIC LIBRARY
2 Funding
Year 2014
3a Entity Number 145280
3b FCC Registration
Number 0011877545
4a Street Address,
P.O. Box, or Route Number
1102 TACOMA AVE S
City TACOMA
State WA Zip Code 98402-2006
4b Telephone
Number (253)
591-5607
4c Fax
Number (253)
591-5470
5a Type
of Application (check only one)
 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 defined
under LSTA)
Consortium
(intermediate service agencies, states, state networks, special 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:
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Private
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 Public
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Charter
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Tribal
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Head
Start
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State
Agency
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Entity Number:
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Applicant's Form Identifier:
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Contact Person:
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Contact Phone Number:
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Block 1: Billed Entity Address and Identifications (continued)
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6a Contact Person's
Name
Steve Hjelmstad
If the Contact Person’s Street Address is the same as Item 4 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
about this form.
1102 TACOMA AVE S
City TACOMA State WA Zip Code 98402-2006
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 (253)
292 - 2001
6d Fax Number (253)
383 - 1945
6e E-Mail Address shjelmstad@tacomapubliclibrary.org
Re-enter E-mail Address shjelmstad@tacomapubliclibrary.org
6f Holiday/vacation/summer
contact information: please include name of alternate contact (if applicable) and
alternate phone, fax or E-mail address
If a consultant is assisting you with your application process, please complete Item
6g below:
6g Consultant
Name NICOLE KUPSER
Name of Consultant’s Employer FundEd Consulting Group
Consultant’s Street Address FundED Consulting Group
20885 N. 90th Place, Suite 110
City Scottsdale State AZ Zip Code 85255
Consultant’s Telephone Number (480) 419-5729 Ext.
Consultant’s Fax Number (866) 800-5147
Consultant’s E-mail Address nicole.kupser@getfunded.net
Re-enter E-mail Address nicole.kupser@getfunded.net
Consultant Registration Number 16057463
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Blocks 2 and 3 [Reserved]
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Entity Number:
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Applicant's Form Identifier:
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Contact Person:
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Contact Phone Number:
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Block 4: Discount Calculation Worksheet
Worksheet - 1684338
Page 1 of 2
The Block 4 worksheet is used to calculate your discount for services. You will
complete one or more worksheets depending on the type of application
you are filing. If you file more than one worksheet, please number the completed
worksheets to assure that they are all processed correctly. Please refer to the instructions
for information specific to the Type of Application you
indicated in Block 1, Item 5.
Check here if this worksheet contains all eligible entities in the school district or library system. 9a List entities and calculate discount(s):
(For Administrator’s Use)
School District or Library System Name:
School District or Library System Entity Number:
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
| Name of Eligible Entity |
Entity Number AND NCES Code (for Schools) or FSCS Code (for Libraries) |
Urban or Rural U or R |
Total Number of Students |
Number of Students Eligible for NSLP |
Percent of Students Eligible for NSLP (Col. 5 / Col. 4) |
Disc. from Disc. Matrix |
New Cons tructi on |
Admin Entity or NIF |
Alt Disc Mech |
Weighted Product for Calculating Shared Discount (Col. 4 x Col. 7) |
Insert appropriate codes(s): P= pre-K, H = Head Start, A = Adult Education, J = Juvenile Justicem E = ESA, D = Dormatory |
Entity Number of School District in which Library Outlet/Branch is Located |
Discount of Member Entity |
Shared Discount |
| ALL ENTITIES |
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SCHOOLS AND LIBRARIES |
Schools with shared services |
Schools |
Library Outlet/Branch |
Consortia |
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| TACOMA PUBLIC LIBRARY |
145280
|
U
| 29496 | 18521 |
62.792%
| 80 |
N
| N | N |
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145279
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9b Shared Services
| SCHOOL DISTRICTS: (Including groups of schools within
school districts.) Calculate the totals of Columns 4 and 11.
Divide the total of Column 11 by the total of Column 4. Enter
the result in Column 15. |
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| LIBRARY SYSTEMS: Calculate the total of Column 7.
