The University of Memphis

Subrecipient Commitment Form

*Complete and return to The UofM Research Support
Services (RSS) Administrator listed in Section A below.
General Information
SECTION A - Proposal Information
U of M's PI: Phone: E-mail:
*U of M's RSS Administrator: Phone: E-mail:
RSS Proposal #: Prime Sponsor:  
Proposal Title:
Subrecipient PI: Phone: E-mail:
SUB.'s Proposal/Contract Admin: Phone: E-mail:

The following documents are included in our subagreement proposal submission and covered by the certifications below:

STATEMENT OF WORK (required)
BUDGET AND BUDGET JUSTIFICATION (required)
This SUBRECIPIENT COMMITMENT FORM (required) completed and signed by Subrecipient's Authorized Official
Other:

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 the F&A rate agreement must be furnished to The UofM before a subagreement will be issued.)
Other rates (Please specify the basis on which the rate has been calculated in Section D Comments below.)

Fringe Benefit (FB) Rates included in this proposal have been calculated based on:

Rates consistent with, or lower than, our federally-negotiated rates. (If this box is checked, a copy of the FB rate agreement must be furnished to The UofM before a subagreement will be issued.)
Other rates (Please specify the basis on which the rate has been calculated in Section D Comments below.)

Cost Sharing? Yes No
If Yes, enter amount: (Cost sharing amounts and justification should be included in the Subrecipient's budget.)

Regulatory Approvals; Indicate if proposal involves the following: (A copy of approval must be provided before any subagreement will be issued.)

Human subjects
Lab animals
Recombinant DNA
Select agents

SECTION B - Special Review and Certifications
By signing below, the authorized Subawardee official certifies, to the best of his/her knowledge and belief, that:

Certification Regarding Lobbying

  1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the Subawardee, 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 the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
  2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or intending 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 Federal contract, grant, loan, or cooperative agreement, the Subawardee shall complete and submit Standard Form -LLL, "Disclosure Form to Report Lobbying," to The Office of Research Support Services (RSS).

Debarment, Suspension, and Other Responsibility Matters

  1. Subawardee certifies that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.
  2. Subawardee certifies that it is not delinquent on any Federal debt.

Conflict of Interest

The Subawardee and/or the Subawardee’s principals have a significant financial interest in this proposal that may affect, or be perceived to affect, the results of the research proposed. Yes No

If Yes, explain in Section D, Comments, below

SECTION C - Audit Status

A-133 “Audits of States, Local Governments and Non-Profit Organizations” Audit Status

Does the Subrecipient receive an annual audit in accordance with OMB Circular A-133? Yes No
If "Yes": Has the audit been completed for the most recent fiscal year? Yes No

If "Yes": Were any audit findings reported? Yes No  (If "Yes," explain in Section D, Comments, below.)
Note:  A complete copy of Subrecipient’s most recent audit report, or the Internet URL link to a complete copy, must be furnished to The UofM before a subagreement will be issued.

If "No": Does the Subrecipient receive overall federal funding of at least $500,000 per year? Yes No
Is the Subrecipient a:
Non-profit entity expending less than $500,000 per year in Federal or Sub-Federal funds annually
For-profit entity that expends Federal or Sub-Federal funds and has a DCAA audited rates
For-profit entity that does not expend Federal funds or have annual audits
Foreign entity
If a for-profit entity, is the Subrecipient a:
Small business
Large business

Note: If a subrecipient does not receive an A-133 audit, The UofM may require the entity to complete an Audit Certification and Financial Status Questionnaire, and may require a limited scope audit, before a subagreement will be issued.

Contact information for audit questions:

   
SECTION D - Comments (attach additional sheets if needed)
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 subagreements and are prepared to establish the necessary agreements consistent with those policies.

Any work begun and/or expenses incurred prior to execution of a subagreement are at the subrecipient's own risk.


Signature of Subrecipient's Authorized Official Date
   

The University of Memphis, one of the Tennessee Board of Regents institutions, is an Equal Opportunity/Affirmative Action University.