Fillable Subrecipient Information Form-Domestic RE 1 Subrecipient Information Form

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Subrecipient Information Form-Domestic RE 1 Subrecipient Information Form

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Revised 6/15/2018
SUBRECIPIENT INFORMATION FORM
This form must be completed by all proposed subrecipients to Tennessee Tech University (TTU)
and signed by an authorized representative.
NOTE: THIS IS NOT A SUBCONTRACT – COMPLETING THIS FORM DOES NOT AUTHORIZE SPENDING ON THIS GRANT
SECTION A – SUBRECIPIENT INFORMATION
Legal Name:
DUNS#:
Organization’s Address:
Congressional District:
Domestic Organizations
International Organizations
Federal Employer ID # (EIN):
NAIS Code:
Registered in SAM?
Yes
No
NCAGE Code:
If “Yes,” expiration date:
(MM/DD/YYYY)
CAGE Code:
Subrecipient’s Principal Investigator:
Phone:
E-mail:
Subrecipient PI’s Address:
TTU’s Principal Investigator:
Proposal Title:
Prime Sponsoring Agency:
Organization’s Funding Request:
End Date:
Please attach the following documents to this Subrecipient Submission Form:
Statement of Work
Budget
Narrative Budget Justification
Biosketches of key personnel in agency-required format (if required by agency)
Small/Small Disadvantaged Business Subcontracting Plan, in agency-required format (for Federal
subcontract budgets over $650,000)
Justification of “Major Project” status (for federal projects only)
Other
SECTION B – PROPOSAL DOCUMENTS
Page 2 of 5
Subrecipient Form
1. Facilities and Administrative (F&A) Rates included in this proposal have been calculated based on:
Our federally negotiated F&A rates for this type of work, or a reduced F&A rate that we hereby agree to
accept.
(If this box is checked, a copy of your F&A rate agreement or a URL link to the agreement must be
furnished to TTU.)
Other rates (Please specify how the rate was calculated in Section E Comments.)
Not applicable (No F&A costs are requested by subrecipient.)
2. Fringe Benefit Rates included in this proposal have been calculated based on the following:
Rates consistent with or lower than our federally negotiated rates.
(If this box is checked, a copy of your fringe benefit rate agreement or a URL link to the agreement
must be provided.)
Other rates (Please specify the basis on which the rate has been calculated in Section E Comments.)
3. Subrecipient Business Status (Check one):
Large Business
Small Business*
Institution of Higher Education
Other
*As defined by 13 CFR 124.1002
If a small business, identify business:
Small disadvantaged business
Women-owned small business
Veteran-owned small business
Service-disabled, veteran-owned small business
HUBZone small business concern
*Certified by the Small Business Administration
4. For Profit/Commercial Entities:
Note: Vendors are not subject to many of the flow-down provisions required of subrecipients. Therefore, it is important
that the work provided by any for-profit/commercial entities be classified appropriately as vendor or subrecipient.
Yes No The goods and/or services provided under this transaction will be comparable to the goods and/or
services provided by subrecipient to many different customers during the course of its normal
business operations.
Yes No The goods and/or services provided under this transaction will be ancillary to the operation of the
sponsored program and subrecipient will not be responsible for programmatic decision-making.
If “No,” please attach a description of how your organization’s goods and services will contribute to the objectives
of the program and how your organization’s performance will be measured against these objectives, and provide the
names of your organization’s representatives who will be responsible for making programmatic decisions.
(Attach additional pages if necessary.)
SECTION C – SPECIAL REVIEW AND CERTIFICATIONS
P
age 3 of 5
Subrecipient Form
5. Cost Sharing:
Yes
No
If yes, amount:
$ __________________________
Cost sharing amounts and justification must be included in the subrecipient’s budget.
6. Human Subjects: Yes No
If “Yes,” copies of the IRB approval and approved Informed Consent form must be provided before any subaward will
be issued.
7. C
onflict of Interest:
Not applicable as this project is not being funded by NIH, NSF, or any other sponsor that has adopted the federal
financial disclosure requirements.
Subrecipient organization/institution hereby 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 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 any resulting agreement.
Subrecipient does not have an active and/or enforced Conflict of Interest policy and hereby agrees to abide by
TTU
Policy 132: Conflict of Interest.
8. Re
sponsible Conduct of Research (applicable to projects funded by NSF):
Not applicable because this project is not being funded by NSF.
Sub-recipient organization/institution hereby certifies that it will ensure that all undergraduates, graduate students,
and postdoctoral researchers who will be supported by this NSF project will be trained in overseeing the responsible
and ethical conduct of research.
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? (If “yes,” please explain in Section E
Comments.)
Yes No
T
he Organization certifies they (answer all questions below):
are not presently debarred, suspended, proposed for debarment, or declared ineligible for
award of federal contracts.
are
are
are not presently indicted for, or otherwise criminally or civilly charged
b
y a government agency.
have
have not within three (3) years preceding this offer, been convicted of or had a civil judgment
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
submission of offers; or commissions of 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.