Divide this total by the number of outlets/branches. Enter the
result in Column 15. |
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80 |
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80% |
| CONSORTIA: Calculate the total of Column 14. Divide this
total by the number of member entities. Enter the result in
Column 15. |
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Entity Number:
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Applicant's Form Identifier:
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Contact Person:
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Contact Phone Number:
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Block 4: Discount Calculation Worksheet
Worksheet - 1684339
Page 2 of 2
The Block 4 worksheet is used to calculate your discount for services. You will
complete one or more worksheets depending on the type of application
you are filing. If you file more than one worksheet, please number the completed
worksheets to assure that they are all processed correctly. Please refer to the instructions
for information specific to the Type of Application you
indicated in Block 1, Item 5.
Check here if this worksheet contains all eligible entities in the school district or library system. 9a List entities and calculate discount(s):
(For Administrator’s Use)
School District or Library System Name:
School District or Library System Entity Number:
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
| Name of Eligible Entity |
Entity Number AND NCES Code (for Schools) or FSCS Code (for Libraries) |
Urban or Rural U or R |
Total Number of Students |
Number of Students Eligible for NSLP |
Percent of Students Eligible for NSLP (Col. 5 / Col. 4) |
Disc. from Disc. Matrix |
New Cons tructi on |
Admin Entity or NIF |
Alt Disc Mech |
Weighted Product for Calculating Shared Discount (Col. 4 x Col. 7) |
Insert appropriate codes(s): P= pre-K, H = Head Start, A = Adult Education, J = Juvenile Justicem E = ESA, D = Dormatory |
Entity Number of School District in which Library Outlet/Branch is Located |
Discount of Member Entity |
Shared Discount |
| ALL ENTITIES |
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SCHOOLS AND LIBRARIES |
Schools with shared services |
Schools |
Library Outlet/Branch |
Consortia |
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| MOTTET BRANCH LIBRARY |
115884
WA 0068 008
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U
| 0 | 0 |
0.000%
| 80 |
| | N |
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145279
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| GEORGE O SWASEY BRANCH LIBRARY |
115905
WA 0068 011
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U
| 0 | 0 |
0.000%
| 80 |
| | N |
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145279
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| A E MCCORMICK BRANCH LIBRARY |
115916
WA 0068 006
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U
| 0 | 0 |
0.000%
| 80 |
| | N |
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145279
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| FERN HILL BRANCH LIBRARY |
115966
WA 0068 003
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U
| 0 | 0 |
0.000%
| 80 |
| | N |
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145279
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| SOUTH TACOMA BRANCH LIBRARY |
115933
WA 0068 009
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U
| 0 | 0 |
0.000%
| 80 |
| | N |
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145279
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| KOBETICH BRANCH LIBRARY |
115944
WA 0068 005
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U
| 0 | 0 |
0.000%
| 80 |
| | N |
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145279
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| GRACE R MOORE BRANCH LIBRARY |
115925
WA 0068 007
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U
| 0 | 0 |
0.000%
| 80 |
| | N |
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145279
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9b Shared Services
| SCHOOL DISTRICTS: (Including groups of schools within
school districts.) Calculate the totals of Columns 4 and 11.
Divide the total of Column 11 by the total of Column 4. Enter
the result in Column 15. |
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| LIBRARY SYSTEMS: Calculate the total of Column 7.
Divide this total by the number of outlets/branches. Enter the
result in Column 15. |
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560 |
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80% |
| CONSORTIA: Calculate the total of Column 14. Divide this
total by the number of member entities. Enter the result in
Column 15. |
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Entity Number:
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Applicant's Form Identifier:
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Contact Person:
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Contact Phone Number:
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Block 5: Discount Funding Request(s)
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 needed,
and number the completed pages to assure that they are all processed correctly.
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Block 5, page
1 of 4
FRN 2648063
(to be assigned by administrator)
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10
If this is a duplicate
Funding Request (e.g., of an FRN that is not yet approved, under appeal,
etc.),
check this box and enter the original FRN in the space provided:
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11 Category of Service ( only ONE category should be checked)
PRIORITY 1
Telecommunications Service
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PRIORITY 2
Internal Connections Other than Basic
Maintenance
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Internet Access
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Basic Maintenance of Internal Connections
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12 Form 470
Application Number
895270001139308
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13 SPIN – Service
Provider Identification Number
143031202
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14 Service Provider
Name
Appia Communications, Inc.
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15a
Check this box if this Funding Request is
for non-contracted tariffed or month-to-month services.
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15b Contract
Number
MTM
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15c
Check this box if this Funding Request is
covered under a master contract (a contract negotiated by a third party, the terms
and conditions of which are then made available to an eligible entity that purchases
directly from the service provider).
