Request for OUSF Funding

BEFORE THE CORPORATION COMMISSION OF OKLAHOMA

IN THE MATTER OF THE REQUEST OF )

***PROVIDER***, ) CAUSE NO. PUD 201

FOR FUNDING FROM THE )

OKLAHOMA UNIVERSAL SERVICE FUND )

FOR SPECIAL UNIVERSAL SERVICES )

PROVIDED TO ***OUSF BENEFICIARY*** )

REQUEST FOR OUSF FUNDING

***Provider*** requests funding from the Oklahoma Universal Service Fund (“OUSF”) pursuant to 17 O.S. § 139.106(D) for its provision of Special Universal Services to ***OUSF Beneficiary*** (***School or Library or Healthcare Entity***). The organization-location code assigned by the OUSF Administrator is ***organization-location code***.

REQUESTING ENTITY:

Contact information for ***Provider*** is:

Contact Name: ***

Address: ***

Telephone Number: ***

Email Address: ***

FACTS:

In support of this Request for OUSF Funding (“Request”), ***Provider*** states as follows:

1.  ***Provider*** is an Eligible Provider and is entitled to funding from the OUSF for its provision of Special Universal Services pursuant to 17 O.S. § 139.109.1.

2.  ***School or Library or Healthcare Entity*** is a ***public school / public library / healthcare entity*** as defined by 17 O.S. § 139.102.

3.  ***School or Library or Healthcare Entity*** is entitled to receive Special Universal Services under 17 O.S. § 139.109.1.

4. The amount of OUSF funding sought by ***Provider*** is described on Form ***SUSF-2 or SUSF-3***, attached hereto and incorporated herein.

5. (for schools and libraries – or use #5 below for healthcare entities) ***Provider*** acknowledges and certifies that services that are the subject of this Request are all included in the E-rate Eligible Service List for Category One services as determined by the Federal Communications Commission for the applicable Funding Year or, in the absence of such a list, as published by the Universal Service Administrative Company, and includes reasonable installation and network termination equipment owned and operated by the eligible provider that is necessary to provide the eligible service.

5. (for healthcare entities – or use #5 above for schools and libraries) ***Provider*** acknowledges and certifies that the Special Universal Services includes only the telemedicine line, reasonable installation, and network termination equipment owned and operated by the Eligible Provider that is necessary to provide the eligible service.

6. Additional information necessary to support this Request, including the Affidavit of *** School or Library or Healthcare Entity*** in support of Request for Special Universal Services, is being submitted to the OUSF Administrative staff under separate cover.

JURISDICTION:

The Commission has jurisdiction in this cause pursuant to Okla. Const. art. IX, § 18, and 17 O.S. § 139.101et seq.

RELIEF REQUESTED:

***Provider*** requests that the Request for OUSF Funding be granted, as set forth in herein.

Respectfully submitted,

***PROVIDER***

By: ______

***ATTORNEY NAME***

***ADDRESS***

***PHONE***

***EMAIL***


CERTIFICATE OF SERVICE

The undersigned hereby certifies that on this ___ day of ***Month, year***, a true and correct copy of the foregoing was provided, via federal express/overnight delivery, mail, or email to the following:

Office of Oklahoma Attorney General

c/o Dara Derryberry

Assistant Attorney General

313 N.E. 21st Street

Oklahoma City, OK 73105

Kimberly Prigmore, Deputy General Counsel

Office of the General Counsel

Oklahoma Corporation Commission

P.O. Box 52000

Oklahoma City, OK 73152-5200

Brandy Wreath, Director

OUSF Administrator / Public Utility Division

Oklahoma Corporation Commission

P.O. Box 52000

Oklahoma City, OK 73152-5200

Signed,

______

***Name***

***Title***

***Provider***

***Address***

***Phone***

***Email***