ࡱ>  3bjbj 4(84 |ur=(eeepc.fguuuuuuu$'wy@Bu-hZbc^hhBu>meeBou>m>m>mh^eReu>mhu>m>mVr@Ji"s ZQAIhj(s uu0u4sx{Ji{s>ms\hhhBuBu>mhhhuhhhh{hhhhhhhhh+ :   SUBRECIPIENT COMMITMENT FORM Subrecipient Legal Name:  FORMTEXT Enter name legal name of the organization or institution Subrecipient PI Name:  FORMTEXT Enter Principle Investigators Name Subrecipient Address:  FORMTEXT Full address, city, state & zip code+4 (To find your zip code +4 go to https://tools.usps.com/go/ZipLookupAction_input) Address where research will be performed:  FORMTEXT Full address, city, state & zip code+4 Proposal Title:  FORMTEXT Enter Proposal Title Performance Period: Begin Date:  FORMTEXT MM/DD/YYYY End Date:  FORMTEXT MM/DD/YYYY University of Toledo PI Name:  FORMTEXT Enter UT PI Name Prime Sponsor:  FORMTEXT Enter primary sponsor name Total Amount Requesting: $ FORMTEXT ###,###,###.##  The following documents are included in our proposal submission and covered by the certifications below (check as applicable)  FORMCHECKBOX  STATEMENT OF WORK (required)  FORMCHECKBOX  DETAILED BUDGET (required)  FORMCHECKBOX  BUDGET JUSTIFICATION (required)  FORMCHECKBOX  INSTITUTIONAL/COMPANY LETTER OF COMMITMENT (required)  FORMCHECKBOX  Small/Small Disadvantaged Business Subcontracting Plan, in agency-required format  FORMCHECKBOX  Biosketches of ALL Key Personnel, in agency-required format  FORMCHECKBOX  Other:  FORMTEXT        Facilities and Administrative Rates included in this proposal have been calculated based on:  FORMCHECKBOX  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, please attached a copy of your F&A rate agreement or provided a URL link to the agreement.)  FORMCHECKBOX  Other rates (please specify the basis on which the rate has been calculated in Section D Comments below) Fringe Benefit Rate included in this proposal have been calculated based on:  FORMCHECKBOX  Rates consistent with or lower than our federally-negotiated rates (If this box is checked, please attach a copy of your FB rate agreement or provided a URL link to the agreement.)  FORMCHECKBOX  Other rates (please specify the basis on which the rate has been calculated in Section D Comments below) Small Business Concern  FORMCHECKBOX  Yes  FORMCHECKBOX  No Subrecipient represents that it is a small business concern as defined in 13 CFR 124.1002 If Yes: Subrecipient represents that it is a:  FORMCHECKBOX  Small disadvantaged business as certified by the Small Business Administration  FORMCHECKBOX  Women-owned small business concern  FORMCHECKBOX  Veteran-owned small business concern  FORMCHECKBOX  Service-disabled veteran-owned small business concern  FORMCHECKBOX  HUB Zone small business concern Cost Sharing  FORMCHECKBOX  Yes  FORMCHECKBOX  No Amount: $ FORMTEXT ###,####.## (Cost sharing amounts and justification should be including in the subrecipients budget) Human Subjects  FORMCHECKBOX  Yes  FORMCHECKBOX  No Approval Date:  FORMTEXT MM/DD/YYYY If Yes: Copies of the IRB approval and approved Informed Consent form must be provided before any subaward will be issued. Please forward these documents to The University of Toledos PI and The University of Toledos Office of Research and Sponsored Programs as soon as they become available. In accordance with the Universitys policy, UTs IRB must conduct a secondary review of the subaward and issue a companion approval before any subaward will be issued. If Yes: Have all key personnel involved completed Human Subjects Training?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Animal Subjects  FORMCHECKBOX  Yes  FORMCHECKBOX  No Approval Date:  FORMTEXT MM/DD/YYYY If Yes: Copies of the IACUC approval and approved Informed Consent form must be provided before any subaward will be issued. Please forward these documents to The University of Toledos PI and The University of Toledos Office of Research and Sponsored Programs as soon as they become available. In accordance with the Universitys policy, UTS IACUC must conduct a secondary review of the subaward work and issue a companion approval before any subaward will be issued. Conflict of Interest (applicable NIH, NSF or other sponsors that have adopted the federal financial disclosure requirements)  FORMCHECKBOX  Not applicable because this project is not being funded by NIH, NSF or other sponsor that has adopted the federal financial disclosure requirements  FORMCHECKBOX  Subrecipient Organization/Institution 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 Institutions knowledge: 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 All identified Conflicts of Interest policy prior to the expenditures of any funds under any resultant agreement.  