15d
Check this box if this Funding Request is
a continuation of an FRN from a previous funding year based on a multi-year contract.
If so, provide that FRN here:
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16a Billing
Account Number (e.g., billed telephone number)
16b Check
this box if there are multiple Billing Account Numbers and attach a complete list
of those numbers to this page.
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17 Allowable
Vendor Selection/Contract Date (mm/dd/yyyy)
(based on Form 470 filing)
12/09/2013
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18 Contract
Award Date (mm/dd/yyyy)
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19 Service Start
Date (mm/dd/yyyy)
07/01/2014
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20a Service End Date
(mm/dd/yyyy)
06/30/2015
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Contract
Expiration Date
20b (mm/dd/yyyy)
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23
Calculations
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Recurring Charges
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A. Monthly charges (total amount
per month for service)
$2,311.50
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B. How much of the amount in A
is ineligible?
$0.00
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C. Eligible monthly pre-discount
amount (A minus B)
$2,311.50
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D. Number of months service provided
in funding year
12
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E. Annual pre-discount amount for
eligible recurring charges (C x D)
$27,738.00
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Non-Recurring Charges
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F. Annual non-recurring charges
$0.00
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G. How much of the amount in F
is ineligible?
$0.00
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H. Annual eligible pre-discount
amount for non-recurring charges (F minus G)
$0.00
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Total Charges
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I. Total funding year pre-discount
amount (E + H)
$27,738.00
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J. Discount from Block 4 Worksheet
80.00
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K. Funding Commitment Request (I
x J)
$22,190.40
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21 Description
of This Service: NOTE: All Item 21 Attachments must be filed before the close of
the filing window. Attachment
You MUST attach a description of the service, including
a breakdown of components, costs, manufacturer name, make and model number. You
must include any additional account or telephone numbers
if the billed account has multiple numbers. Label the description with an Attachment
Appia VoIP
Number, and note number in space provided.
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22
Entity/Entities Receiving This Service:
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a. 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:
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b. If the service is shared by all entities on a Block 4
worksheet, list the worksheet number (e.g., 1):
1684339
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Entity Number:
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Applicant's Form Identifier:
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Contact Person:
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Contact Phone Number:
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Block 5 (Continued):
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24 |
Description of Broadband and other Connectivity Services Ordered for Schools and
Libraries from this
funding request
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Complete the information below for this funding request only if requesting Telecommunications Services or Internet Access for the
purpose of providing broadband and other types of connectivity to school and/or library facilities.
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Check this box if this request is for services or equipment that do not provide broadband or connectivity. For instance, check the box if this
funding request is for internal connections, basic maintenance, or requests for services like e-mail or phone service.
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a |
Which technology(ies) and speed(s) are being provided in this Funding Request? Please list the number of lines and average download speed
for the lines included in this funding request. If there are multiple download speeds for the lines within one type of broadband connection, this
form provides two additional lines per broadband connection category. If you need additional space, please makes copies of this page and
number the completed pages to assure that they are all processed correctly. A response to this Item is not a substitute for a complete response
to Item 21 but should be consistent with the description of services in the response to Item 21. Please ask your service provider if you need
assistance.
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| Type of Connection | Number of lines
included in this FRN | Download speed per
line in Mbps |
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b |
If the Internet service is available to students or patrons in more than just a single location or office, please indicate:
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1.
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If the access is provided by wired connections, approximately what percentage of
the school classroom or public library rooms
included in the Block 4 worksheet for
this FRN will have access to wired drops? ___%
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| 2. |
If the access is provided by Wi-FI connections, approximately what percentage
of the school classroom or public library rooms
included in the Block 4 worksheet
for this FRN will have access to a Wi-Fi signal? ___%
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c |
For consortia and statewide applications, do the connections in this FRN include the last mile connection to the school or library? Yes No
If no above, are these connections only for backbone connections? Yes No
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Entity Number:
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Applicant's Form Identifier:
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Contact Person:
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Contact Phone Number:
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Block 5: Discount Funding Request(s)
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 needed,
and number the completed pages to assure that they are all processed correctly.
|
Block 5, page
2 of 4
FRN 2648093
(to be assigned by administrator)
|
10
If this is a duplicate
Funding Request (e.g., of an FRN that is not yet approved, under appeal,
etc.),
check this box and enter the original FRN in the space provided:
|
11 Category of Service ( only ONE category should be checked)
PRIORITY 1
Telecommunications Service
|
PRIORITY 2
Internal Connections Other than Basic
Maintenance
|
|
Internet Access
|
Basic Maintenance of Internal Connections
|
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12 Form 470
Application Number
895270001139308
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13 SPIN – Service
Provider Identification Number
143035981
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14 Service Provider
Name
Tacoma Public Utilities
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15a
Check this box if this Funding Request is
for non-contracted tariffed or month-to-month services.
