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Fcc Form 479 - Certification By Administrative Authority To Billed Entity Of Compliance With The Children'S Internet Protection Act

OMB Control No. 3060-0853

FCC Form 479

OMB Control No. 3060-0853

Estimated time per response: 1 hour

DO NOT SEND THIS FORM TO THE UNIVERSAL SERVICE ADMINISTRATIVE COMPANY

OR TO THE FEDERAL COMMUNICATIONS COMMISSION

Schools and Libraries Universal Service

Certification by Administrative Authority to Billed Entity of

Compliance with the Children’s Internet Protection Act

Please read instructions before completing.

(To be completed by the Administrative Authority and provided to your Billed Entity)

Administrative Authority’s Form Identifier: __________________________________________

Create your own code to identify THIS FCC Form 479.

Block 1: Administrative Authority Information

1. Name of Administrative Authority

2. Funding Year

2016-2017

3. Mailing Address and Contact Information for Administrative Authority

Street Address, P. O. Box or Route Number

City

State

Zip Code

Name of Contact Person

Telephone Number

Fax Number

Email Address

Persons willfully making false statements on this form can be punished by fine or forfeiture, under the

Communications Act, 47 U.S.C. Secs. 502, 503(b), or fine or imprisonment under Title 18 of the United States

Code, 18 U.S.C. Sec. 1001.

Block 2: Certifications and Signature

4. I am the Administrative Authority for one or more schools or libraries for which Universal Service Support Mechanism

discounts have been requested or approved for eligible services. The Administrative Authority must make the

required certification(s) for the purposes of the Children’s Internet Protection Act (CIPA) in order to receive

discounted services.

5. I recognize that I may be audited pursuant to this form and will retain for at least five years (or whatever retention

period is required by the rules in effect at the time of this certification) any and all records that I rely upon to complete

this form.

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FCC Form 479

December 2013

Fcc Form 479 - Certification By Administrative Authority To Billed Entity Of Compliance With The Children'S Internet Protection Act