have have not within three (3) years preceding this offer, had one or more contracts
terminated for default by any federal agency
Page 4 of 5
Subrecipient Form
10. Fiscal Responsibility (Check each box that applies):
The organization 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 federal awards received and expended and the federal
programs under which they were received.
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 that would impact this project. 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.
11. Lobbying (for U.S. Federal projects):
Yes No The organization certifies that no payments have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this proposed project (If “No,” attach explanation).
12. Export Controls:
Subrecipient is individually responsible for ascertaining its compliance with federal export laws and procedures.
Subrecipient certifies that an export control officer, or other authorized person, has reviewed the subrecipient’s
request for compliance with federal export control laws; and subrecipient has the policy and procedures in place to
comply with federal export laws and procedures.
13. Federal Funding Accountability and Transparency Act (FFATA):
Not applicable because this project is under $25,000.
Subrecipient organization/institution hereby certifies that it is registered with CCR or will be registered prior to
an agreement being issued for completion of this proposal.
Yes No During the previous fiscal year, did the subrecipient receive 80% or more of its
annual gross revenues in federal awards AND $25 million or more in annual gross
revenues from federal awards?
Yes No Does the public have access to information about the compensation of the top
five executives of the organization through periodic reports filed under section 13(a)
or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d) or section
6104 of the Internal Revenue Code of 1986?
1. a. Does the subrecipient receive an annual audit in accordance with OMB Circular A-133?
Yes No
If a subrecipient does not receive an A-133 audit or has findings on their most recent A-133 audit, TTU will
require the entity to complete an Audit Certification and Financial Status Form and may require added
elements be incorporated into the subaward agreement, such as a limited scope audit or increased monitoring.
b. If “Yes,” has the audit been completed for the most recent fiscal year?
Yes No
2. Were any audit findings reported?
Yes No (If “Yes,” explain in Section E Comments, including plan to remedy findings.)
Note: A complete copy of subrecipient’s most recent audit report, or the URL link to a complete copy,
must be furnished to TTU before a subaward can be issued.
3. If “No” to Question 1.a., does the subrecipient receive overall federal funding of at least $750,000 per year?
Yes No If “No,” skip question 4.
If “No,” when is it expected to be completed (MM/DD/YYYY)? ________________
SECTION D – AUDIT
P
age 5 of 5
Subrecipient Form
4. S
ubrecipient is a:
For-profit entity that expends federal or sub-federal funds and has a DCAA audited rate
For-profit entity that does not expend federal funds or have annual audits
Foreign entity
Non-profit (under federal funding threshold)
Government entity
5. On what month and day does the subrecipient’s fiscal year end? (MM/DD/YYYY) __________________________
By signing this form, I certify that the above information, certifications, and representations have been read, are understood, are
accurate and true to the best of my knowledge, and that I am authorized to act on behalf of the subrecipient named herein. The
appropriate programmatic and administrative personnel involved in this application are aware of agency policies in regard to
subawards/contracts and are prepared to establish the necessary inter-institutional agreements that ensure compliance with such
regulations and policies should this proposal be funded. Any work begun and/or expenses incurred prior to execution of a
subaward/contract agreement are at the subrecipient’s own risk.
Signature of Subrecipient’s Authorized Date
Institutional Representative
Name/Title Phone #
Address Email Address
City, State, Zip Name/Phone # of person to be contacted in
case of questions regarding this form
SECTION E – COMMENTS
SECTION F – SUBRECIPIENT CERTIFICATION
Page 6 of 6
Subrecipient Form
Title VI of the Civil Rights Act of 1964, as codified in 42 U.S.C. 2000d, states that:
No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in,
be denied the benefits of, or be subject to discrimination under any program or activity receiving federal financial
assistance.
Therefore, whenever Tennessee Technological University conducts federally funded research through subawardees, the University
requires a representative of the entities to certify that the subawardee will comply with the requirements of Title VI in regard to the
provision of educational programs and services and the research program will be conducted in compliance with all requirements
imposed by Title VI. You are requested to complete the assurance statement below to document your entity’s compliance with
Title VI.
I, , have reviewed the protocol or statement of work to be performed under the
subaward between Tennessee Technological University and _______________________ (insert name of subawardee), as well as
the federal regulations concerning Title VI. I certify that (insert name of subawardee) provides
EQUAL OPPORTUNITY in all programs receiving federal financial assistance and that
(insert name of subawardee) will conduct the subaward in compliance with all requirements imposed by Title VI.
Representative of Subawardee
Date
ASSURANCE OF TITLE VI COMPLIANCE
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Completed 14 March 2020

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