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DO NOT STAPLE

OMB Control No. 3060-0853

Entity Number ___________________ Applicant’s Form Identifier ______________________________________

Contact Person __________________________________ Phone Number ________________________________

11. FOR A BILLED ENTITY WHO IS THE ADMINISTRATIVE AUTHORITY:

I certify that as of the date of the start of discounted services:

the recipient(s) of service represented in the Funding Request Number(s) on this Form 486 has (have)

complied with the requirements of the Children's Internet Protection Act, as codified at 47 U.S.C. § 254(h)

and (l).

pursuant to the Children's Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), the recipient(s) of

service represented in the Funding Request Number(s) on this Form 486:

(FOR SCHOOLS and FOR LIBRARIES IN THE FIRST FUNDING YEAR FOR PURPOSES OF CIPA) is (are)

undertaking such actions, including any necessary procurement procedures, to comply with the

requirements of CIPA for the next funding year, but has (have) not completed all requirements of CIPA for

this funding year.

(FOR FUNDING YEAR 2003 ONLY: FOR LIBRARIES IN THE SECOND OR THIRD FUNDING YEAR FOR

PURPOSES OF CIPA) is (are) in compliance with the requirements of CIPA under 47 U.S.C. § 254(l) and

undertaking such actions, including any necessary procurement procedures, to comply with the

requirements of CIPA under 47 U.S.C. § 254(h) for the next funding year.

the Children's Internet Protection Act, as codified at 47 U.S.C. § 254(h) and (l), does not apply because the

recipient(s) of service represented in the Funding Request Number(s) on this Form 486 is (are) receiving

discount services only for telecommunications services.

FOR A BILLED ENTITY WHO REPRESENTS ONE OR MORE ADMINISTRATIVE AUTHORITIES:

I certify as the Billed Entity for the consortium that I have collected duly completed and signed FCC Forms

479 from all eligible members of the consortium.

I certify as the Billed Entity for the consortium that the only services that have been approved for discounts

under the universal service support mechanism on behalf of eligible members of the consortium are

telecommunications services, and therefore the requirements of the Children's Internet Protection Act, as

codified at 47 U.S.C. § 254(h) and (l), do not apply.

For Funding Years after Funding Year 2001: If you checked Item 11d above, check ONE of the boxes below:

I certify that some or all of the eligible consortium members checked FCC Form 479 Item 6d to seek a CIPA

Waiver, and upon request from the Administrator I can provide this information; OR

I certify that no eligible consortium members checked FCC Form 479 Item 6d to seek a CIPA Waiver.

The certification language above is not intended to fully set forth or explain all the requirements of the statute.

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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 5