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15b Contract
Number
MTM
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15c
Check this box if this Funding Request is
covered under a master contract (a contract negotiated by a third party, the terms
and conditions of which are then made available to an eligible entity that purchases
directly from the service provider).
15d
Check this box if this Funding Request is
a continuation of an FRN from a previous funding year based on a multi-year contract.
If so, provide that FRN here:
|
16a Billing
Account Number (e.g., billed telephone number)
16b Check
this box if there are multiple Billing Account Numbers and attach a complete list
of those numbers to this page.
|
17 Allowable
Vendor Selection/Contract Date (mm/dd/yyyy)
(based on Form 470 filing)
12/09/2013
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18 Contract
Award Date (mm/dd/yyyy)
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19 Service Start
Date (mm/dd/yyyy)
07/01/2014
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20a Service End Date
(mm/dd/yyyy)
06/30/2015
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Contract
Expiration Date
20b (mm/dd/yyyy)
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23
Calculations
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Recurring Charges
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A. Monthly charges (total amount
per month for service)
$8,050.00
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B. How much of the amount in A
is ineligible?
$0.00
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C. Eligible monthly pre-discount
amount (A minus B)
$8,050.00
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D. Number of months service provided
in funding year
12
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E. Annual pre-discount amount for
eligible recurring charges (C x D)
$96,600.00
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Non-Recurring Charges
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F. Annual non-recurring charges
$0.00
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G. How much of the amount in F
is ineligible?
$0.00
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H. Annual eligible pre-discount
amount for non-recurring charges (F minus G)
$0.00
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Total Charges
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I. Total funding year pre-discount
amount (E + H)
$96,600.00
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J. Discount from Block 4 Worksheet
80.00
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K. Funding Commitment Request (I
x J)
$77,280.00
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21 Description
of This Service: NOTE: All Item 21 Attachments must be filed before the close of
the filing window. Attachment
You MUST attach a description of the service, including
a breakdown of components, costs, manufacturer name, make and model number. You
must include any additional account or telephone numbers
if the billed account has multiple numbers. Label the description with an Attachment
TPU Click IA
Number, and note number in space provided.
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22
Entity/Entities Receiving This Service:
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a. 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:
|
b. If the service is shared by all entities on a Block 4
worksheet, list the worksheet number (e.g., 1):
1684339
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Entity Number:
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Applicant's Form Identifier:
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Contact Person:
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Contact Phone Number:
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Block 5 (Continued):
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24 |
Description of Broadband and other Connectivity Services Ordered for Schools and
Libraries from this
funding request
|
| |
|
Complete the information below for this funding request only if requesting Telecommunications Services or Internet Access for the
purpose of providing broadband and other types of connectivity to school and/or library facilities.
|
| |
|
Check this box if this request is for services or equipment that do not provide broadband or connectivity. For instance, check the box if this
funding request is for internal connections, basic maintenance, or requests for services like e-mail or phone service.
|
| |
a |
Which technology(ies) and speed(s) are being provided in this Funding Request? Please list the number of lines and average download speed
for the lines included in this funding request. If there are multiple download speeds for the lines within one type of broadband connection, this
form provides two additional lines per broadband connection category. If you need additional space, please makes copies of this page and
number the completed pages to assure that they are all processed correctly. A response to this Item is not a substitute for a complete response
to Item 21 but should be consistent with the description of services in the response to Item 21. Please ask your service provider if you need
assistance.
|
| |
|
| Type of Connection | Number of lines
included in this FRN | Download speed per
line in Mbps |
| Fiber optic/OC-x | 1 | 100 |
| Fiber optic/OC-x | 7 | 10 |
| Fiber optic/OC-x | 1 | 100 |
|
| |
b |
If the Internet service is available to students or patrons in more than just a single location or office, please indicate:
|
1.
