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DO NOT STAPLE

OMB Control No. 3060-0853

Entity Number ________________________ Applicant’s Form Identifier ________________

Contact Person __________________________________ Phone Number _________________________

Block 4:Certifications and Signature

I certify that, if required by program rules, the entity(ies) receiving discounted services as indicated on this

FCC Form 486 are covered by technology plan(s) that have been approved by a state or other authorized body

(i.e., a USAC-certified technology plan approver) prior to the commencement of service and that cover all 12

months of the funding year. Provide the name(s) of the organization(s) that approved a technology plan for any

eligible entity that is receiving services covered under this FCC Form 486 or, if EVERY FRN listed in this FCC

Form 486 is for services that do not require a technology plan, enter "NONE" here.

____________________________________________________________________________________________

I certify that the services listed on this FCC Form 486 have been, are planned to be, or are being provided to

all or some of the eligible entities identified in the FCC Form 471 application(s) cited above. I certify that there are

signed contracts covering all of the services listed on this FCC Form 486 except for those services provided

under tariff or on a month-to-month basis. I certify that I am authorized to submit this receipt of service

confirmation on behalf of the above-named Billed Entity; that I have examined this request; and that, to the best of

my knowledge, information, and belief, all statements of fact contained herein are true.

10.

I understand 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 services receive an

appropriate share of benefits from those services. I recognize that I may be audited pursuant to this application

and will retain for five years (or whatever retention period is required by the rules in effect at the time of this

certification) any and all records, including FCC Forms 479 where required, that I rely upon to complete this form

and, if audited, will make such records available to the Administrator.

NOTES FOR COMPLETING THE CERTIFICATIONS IN ITEM 11: A Billed Entity who is the Administrative

Authority must check Item 11a or 11b or 11c. Check only ONE item. If the Billed Entity is not the

Administrative Authority, skip to Item 11d. A Billed Entity who represents one or more Administrative

Authorities must check Item 11d or 11e. A Billed Entity who represents one or more Administrative

Authorities in Funding Years after Funding Year 2001 and who checks Item 11d must check Item 11f or 11g.

See the FCC Form 486 Instructions for Item 11, "Special Notes for Billed Entities Who Represent One or

More Administrative Authorities."

IF THIS FORM PERTAINS TO A FUNDING YEAR PRIOR TO FUNDING YEAR 2001 (THE FUNDING

YEAR BEGINNING JULY 1, 2001), SKIP TO ITEM 12.

Page 4 of 7

FCC Form 486

December 2013

Fcc Form 486 - Schools And Libraries Universal Service Receipt Of Service Confirmation And Children'S Internet Protection Act And Technology Plan Certification Form Page 4