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Office of Research and Sponsored Programs 100 Administration (University of Tennessee, Martin)

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Office of Research and Sponsored Programs 100 Administration Building Martin, TN 38238
Dr. Charley Deal, Executive Director
731.881.7015 731.881.7018 orsp@utm.edu www.utm.edu/orsp
Date:
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
SUBRECIPIENT INFORMATION
Subrecipient Full Legal Name:________________________________________________________________________________
Subrecipient Employee Identification Number:_____________________________________________________________
Subrecipient Principal Investigator(PI):_____________________________________________________________________
Un
iversity of Tennessee at Martin (UTM) PI:________________________________________________________________
Pr
ime Sponsor:_________________________________________________________________________________________________
Su
bmitted Proposal Title:_____________________________________________________________________________________
Pr
oposal Performance Period: Begin: End:
Tot
al Subrecipient Funding Request: $________________________________________________
Print Form
2 | Page
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
Is subrecipient currently registered in Center Contractor Registration (CCR) database?
YES NO If yes, Expiration Date:
Is the subrecipient currently registered in System for Award Management (SAM) database?
YES NO
(If Subrecipient has not registered with CCR or if registration is expired, SAM registration is required. https://sam.gov)
Data Universal Numbering System (DUNS+4) # (REQUIRED):____________________________________________
Subrecipient Business Address: ______________________________________________________________________________
Street, City, State, Zip Code, Phone#, and email):___________________________________________________________
Congressional District (N/A for Foreign Subrecipients):___________________________________________________
3 | Page
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
SUBRECIPIENT CONTACTS
Administrative Contact:
Name: Address:
Title:
Email: Phone: Fax:
Project Director:
Name: Address:
Title:
Email: Phone: Fax:
Financial Contact:
Name: Address:
Title:
Email: Phone: Fax:
A-133 Audit Contact
Name: Address:
Title:
Email: Phone: Fax:
Authorized Official
Name: Address:
Title:
Email: Phone: Fax:
4 | Page
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
Section A Proposal Documents
The following documents are included in the subrecipient proposal submission and covered by
certifications in Section B:
Statement of Work (required): Includes work to be performed, project description, PI,
period of performance, deliverables, and milestones.
B
UDGET AND BUDGET JUSTIFICATION (required): Budget for entire length of project (in
agency format) and broken down by budget period.
Th
is Subrecipient Commitment Form signed by Subrecipient Authorized Official (required).
Oth
er:
Section B Special Review and Certifications
1. Facilities and Administrative Rates included in this proposal have been calculated based on:
Subrecipient federally-negotiated F&A rates for this type of work, or a reduced F&A
rate that the subrecipient herby agrees to accept. (If this box is checked, a copy of the
subrecipient’s F&A agreement must be furnished to UT Martin before a subaward will be
issued. Submit along with this Subrecipient Commitment Form.)
If possible, please attach a copy or enter a URL to your F&A rate agreement here:
Other rates. (Please specify basis on which rate has been calculated in “Section C
Comments” at the end of form.)
Attach explanations supporting this rate or provide URL here:
5 | Page
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
2. Fringe Benefit Rates included in this proposal have been calculated based on:
Rates consistent with or lower than subrecipient’s federally-negotiated rates. (If this box is
checked, a copy of the subrecipient’s Fringe Benefit rate agreement must be furnished to UT
Martin before subaward will be issued.)
Submit along with this form or provide URL here:
Other rates. Please attach or specify the basis on which the rate has been calculated.
3. Cost Sharing: YES NO If yes, Amount: $
(Complete cost sharing documentation including amounts, resources, and justification
should be included with subrecipient budget)
Regulatory Approvals (Questions 4-12)
4. Affirmation Action Compliance
In accordance with the rules and regulations of the Secretary of Labor (41 CFR 60-1 and 60- 2), if
your organization has more than 50 employees and subaward will be for $50,000 or more, you are
required to have a written affirmative action program. Indicate whether your organization has a
written affirmative action program.
Yes, we have a written affirmative action program developed and on file.
No, we do not have a written affirmative action program.
