A. PRIME PROPOSAL INFORMATION
SPONSOR:
SOLICITATION #:
UM PI NAME:
UM PROJECT #:
PROJECT TITLE:
B. SUBRECIPIENT INFORMATION
1. SUBRECIPIENT’S LEGAL NAME:
ADDRESS (include “+4” zip code):
DUNS #:
or SAM/CCR Registration:
EIN #:
CONGRESSIONAL DISTRICT:
2. SUBRECIPIENT PI:
ADDRESS:
PHONE:
FAX:
EMAIL:
3. SUBRECIPIENT BUSINESS/FINANCIAL CONTACT:
ADDRESS:
PHONE:
FAX:
EMAIL:
4. SUBRECIPIENT AUTHORIZED OFFICIAL:
ADDRESS:
PHONE:
FAX:
EMAIL:
5.
Federal Government
Foreign Government
Individual
C. REQUIRED PROPOSAL DOCUMENTS
X Statement of Work (required)
X Budget and Budget Justification (required)
PERIOD OF PERFORMANCE:
TOTAL AMOUNT REQUESTED:
Biosketches and Other Support
Letter of Support from PI
Yes
No
Date updated:
Facilities
Letter of Support for PI
Commitment Letter
TYPE OF ORGANIZATION
Other:
Institution of Higher Ed.
State of Tennessee
Other State (non TN)
Corporation
Non-profit Org
Foundation
UEI #:
2. Fringe Benefit Rate: %
Please check one of the following:
Consistent with or lower than the subrecipient’s federally-negotiated fringe benefit rate. (A copy of the subrecipient’s fringe
benefit rate agreement must be provided to the University of Memphis before a subaward will be issued.)
Other rate (please specify the basis on which the rate has been calculated):
E. ASSURANCES
1. Debarment, Suspension, Proposed Debarment
Is the PI or any other employee or student participating in this project debarred, suspended, or otherwise excluded from or ineligible
for participation in federal assistance programs or activities? If the subrecipient is owned by a parent entity, is the parent entity
debarred, suspended, or otherwise excluded from or ineligible for participation in federal assistance programs or activities?
No Yes (please explain):
The organization/institution certifies that it: (answer all questions below)
is is not presently debarred, suspended, proposed for debarment, or declared ineligible for award of federal contracts;
is is not presently indicted, or otherwise criminally or civilly charged, by a governmental entity;
is is not within three (3) years preceding this offer, convicted of or had a civil judgment rendered against them for
is is not within three (3) years preceding this offer, subject to contract(s) termination by any federal agency for default.
2. Conflict of Interest
42 CFR Part 50.604 requires that institutions conducting PHS-funded research “Maintain an up-to-date, written, enforced policy on
financial conflicts of interest.” Further, “If the Institution carries out the PHS-funded research through a subrecipient (e.g.,
subcontractors or consortium members), the Institution (awardee Institution) must take reasonable steps to ensure that any
subrecipient Investigator complies with this subpart by incorporating as part of a written agreement with the subrecipient terms that
establish whether the financial conflicts of interest policy of the awardee Institution or that of the subrecipient will apply to the
subrecipient's Investigators.”
Subrecipient hereby certifies that it has a conflict of interest policy that complies with 42 CFR Part 50, Subpart F, “Responsibility
of Applicants for Promoting Objectivity in Research.” Subrecipient also certifies that, to the best of the organization/institution’s
knowledge (1) all financial disclosures have been made related to the activities that may be funded by or through a resulting
agreement and required by its conflict of interest policy; and (2) all identified conflicts of interest have or will have been
satisfactorily managed, reduced, or eliminated in accordance with subrecipient’s conflict of interest policy prior to the expenditure
of any funds under a resulting agreement.
Subrecipient does not have a conflict of interest policy that complies with 42 CFR Part 50, Subpart F.
Note: The University of Memphis will evaluate on a case-by-case basis each proposal including a subrecipient that does not have a
conflict of interest policy that complies with 42 CFR Part 50, Subpart F. The University of Memphis will not submit to a PHS agency
any application including such subrecipients prior to review and resolution.
Not applicable because this project is not funded by the NIH, AHRQ, ATSDR, CDC, FDA, HRSA, IHS, SAMHSA, or any other
sponsor that has adopted these federal financial disclosure requirements.
By signing below, Subrecipient certifies that the required training will be completed by each investigator prior to engaging in any
research related to any federally-sponsored funded contract/grant. For those adopting University of Memphis' policy, the training is
located online at https://www.citiprogram.org.
commission of fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public
(federal, state, or local) contract or subcontract; violation of federal or state antitrust statutes relating to the
submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records,
making false statements or receiving stolen property;
D. APPLICABLE RATES
1. Facilities and Administration (F&A) Rate: %
Please check one of the following:
Subrecipient’s federally-negotiated F&A rate for this type of work. (A copy of the subrecipient’s F&A rate agreement must
be provided to the University of Memphis before a subaward will be issued.)
Other rate (please specify the basis on which the rate has been calculated):
maintains internal controls to assure that it is managing federal awards in compliance with applicable laws, regulations, and
the provision of contracts or grants;
4.
Subrecipient receives an annual audit in accordance with Uniform Guidance Subpart F Audit Requirements.
Most recent fiscal year audit completed:
Were there any findings? Yes No
URL for the subrecipient’s most recent audit report:
Subrecipient DOES NOT receive an annual audit in accordance with Uniform Guidance Subpart F Audit Requirements.
Subrecipient is a: Non-profit entity (under federal-funding threshold) Foreign entity
For-profit entity
Government
F. CERTIFICATIONS
1. Human Subjects
Will human subjects be involved in subrecipient’s portion of this project?
Yes No
2. Animal Subjects
Will animal subjects be involved in subrecipient’s portion of this project?
Yes No
3. Recombinant DNA:
Will recombinant DNA be involved in subrecipient’s portion of this project?
Yes No
4. Stem Cells:
Will stem cells be involved in the subrecipient’s portion of this project?
Yes No
5. For Clinical Trials, please provide the following: maximum patient enrollment, per patient amount, and, if applicable, the
Institutional Review Board (IRB) fee required by the Subrecipient.
APPROVED FOR SUBRECIPIENT
The information, certifications, and representations above have been read, signed, and made by an authorized official of the
subrecipient named herein. The appropriate programmatic and administrative personnel involved in this application are aware of
agency policy in regard to subawards and are prepared to establish the necessary inter-institutional agreements consistent with those
policies. Any work begun and/or expenses incurred prior to execution of a subaward agreement are at the subrecipient’s own risk.
_
Subrecipient Authorized Official
Date
Printed Name and Title
Division of Research and Sponsored Programs Rev. 5/2016
3. Fiscal Responsibility
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received;
has the capability to identify, in its accounts, all federal awards received and expended and the federal programs under
which they were received
