Schools & Libraries / E-Rate Discount Method Election Form
Funding Year ________________ SPIN _______________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Contact Name: _____________________________________________ Contact Phone Number: Contact E-Mail Address: _____________________________________________ _____________________________________________ Billed Entity Number: Funding Request Number: _____________________________________________ _____________________________________________ Form 471 App. Number: _____________________________ Date: __________ Authorized Signature: School or Library Name: Address:
The purpose of this form is to provide the CenturyTel Service Group with a list of the eligible accounts (working telephone numbers) for which the above named school or library is seeking to have the Schools & Libraries Division (SLD) discount applied to its bill on a month to month basis. It will be the responsibility of the Billed Entity to insure the accuracy of this list. A separate listing should be provided for each Funding Request Number (FRN) and should only include accounts and charges associated with that FRN. Additional copies of this form may be attached as necessary to accommodate additional numbers and/or charges. This election will be in effect for the complete funding year and may not be changed during the funding year. A new form with an updated FRN should be submitted for each funding year. Please list all telephone numbers, or Billing Account Numbers, to be considered for discounts in the space provided below. This form should be returned to CenturyTel, at the address provided below. CenturyTel must receive your Form 486 no later than November 1 of the desired funding year in order to utilize the Discount Option. Forms received after this date will be processed on a month to month basis with a year-end true up.
Billed Account No. (BAN)
(attach list if needed)
Exceptions: Items listed on monthly bill but not included in the E-Rate Funding. (i.e. PBX Leased equipment, touchtone phone set, …) Description _______________Billed Telephone Number Charge
General Purpose of FRN: (i.e. Internet, Long Dist.) _______________________________________ Return Form To: Cecil Lipscomb CenturyTel Service Group 100 CenturyTel Dr. Page ___ of ___ Monroe, LA 71203 Rev. 5/ 06 Fax (318) 362-1649 FOR CENTURYTEL USE ONLY Date Received: _________________ Date Entered: _________________ Entered By: _________________ FRN Funding Cap: _______________________ Discount Rate: __________________________