Not applicable, as we have less than 50 employees or anticipate subward amount less than
$50,000.
5. Human Subjects: YES NO
Check YES if proposal includes surveys, interviews, observations, or secondary data.) If “Yes”:
Copies of the Institutional Review Board (IRB) or Ethics Committee approval must be provided
before any subaward will be issued. If pending, obtain approval as required and forward these
documents to UT Martin’s Office of Research and Sponsored Programs as soon as it’s available.
If approval is available electronically, please provide URL here:
6 | Page
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
If “Yes”: Have all key personnel involved completed Human Subject’s Training?
YES NO
6. Animal Subjects: YES NO
If “Yes”: A copy of the IACUC Committee approval must be provided before a subaward will be
issued. If pending, obtain approval as required and forward these documents to UT Martin’s Office
of Research, Grants, and Contracts as soon as available.
If approval is available electronically, please provide URL here:
7. Does this project involve recombinant DNA, microorganisms, biological toxins, blood borne
pathogens, human clinical specimens, and/or hazardous chemicals?
YES NO
If yes, please attach a copy of the Institutional Safety Committee approval for or letter.
8. Does this project involve radioactive material, lasers, or radiation producing material?
YES NO
If yes, please attach a copy of the Institutional Radiation Committee approval form or letter.
9. 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?
YES NO
Subrecipient certifies that they: (answer all questions below)
Are Are not presently debarred, suspended, proposed for debarment, or
declared ineligible for award of Federal contracts.
Are Are not presently indicted for, or otherwise criminally or civilly charged by a
government entity.
Have Have Not within three (3) years preceding this offer, been convicted of or
had a civil judgement rendered against them for 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
7 | Page
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property.
Have Have not within three (3) years preceding this offer, had one or more
contracts terminated for default by any Federal agency.
10. Conflict of Interest Policy
Subrecipient herby certifies that it has an active and enforced conflict of interest policy that
is consistent with the provision of 42 CFR PART 50, Subpart F “Responsibility of Applicants
for Promoting Objectivity in Research.” Subrecipient also certifies that, to the best of the
subrecipient’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
satisfactory managed, reduced or eliminated in accordance with subrecipient’s conflict of
interest policy prior to the spending of funds under any resultant agreement.
Subrecipient does not have an active and/or enforced conflict of interest policy and agrees
to adopt and implement a policy prior to execution of subward agreement. The
undersigned certifies that to the best of his/her knowledge there is no officer or employee
of
who has, or who’s relative has substantial interest in any contract resulting from this
request.
11. Subrecipient Federal Conflict of Interest (FCOI) Policy (applicable to PHS and other assorted
organizations)
The investigators listed on page one, as well as any personnel involved with the proposed
project, have disclosed any potential financial conflicts of interest to
as well as completed the required PHS-NIH financial conflict of interest training.
12. Responsible Conduct in Research (RCR) (applicable to NSF and NIH)
N/A, this project is not funded by NSF or NIH
8 | Page
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
N/A, no educational institution
By checking this box, subrecipient certifies, if applicable, that it maintains an institutional
Plan to meet NSF’s Educational Requirements for the Responsible Conduct of Research,
as required under the “America COMPETES Acts” PUBLIC LAW 110-69-August 9,2007.
Subrecipient certifies that is has a training program in place and will train all
undergraduate and graduate students and postdocs in accordance with NSF’s RCR
training requirements.
By checking this box, subrecipient certifies, if applicable, that for NIG Grants for Training
and Fellowship awards, that subrecipient will monitor and maintain records for the
individual training plans as proposed by subrecipient, in accordance with NIH’s RCR
training requirements.
13
. Fiscal Responsibility
Subrecipient certifies that its financial system is in accordance with generally accepted
accounting principles and:
has the capability to identify, in its accounts, all Federal awards received and expended and
the Federal programs under which they were received.
maintains internal controls to assure that it is managing in compliance with applicable
laws, regulations and the provision of contracts or grants.
complies with applicable laws and regulations.
can prepare appropriate financial statements, including the schedule of expenditures of
Federal awards.