|
If the access is provided by wired connections, approximately what percentage of
the school classroom or public library rooms
included in the Block 4 worksheet for
this FRN will have access to wired drops? __90_%
|
| 2. |
If the access is provided by Wi-FI connections, approximately what percentage
of the school classroom or public library rooms
included in the Block 4 worksheet
for this FRN will have access to a Wi-Fi signal? __90_%
|
|
| |
c |
For consortia and statewide applications, do the connections in this FRN include the last mile connection to the school or library? Yes No
If no above, are these connections only for backbone connections? Yes No
|
|
Entity Number:
|
Applicant's Form Identifier:
|
|
Contact Person:
|
Contact Phone Number:
|
Block 5: Discount Funding Request(s)
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 needed,
and number the completed pages to assure that they are all processed correctly.
|
Block 5, page
3 of 4
FRN 2648126
(to be assigned by administrator)
|
10
If this is a duplicate
Funding Request (e.g., of an FRN that is not yet approved, under appeal,
etc.),
check this box and enter the original FRN in the space provided:
|
11 Category of Service ( only ONE category should be checked)
PRIORITY 1
Telecommunications Service
|
PRIORITY 2
Internal Connections Other than Basic
Maintenance
|
|
Internet Access
|
Basic Maintenance of Internal Connections
|
|
12 Form 470
Application Number
895270001139308
|
13 SPIN – Service
Provider Identification Number
143026181
|
14 Service Provider
Name
T-Mobile USA, Inc.
|
|
15a
Check this box if this Funding Request is
for non-contracted tariffed or month-to-month services.
|
15b Contract
Number
MTM
|
15c
Check this box if this Funding Request is
covered under a master contract (a contract negotiated by a third party, the terms
and conditions of which are then made available to an eligible entity that purchases
directly from the service provider).
15d
Check this box if this Funding Request is
a continuation of an FRN from a previous funding year based on a multi-year contract.
If so, provide that FRN here:
|
16a Billing
Account Number (e.g., billed telephone number)
16b Check
this box if there are multiple Billing Account Numbers and attach a complete list
of those numbers to this page.
|
17 Allowable
Vendor Selection/Contract Date (mm/dd/yyyy)
(based on Form 470 filing)
12/09/2013
|
18 Contract
Award Date (mm/dd/yyyy)
|
19 Service Start
Date (mm/dd/yyyy)
07/01/2014
|
20a Service End Date
(mm/dd/yyyy)
06/30/2015
|
Contract
Expiration Date
20b (mm/dd/yyyy)
|
|
|
23
Calculations
|
|
Recurring Charges
|
A. Monthly charges (total amount
per month for service)
$510.00
|
B. How much of the amount in A
is ineligible?
$0.00
|
C. Eligible monthly pre-discount
amount (A minus B)
$510.00
|
D. Number of months service provided
in funding year
12
|
E. Annual pre-discount amount for
eligible recurring charges (C x D)
$6,120.00
|
|
Non-Recurring Charges
|
F. Annual non-recurring charges
$0.00
|
G. How much of the amount in F
is ineligible?
$0.00
|
H. Annual eligible pre-discount
amount for non-recurring charges (F minus G)
$0.00
|
|
Total Charges
|
I. Total funding year pre-discount
amount (E + H)
$6,120.00
|
J. Discount from Block 4 Worksheet
80.00
|
K. Funding Commitment Request (I
x J)
$4,896.00
|
|
21 Description
of This Service: NOTE: All Item 21 Attachments must be filed before the close of
the filing window. Attachment
You MUST attach a description of the service, including
a breakdown of components, costs, manufacturer name, make and model number. You
must include any additional account or telephone numbers
if the billed account has multiple numbers. Label the description with an Attachment
TMobile cell
Number, and note number in space provided.
|
|
22
Entity/Entities Receiving This Service:
|
a. 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:
|
b. If the service is shared by all entities on a Block 4
worksheet, list the worksheet number (e.g., 1):
1684339
|
|
|
Entity Number:
|
Applicant's Form Identifier:
|
|
Contact Person:
|
Contact Phone Number:
|
Block 5 (Continued):
|
| |
24 |
Description of Broadband and other Connectivity Services Ordered for Schools and
Libraries from this
funding request
|
| |
|
Complete the information below for this funding request only if requesting Telecommunications Services or Internet Access for the
purpose of providing broadband and other types of connectivity to school and/or library facilities.
|
| |
|
Check this box if this request is for services or equipment that do not provide broadband or connectivity. For instance, check the box if this
funding request is for internal connections, basic maintenance, or requests for services like e-mail or phone service.
