Oklahoma Corporation Commission

Oklahoma Corporation Commission Oklahoma Universal Service Fund Request for Public Schools

TO: DATE: Name of Telecommunications/Data Service Provider SPIN

Pursuant to 17 O.S. § 139.109, each public school building wherein classrooms are contained shall, upon written request, receive one access line, free of charge, with the ability to connect to an Internet service provider at 1.5 Mbps, in the most economically efficient manner for the carrier, or an equivalent dollar credit to be applied by the public school toward similar service provided by the same carrier, for the purpose of accessing the Internet. "Public school" is defined as all free schools supported by public taxation, and shall include grades kindergarten through twelve.

This is the written request of (insert name of school district) for the one access line with the ability to connect to an Internet provider at 1.5 Mbps, or an equivalent dollar credit to be applied toward similar service provided by the same carrier.

Contact School Name/Primary Address Contact Person/Telephone No.

______

BEN Number of School or District (if applicable) Total number of buildings in this request

If you are already receiving OUSF and this is a change in provider; please list your previous provider and the date of service termination:

If you are adding access to your district (additional buildings, LAN/WAN), list all of your current service providers and please indicate the type of service they provide and locations of their services on your network diagram.

Request is to provide: (check) □ Internet Access □ LAN/WAN connectivity

Request: (check) □ 1.5 Mbps per building or □ Equivalent Credit

The total Internet bandwidth being requested for the school district (if applicable) is

School/District and Carrier, please provide the following required documents as attachments to complete this application:

A. Form OUSF - Summary

B. Special Universal Service Request Form (SUSF 1)

C. Eligible Buildings Requested - Please complete and submit and duplicate as necessary for each building in this application.

D. Please attach a district network diagram to this application. Each building in the district and buildings which are part of this request must be indicated on the diagram, along with each carrier providing data service to the district. Also indicate circuit numbers (if available) and bandwidth for Internet and LAN/WAN.

E. Please attach a copy of the customer contract and invoices for the time period requested. Revised 1/2013 http://www.occeweb.com/pu/OUSF/OUSF.htm F. Submit a copy of the tariffed rate for 1.5 Mbps or its equivalent. If there is no tariffed rate for 1.5 Mbps, please provide a copy of the Individual Case Basis pricing or document that describes the rates being charged.

The schools listed on this form currently have the appropriate computer equipment in order to be able to utilize the access line (or equivalent credit per building) as soon as it is installed.

I understand that if the access line for internet connection is not requested for a particular school building at this time, the school district will not be prohibited from making such request in the future. I further understand that the access line with ability to connect to the Internet is for the exclusive use of each school and that under no circumstances shall the service be sold, repackaged or shared with any other entity. I understand that in the event that the school district chooses another provider, it is the school district’s responsibility to advise the current provider of the discontinuation of service. Initial

I further understand that an access line will be provided to each school building without cost to the school district, and that the telecommunications/data service provider may seek to recover the cost of providing this service from the Oklahoma Universal Service Fund, which is funded by fees assessed, by law, to all telecommunications carriers and that the carriers, by law, may pass the assessed fees on to their telephone customers within Oklahoma. Initial

I hereby authorize the carrier to provide to the Oklahoma Corporation Commission our invoices, related contracts, and other supporting documentation for services eligible to be reimbursed from the Oklahoma Universal Service Fund. I understand the purpose of this release of records is to allow the Corporation Commission to review requests for OUSF support submitted by the carrier on behalf of our school and/or school district. Initial

The undersigned certifies that he/she has the authority to make this request on behalf of the above-named school district.

Signature of Superintendent Printed Name of Superintendent

Street Address Telephone Number

Address

State of Oklahoma

County of

Subscribed and sworn to before me this day of , 20

Notary Public (Seal)

My commission expires .

Revised 1/2013 http://www.occeweb.com/pu/OUSF/OUSF.htm Revised 1/2013 http://www.occeweb.com/pu/OUSF/OUSF.htm Attachment C Eligible Building Request

Duplicate this page as necessary for each additional school building in this application.

List the name and information for each qualified public school building for which the request is made.

Building Name:

Building Address:

Classes/Grade Levels:

Educational Internet Access Usage:

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Building Name:

Building Address:

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Building Name:

Building Address:

Revised 10/2012 http://www.occeweb.com/pu/OUSF/OUSF.htm

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Revised 10/2012 http://www.occeweb.com/pu/OUSF/OUSF.htm