There are no outstanding audit findings which would impact contract costs. If there are
findings submit a copy of the most recent report that describes the finding and steps to be
taken to correct the finding.
14. A-133 Audit and Financial Status
We have completed our A-133 audit for the most recent period. From To
9 | Page
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
The audit disclosed no material weakness, no material instances of noncompliance with
federal laws or regulations, no reportable conditions, no findings, and there are no
unresolved prior year findings.
The link to our A-133 audit can be found here:
Relevant findings, our responses and corrective action plan are discussed on page(s):
We have not completed our A-133 audit for the fiscal year ending:
Our fiscal year ended: and we expect the audit to be completed by:
Within thirty days of completion, we will provide you with written certification and
will send a copy of the audit report, including relevant findings, our responses and
corrective action plan if the audit discloses any material weakness, material
instances of noncompliance with federal laws or regulations, reportable conditions,
findings, or unresolved prior year findings.
We are not subject to the provisions of OMB Circular A-133 because our
organization is a:
Non-Profit entity which expended less than $500,000 in federal awards during our
most recent fiscal year ending:
Foreign
For-profit entity
Other:
If y
ou are not subject to OMB Circular A-133, you may be asked to provide additional information
regarding your organization’s financial status.
15. Completion of the following section is required only if subawardee has not been audited by a US
Government agency or by an independent CPA firm for the most recently completed fiscal year.
General Information
YES NO Does your organization have its financial statements reviewed by an
independent public accounting firm? (Please enclose a copy of the most recent financial
statements for your organization, audited or unaudited.)
10 | Page
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
YES NO Are duties separated so that no one individual has complete
authority over an entire financial transaction?
YES NO Does your organization have controls to prevent spending of funds
in excess of approved budgeted amounts?
YES NO Other than financial statements, has any respect of your
organization’s activities been audited within the last two years by a governmental agency or
independent public accountant? Explain and please attach a copy of the report.
Cash Management
YES NO Are all disbursements properly documented with evidence of receipt
of goods or performance of services?
YES NO Are all bank accounts reconciled monthly?
Payroll
YES NO Are payroll charges again program budgets?
What system does your organization use to control paid time, especially time charged to the
sponsored agreements?
Procurement
YES NO Are there procedures to ensure procurement at competitive prices?
Is there an effective system of authorization and approval of:
YES NO Capital equipment expenditures
YES NO Travel Expenditures
Property Management
YES NO Are detailed records of individual capital assets kept and periodically
balanced with the general ledger accounts?
YES NO Are there effective procedures for authorizing payment and
accounting for the disposal of property and equipment?
YES NO Are detailed property records periodically checked by physical
inventory? Briefly describe the organization’s policies concerning capitalization and
depreciation.
11 | Page
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
Cost Transfer
How does the organization ensure that all cost transfers are legitimate and appropriate?
Indirect Costs
YES NO Does the organization have an indirect cost allocation plan or
negotiated indirect cost rate? Explain. (Please provide a copy of any negotiated indirect
cost rate agreement.
YES NO Does the organization have procedures which provide assurance
that consistent treatment is applied in the distribution of charges to all grants, contracts,
and cooperative agreements? Explain.
Cost Sharing
How does the organization determine that it has met cost sharing requirements?
Compliance
YES NO Does your organization have a formal policy of nondiscrimination
and a formal system for complying with Federal civil rights requirements?
YES NO Does your organization have cash forecasting process which will
minimize the time elapsed between the drawing down of funds and the disbursement of
those funds? Please provide a list of recent grants, contracts or cooperative agreements
your organization has received from
UT Martin. Please explain.
12 | Page
SUBRECIPIENT COMMITMENT FORM
For Organizations Subject to A-133 Audit Requirements
Attachments
YES NO Recent Financial Statements External Review or Audit Report
YES NO Financial Statements, Audited or Unaudited
YES NO Indirect Cost Rate Agreement
Address
P
hone: Fax:
Authorized Official Name:
Title:
Email:
Signature ___________________________________________ Date_____________________
Section C Comments
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Completed 30 August 2020

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