|
| |
a |
Which technology(ies) and speed(s) are being provided in this Funding Request? Please list the number of lines and average download speed
for the lines included in this funding request. If there are multiple download speeds for the lines within one type of broadband connection, this
form provides two additional lines per broadband connection category. If you need additional space, please makes copies of this page and
number the completed pages to assure that they are all processed correctly. A response to this Item is not a substitute for a complete response
to Item 21 but should be consistent with the description of services in the response to Item 21. Please ask your service provider if you need
assistance.
|
| |
|
| Type of Connection | Number of lines
included in this FRN | Download speed per
line in Mbps |
|
| |
b |
If the Internet service is available to students or patrons in more than just a single location or office, please indicate:
|
1.
|
If the access is provided by wired connections, approximately what percentage of
the school classroom or public library rooms
included in the Block 4 worksheet for
this FRN will have access to wired drops? ___%
|
| 2. |
If the access is provided by Wi-FI connections, approximately what percentage
of the school classroom or public library rooms
included in the Block 4 worksheet
for this FRN will have access to a Wi-Fi signal? ___%
|
|
| |
c |
For consortia and statewide applications, do the connections in this FRN include the last mile connection to the school or library? Yes No
If no above, are these connections only for backbone connections? Yes No
|
|
Entity Number:
|
Applicant's Form Identifier:
|
|
Contact Person:
|
Contact Phone Number:
|
Block 5: Discount Funding Request(s)
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 needed,
and number the completed pages to assure that they are all processed correctly.
|
Block 5, page
4 of 4
FRN 2648145
(to be assigned by administrator)
|
10
If this is a duplicate
Funding Request (e.g., of an FRN that is not yet approved, under appeal,
etc.),
check this box and enter the original FRN in the space provided:
|
11 Category of Service ( only ONE category should be checked)
PRIORITY 1
Telecommunications Service
|
PRIORITY 2
Internal Connections Other than Basic
Maintenance
|
|
Internet Access
|
Basic Maintenance of Internal Connections
|
|
12 Form 470
Application Number
895270001139308
|
13 SPIN – Service
Provider Identification Number
143023886
|
14 Service Provider
Name
Integra Telecom Of Washington, Inc.
|
|
15a
Check this box if this Funding Request is
for non-contracted tariffed or month-to-month services.
|
15b Contract
Number
MTM
|
15c
Check this box if this Funding Request is
covered under a master contract (a contract negotiated by a third party, the terms
and conditions of which are then made available to an eligible entity that purchases
directly from the service provider).
15d
Check this box if this Funding Request is
a continuation of an FRN from a previous funding year based on a multi-year contract.
If so, provide that FRN here:
|
16a Billing
Account Number (e.g., billed telephone number)
16b Check
this box if there are multiple Billing Account Numbers and attach a complete list
of those numbers to this page.
|
17 Allowable
Vendor Selection/Contract Date (mm/dd/yyyy)
(based on Form 470 filing)
12/09/2013
|
18 Contract
Award Date (mm/dd/yyyy)
|
19 Service Start
Date (mm/dd/yyyy)
07/01/2014
|
20a Service End Date
(mm/dd/yyyy)
06/30/2015
|
Contract
Expiration Date
20b (mm/dd/yyyy)
|
|
|
23
Calculations
|
|
Recurring Charges
|
A. Monthly charges (total amount
per month for service)
$467.39
|
B. How much of the amount in A
is ineligible?
$0.00
|
C. Eligible monthly pre-discount
amount (A minus B)
$467.39
|
D. Number of months service provided
in funding year
12
|
E. Annual pre-discount amount for
eligible recurring charges (C x D)
$5,608.68
|
|
Non-Recurring Charges
|
F. Annual non-recurring charges
$0.00
|
G. How much of the amount in F
is ineligible?
