form 472 step-by-step billed entity applicant reimbursement bear

1. Form 472 Step-by-StepBilled Entity Applicant Reimbursement (BEAR)

3. Form 472 � Billed Entity Applicant Reimbursement Form Purpose (cont.) The Billed Entity should submit a BEAR Form to the SLD when all of the following conditions occur: The Billed Entity must have received an FCDL Services have been or are being received and have been paid for in full (including discounts) The Billed Entity has filed FCC Form 486

4. Form 472 � Billed Entity Applicant Reimbursement Form Purpose (cont.) On the Billed Entity�s BEAR Form, the Service Provider: Must acknowledge that it will remit the discounted amount to the Billed Entity no later than 10 calendar days after receipt of the reimbursement Must remit payment of the approved discount amount to the Billed Entity prior to tendering or making use of the payment issued by Universal Service Administrative Company (USAC)

5. Form 472 � Billed Entity Applicant Reimbursement Form Who Must File the Form 472? The Billed Entity representing a school, school district, library (outlet/branch, system), or a consortium of those entities who completed and submitted the Form 471, filed the Form 486, and seeks to receive reimbursement for services already paid in full

6. Form 472 � Billed Entity Applicant Reimbursement Form How Many Form(s) 472 to File? Must submit a separate Form 472 for each Service Provider with a separate Service Provider Identification Number (SPIN) Can combine all Funding Request Numbers (FRNs) from one SPIN on one Form 472

7. Form 472 � Billed Entity Applicant Reimbursement Form When to File? After payment for services has been made

8. Form 472 � Billed Entity Applicant Reimbursement Form Where to File? Must provide a complete copy of Form 472 to the relevant Service Provider Service Provider must sign the Form 472 before it can be submitted by the Billed Entity to the SLD

9. Form 472 � Billed Entity Applicant Reimbursement Form Where to File? (cont.) File with Schools and Libraries Division Manually, mailing address (P.O. Box): SLD - BEAR FormP.O. Box 7026Lawrence, KS 66044-7026

10. Form 472 � Billed Entity Applicant Reimbursement Form Where to File? (cont.) File with Schools and Libraries Division Manually (Express delivery services or U.S. Postal Service Return Receipt) SLD - BEAR Formc/o Ms. Smith3833 Greenway DriveLawrence, KS 66046Telephone number for receipt purposes: 888-203-8100

11. Form 472 � Billed Entity Applicant Reimbursement Form Compliance Schools and libraries filing false information are subject to penalties Applicants should retain the records they use to complete these forms for five years

12. Form 472: Top of Form Data are used to help both applicant and SLD identify each Form 472 you file Do not write in this space: Space is used to apply a barcode upon receipt to track and archive your form

13. Form 472: Top of Form, cont. Top of each page after page 1: To help alleviate problems caused if pages of the application become separated, please provide: Billed Entity Applicant Name (from Item 1 below) Billed Entity Applicant Number (from Item 2 below) Contact Person Name (from Item 4 below) Contact Person Telephone Number (from Item 5 below) Reimbursement Form Number (from Item 6 below)

14. Form 472, Block 1:Header Information Item 1 � Name of Billed Entity Applicant Provide the name of the Billed Entity as indicated on the corresponding Funding Commitment Decision Letter (FCDL) Item 2 � Billed Entity Applicant Number Provide the Billed Entity Number as it appears on your FCDL

15. Form 472, Block 1:Header Information Item 3 � Service Provider Identification Number (SPIN) Provide the number assigned to the Service Provider who is delivering the services for which you are submitting this Form 472 Item 4 � Contact Name Provide the name of the person who should be contacted if SLD has questions about this Form

16. Form 472, Block 1:Header Information Item 5 � Contact Person Telephone Number Provide the telephone number of the contact person identified in Item 4 (including extension) Item 6 � Reimbursement Form Number Assign a unique number to identify this Form 472 for your own records

17. Form 472, Block 1:Header Information Item 7 � Reimbursement Form Date to SLD Provide the date that you completed and mailed this form to SLD Item 8 � Total Reimbursement Amount Provide the total amount associated with this Form This total must be equal to the sum of the entries in Column (15)

18. Form 472, Block 2:Line Information Per FRN Columns (9) through (15) � Provide the following information for each FRN in Rows 1 through 14: Column (9) � 471 Application Number Column (10) � FRN Column (11) � Bill Frequency Do not write in Column 11 The SLD will complete this column

19. Form 472, Block 2:Line Information Per FRN Columns (9) through (15) (cont.) Column (12) � Customer Billed Date Complete this column for reimbursement of bills for recurring services AND for reimbursement of multiple installments paid on non-recurring services Column (13) � Shipping Date / Last Day of Work Performed Complete this column for reimbursement of bills for non-recurring services billed one time only Do not complete both Column (12) and Column (13) for the same FRN

20. Form 472, Block 2:Line Information Per FRN Columns (9) through (15) (cont.) Column (14) � Total (Undiscounted) Amount for Service per FRN Column (15) � Discount Amount Billed to SLD This amount represents the total amount of funds for which you are seeking reimbursement, that is, your discounted portion of Column (14) Before applying the approved discount percentage to the amount in Column (14), deduct charges for ineligible services, services delivered to ineligible recipients, or services used for ineligible purposes

21. Form 472, Block 3:Billed Entity Certification Block 3 Billed Entity Certifications A � Certify that the discount amounts listed in Column 15 represent charges for eligible services delivered to and used by eligible entities for educational purposes B � Certify that the discount amounts listed in Column 15 were already billed by the Service Provider and paid by the Billed Entity C � Certify that the discount amounts listed in Column 15 are for eligible services approved by SLD pursuant to an FCDL D � Certify that you recognize that you may be audited pursuant to this application and you will retain for five years all records you rely on to complete this form

22. Form 472, Block 3:Billed Entity Certification Items 16 through 21 � Authorized Signature The Authorized Person for the Billed Entity must sign the form using an original ink signature in Item 16 and provide: Item 17 - Signature Date Item 18 - Printed Name of Authorized Person whose signature is provided in Item 16 Item 19 - Title or Position of Authorized Person Item 20 - Telephone Number of Authorized Person Item 21 - Mailing Address of Authorized Person

23. Form 472, Block 4:Service Provider Acknowledgment Block 4 Service Provider Acknowledgments A � The Service Provider must remit the discount amount to the Billed Entity no later than 10 calendar days after receipt of the reimbursement payment from USAC B � The Service Provider must remit payment of the approved discount amount to the Billed Entity prior to tendering or making use of the payment issued by USAC

24. Form 472, Block 4:Service Provider Acknowledgment Items 22 through 27 � Authorized Signature The Authorized Person for the Service Provider must sign the form (fax, copy or original signature) in Item 22 and provide: Item 23 - Signature Date Item 24 - Printed Name of Authorized Person whose signature is provided in Item 22 Item 25 - Title or Position of Authorized Person Item 26 - Telephone Number of Authorized Person Item 27 - Mailing Address of Authorized Person

25. Form 472 � Filing of Form Submit completed form: Mailing Address: SLD - BEAR FormP.O. Box 7026Lawrence, KS 66044-7026 For express delivery services or U.S. Postal Service Return Receipt Requested: SLD - BEAR Formc/o Ms. Smith3833 Greenway DriveLawrence, KS 66046Telephone number for receipt purposes: 888-203-8100

26. Where to Go For Help On the Web: www.sl.universalservice.org Client Service Bureau: 1-888-203-8100 Via E-mail: question@universalservice.org Via fax: 1-888-276-8736