FORMCHECKBOX  Subrecipient does not have an active and/or enforced Conflict of Interest policy and agrees to abide by the University of Toledos policy, located online  HYPERLINK "http://www.utoledo.edu/policies/academic/research/pdfs/3364_70_01.pdf" http://www.utoledo.edu/policies/academic/research/pdfs/3364_70_01.pdf Debarment and Suspension 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?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, explain in Section D Comments below The Subrecipient certifies they: (answer all questions below)  FORMCHECKBOX  are  FORMCHECKBOX  are not presently debarred, suspended, proposed for debarment, or declared ineligible for award of federal contracts  FORMCHECKBOX  are  FORMCHECKBOX  are not presently indicted for, or otherwise criminally or civilly charged by a government entity  FORMCHECKBOX  have  FORMCHECKBOX  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 of subcontract; violation of Federal or State antitrust statues 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.  FORMCHECKBOX  are  FORMCHECKBOX  are not within three (3) years preceding this offer, had one or more contracts terminated for default by any federal agency. Audit Status / Fiscal Responsibility  FORMCHECKBOX  Subrecipient receives an annual audit in accordance with Uniform Guidance 200.514 (formerly A-133). Most recent fiscal year completed: FY FORMTEXT YYYY Were any audit findings report? (If Yes, explain in Section D Comments below)  FORMCHECKBOX  Yes  FORMCHECKBOX  No Please attach a copy of your most recent Uniform Guidance 200.514 (formerly A-133) Audit Report or provide in URL link to a complete copy.  FORMTEXT Enter name of Uniform Guidance 200.514 (formerly A-133) Audit Report Here  FORMTEXT Enter URL Link for the Uniform Guidance 200.514 (formerly A-133) Audit Report  FORMCHECKBOX  Subrecipient DOES NOT receive an annual audit in accordance with Uniform Guidance 200.514 (formerly A-133). Subrecipient is a:  FORMCHECKBOX  Non-profit Entity (under federal funding threshold)  FORMCHECKBOX  Foreign Entity  FORMCHECKBOX  For Profit Entity  FORMCHECKBOX  Government Entity Please complete an Audit Certification and Financial Status Questionnaire (OSR Form #47). A limited scope  audit may be required before a subaward will be issued.  FORMTEXT Enter comments from Debarment/Suspension question and/or Audit Status question here  FORMCHECKBOX  Not Applicable (Please check only if not providing comments in Section D)  Subrecipient Parent Entity Information Legal Name:  FORMTEXT Enter name here Address, City, State, Zip:  FORMTEXT Full address, city, state & zip code+4 Congressional District:  FORMTEXT ## County/Parish:  FORMTEXT Enter county or parish of parent entity DUNS Number:  FORMTEXT ######### EIN:  FORMTEXT ##-####### Subrecipient Fiscal Agent Information Name:  FORMTEXT Enter the first & last name of Fiscal Agent here Title:  FORMTEXT Enter the title of the Fiscal Agent here Address, City, State, Zip:  FORMTEXT Fiscal Agent full address, city, state & zip code+4 Email:  FORMTEXT Enter Fiscal Agent email address here Phone:  FORMTEXT ###-###-#### The appropriate programmatic and administrative personnel of subrecipient institution involved in this grant application are aware of the prime sponsors consortium policy and are prepared to establish the necessary inter-institutional agreements consistent with the policy. Any work begun and/or expenses incurred prior to execution of a subaward agreement are at the Subrecipients own risk. Subrecipient also certifies, to the best of subrecipient institutions knowledge, that: Financial disclosures have been made related to the activities for all investigators who may be funded by or through a resulting agreement All identified Conflicts of Interest have or will have been satisfactorily managed, reduced or eliminated in accordance with subrecipients or prime recipients Conflict of Interest policy prior to the expenditure of any funds under a resulting agreement. __________________________________________ ______________________________________________ Signature of Subrecipients Authorized Official Name & Title of Authorized Official Email:  FORMTEXT Enter Authorized Official's Email Address Phone:  FORMTEXT Enter Authorized Official's Phone Date:  FORMTEXT MM/DD/YYYY      Revised: 9/10/2018| v5 Page  PAGE \* Arabic \* MERGEFORMAT 4 of  NUMPAGES \* Arabic \* MERGEFORMAT 4 SECTION A PROPOSAL DOCUMENTS SECTION B CERTIFICATIONS SECTION C AUDIT STATUS SECTION D COMMENTS SECTION E - PARENT ENTITY INFORMATION APPROVED FOR SUBRECIPIENT HEALTH SCIENCE CAMPUS 3000 Arlington Avenue, MS 1020 Toledo, OH 43614 ResearchAdmin.HSC@utoledo.edu Fax: 419.383.4262 MAIN CAMPUS 2801 W. 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