Washington State Library 2/29/2024

OSOS No. I-8051 ATTACHMENT D 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 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 ten years (or whatever retention period is required by the rules in effect at the time of this certification) after the later of the last day of the applicable funding year or the service delivery deadline for the funding request any and all records that I rely upon to complete this form. Page 21 of 29 DocuSign Envelope ID: E4A042D9-7CE3-4C89-804C-071076400140