$0.00
|
H. Annual eligible pre-discount
amount for non-recurring charges (F minus G)
$0.00
|
|
Total Charges
|
I. Total funding year pre-discount
amount (E + H)
$5,608.68
|
J. Discount from Block 4 Worksheet
80.00
|
K. Funding Commitment Request (I
x J)
$4,486.94
|
|
21 Description
of This Service: NOTE: All Item 21 Attachments must be filed before the close of
the filing window. Attachment
You MUST attach a description of the service, including
a breakdown of components, costs, manufacturer name, make and model number. You
must include any additional account or telephone numbers
if the billed account has multiple numbers. Label the description with an Attachment
Integra POTS
Number, and note number in space provided.
|
|
22
Entity/Entities Receiving This Service:
|
a. 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:
|
b. If the service is shared by all entities on a Block 4
worksheet, list the worksheet number (e.g., 1):
1684339
|
|
|
Entity Number:
|
Applicant's Form Identifier:
|
|
Contact Person:
|
Contact Phone Number:
|
Block 5 (Continued):
|
| |
24 |
Description of Broadband and other Connectivity Services Ordered for Schools and
Libraries from this
funding request
|
| |
|
Complete the information below for this funding request only if requesting Telecommunications Services or Internet Access for the
purpose of providing broadband and other types of connectivity to school and/or library facilities.
|
| |
|
Check this box if this request is for services or equipment that do not provide broadband or connectivity. For instance, check the box if this
funding request is for internal connections, basic maintenance, or requests for services like e-mail or phone service.
|
| |
a |
Which technology(ies) and speed(s) are being provided in this Funding Request? Please list the number of lines and average download speed
for the lines included in this funding request. If there are multiple download speeds for the lines within one type of broadband connection, this
form provides two additional lines per broadband connection category. If you need additional space, please makes copies of this page and
number the completed pages to assure that they are all processed correctly. A response to this Item is not a substitute for a complete response
to Item 21 but should be consistent with the description of services in the response to Item 21. Please ask your service provider if you need
assistance.
|
| |
|
| Type of Connection | Number of lines
included in this FRN | Download speed per
line in Mbps |
|
| |
b |
If the Internet service is available to students or patrons in more than just a single location or office, please indicate:
|
1.
|
If the access is provided by wired connections, approximately what percentage of
the school classroom or public library rooms
included in the Block 4 worksheet for
this FRN will have access to wired drops? ___%
|
| 2. |
If the access is provided by Wi-FI connections, approximately what percentage
of the school classroom or public library rooms
included in the Block 4 worksheet
for this FRN will have access to a Wi-Fi signal? ___%
|
|
| |
c |
For consortia and statewide applications, do the connections in this FRN include the last mile connection to the school or library? Yes No
If no above, are these connections only for backbone connections? Yes No
|
|
|
Entity Number:
|
Applicant's Form Identifier:
|
|
Contact Person:
|
Contact Phone Number:
|
Block 6: Certifications and Signature
25
I certify that the entities
listed in Block 4 of this application are eligible for support because they are:
(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, secondary schools, colleges, or universities.
26
I certify that the entity I
represent or the entities listed on this application have secured 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 the entities I represent or
the entities listed on this application have secured access to all of the resources
to pay the discounted charges for eligible services from funds to
which access has been secured in the current funding year. I certify that the Billed
Entity will pay the non-discount portion of the cost of the goods
and services to the service provider(s).
|
a Total funding year
pre-discount amount on this Form 471
(Add the entries from Items 23I on all Block
5 Discount Funding Requests.)
|
136066.68
|
b Total funding commitment
request amount on this Form 471
(Add the entries from Items 23K on all Block
5 Discount Funding Requests.)
|
108853.34
|
c Total applicant
non-discount share
(Subtract Item 26b from Item 26a.)
|
27213.34
|
|
d Total budgeted amount
allocated to resources not eligible for E-rate support
|
27213.20
|
e Total amount necessary
for the applicant to pay the non-discount share of the
services requested on this application AND
to secure access to the resources
necessary to make effective use of the discounts.
(Add Items 26c and 26d.)
|
54426.54
|
f
Check this box if you are receiving
any of the funds in Item 26e directly from a service provider listed on any of the
Forms 471 filed by this
Billed
Entity for this funding year, or if a service provider listed on any of the Forms
471 filed by this Billed Entity for this funding year assisted
you in
locating funds in Item 26e.
|
|
27
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.
28
I certify that (if applicable)
I posted my Form 470 and (if applicable) made any related RFP available for at least
28 days before considering all bids
received and selecting a service provider. I certify that all bids submitted were
carefully considered and the most cost-effective service offering was
selected, with price being the primary factor considered, and is the most cost-effective
means of meeting educational needs and technology plan
goals.
29
I certify that the entity responsible
for selecting the service provider(s) has reviewed all applicable FCC, state, and
local procurement/competitive
bidding requirements and that the entity or entities listed on this application
have complied with them.
