Form Approved Through 10/31/2018
OMB No. 0925-0002
Department of Health and Human Services, Public Health Service
Official Statement Relinquishing Interests
and Rights in a Public Health Service Research Grant
(Return original to awarding unit)
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and
completing and reviewing collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive MSC 7974, Bethesda,
MD 20892-7974, ATTN: PRA (0925-0002). Do not return the completed form to this address.
(date)
Name of Institution
Address (City, State and Zip Code)
Principal Investigator
on Public Health Service grant number
has expressed a desire to continue his/her research project at the
In view of the fact that we do not wish to nominate another principal investigator or continue the research project at this
Institution, this is to signify our willingness to terminate this grant as of
(date) and to relinquish
all claims to any unexpended and uncommitted funds remaining in the grant as of that date, as well as to all
recommended future support of this project.
Equipment Costing $5,000 or More
Transferring with the Project (itemize)
1.
2.
3.
4.
5.
6.
Unexpended Balance — Estimated
The unexpended balance on termination date of
calculated on basis of total amount
awarded for the grant year, will be approximately
$ direct cost
$ indirect cost.
Use separate page for additional items.
That portion of the estimated unexpended balance which has been received will be returned to the Public Health
Service, upon request, with a final adjustment, if required, to be made after the grant account has been audited.
Official Authorized to Sign Application
Signature
Name and Title (print or type)
Privacy Act Statement. The NIH maintains application and grant records as part of a system of records as defined by the
Privacy Act: NIH 09-25-0036, Extramural Awards and Chartered Advisory Committees (IMPAC 2),Contract Information
(DCIS), and Cooperative Agreement Information, HHS/NIH:
http://oma.od.nih.gov/ms/privacy/pa-files/0036.htm .
PHS 3734 (Rev. 06/15)
click to sign
signature
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