Fcc Form 474 - Schools And Libraries Universal Service Service Provider Invoice (Page 3 of 4) in pdf

Fcc Form 474 - Schools And Libraries Universal Service Service Provider Invoice Page 3

Approved by OMB

OMB Control No. 3060-0856

Service Provider Invoice FCC Form 474

Service Provider Form Identifier ______________________________________________________

Contact Person ____________________________________________________________________

Contact Telephone Number ___________________________________________________________

Block 3: Service Provider Certifications & Signature

I declare under penalty of perjury that the foregoing is true and correct and that I am authorized to submit this

Service Provider Invoice Form (FCC Form 474) and acknowledge to the best of my knowledge, information and

belief, as follows:

I certify that this Service Provider 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 certify that the certifications made on the Service Provider Annual Certification Form (FCC Form 473) by this

Service Provider are true and correct.

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.

14. Signature of authorized person

15. Date

16. Printed name of authorized person

17. Title or position of authorized person

18. Telephone number of authorized person

19. Address of authorized person

Page 3 of 4

FCC Form 474

July 2013

Fcc Form 474 - Schools And Libraries Universal Service Service Provider Invoice Page 3