30
I certify that the services
the applicant purchases at discounts provided by 47 U.S.C. § 254 will be used primarily
for educational purposes 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. §§
54.500, 54.513. Additionally, I certify that the entity or entities listed on
this application 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.
31
I certify that I and the entity(ies)
I represent have complied with all program rules, including recordkeeping requirements, and I acknowledge that
failure to do so may result in denial of discount funding and/or cancellation of funding commitments. There are signed contracts
covering all
of the services listed on this Form 471 except for those services provided under non-contracted tariffed or month-to-month
arrangements. I
acknowledge that failure to comply with program rules could result in civil or criminal prosecution by the appropriate law
enforcement authorities.
|
|
Entity Number:
|
Applicant's Form Identifier:
|
|
Contact Person:
|
Contact Phone Number:
|
Block 6: Certification and Signature (Continued)
32
I acknowledge 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.
33
I certify that I will retain
required documents for a period of at least five years (or whatever retention period is required by the rules in effect at the
time of this certification) 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 application for, receipt of, and delivery of
services receiving schools and libraries discounts, and
that if audited, I will make such records available to the Administrator. I acknowledge that I
may be audited pursuant to participation in the schools
and libraries program.
34
I certify that I am authorized
to order telecommunications and other supported services for the eligible entity(ies)
listed on this application. I certify
that I am authorized to submit this request on behalf of the eligible entity(ies)
listed on this application, that I have examined this request, that all of
the information on this form is true and correct to the best of my knowledge, that
the entities that are receiving discounts pursuant to this application
have complied with the terms, conditions and purposes of the program, that no kickbacks
were paid to anyone and that false statements 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 and civil violations of the False Claims Act.
35
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. I will institute
reasonable measures to be informed, and will notify USAC should I be informed or
become aware that I or any of the entities listed on this
application, or any person associated in any way with my entity and/or the entities
listed on this application, is convicted of a criminal violation or
held civilly liable for acts arising from their participation in the schools and
libraries support mechanism.
36
I certify that if any of the
Funding Requests on this Form 471 are for discounts for products or services that
contain both eligible and ineligible
components, that I have allocated the eligible and ineligible
components as required by the Commission's rules at 47 C.F.R.
§ 54.504(g)(1), (2).
37
I certify that this funding
request does not constitute a request for internal connections services, except
basic maintenance services, in violation of
the Commission requirement that eligible entities are not eligible for such support
more than twice every five funding years as required by the
Commission's rules at 47 C.F.R. § 54.506(c).
38
I certify that the non-discount
portion of the costs for eligible services will not be paid by the service provider.
The pre-discount costs of eligible
services featured on this Form 471 are net of any rebates or discounts offered by
the service provider. I acknowledge that, for the purpose of this
rule, the provision, by the provider of a supported service, of free services or
products unrelated to the supported service or product constitutes a
rebate of some or all of the cost of the supported services.
|
39
Signature of
authorized
person
|
40
Date
03/17/2014
|
41
Printed name
of
authorized
person
Steve Hjelmstad
42
Title or position
of
authorized
person
Network Manager
Check here if the consultant in Item 6g is the Authorized
Person.
43a
Street Address, P.O. Box, or Route Number
1102 Tacoma Ave S
City
Tacoma
State
WA
Zip Code
98402-2006
|
|
Entity Number:
|
Applicant's Form Identifier:
|
|
Contact Person:
|
Contact Phone Number:
|
43b Telephone
Number
Ext.
of
authorized
Person
(253) 292-2001
1520
43c Fax
Number of Authorized Person
(253) 194-1945
43d E-mail
Address
of
authorized
Person
shjelmstad@tacomapubliclibrary.org
Re-enter
E-mail Address
shjelmstad@tacomapubliclibrary.org
43e Name
of Authorized
Person’s
Employer
Tacoma Public Library
|
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 Services Ordered and Certification Form
(FCC Form 471) with the Universal Service Administrator. 47 C.F.R.§ 54.504(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 47C.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 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, 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
4 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.
Please submit this form to:
SLD-Form 471
P.O. Box 7026
Lawrence, Kansas 66044-7026
For express delivery services or U.S. Postal Service, Return Receipt
Requested, mail this form to:
SLD Forms
ATTN: SLD Form 471
3833 Greenway Drive
Lawrence, Kansas 66046
(888) 203-8100
|
|
FCC Form 471 - December 2013
|
|