University of Alabama at Birmingham
Office of Sponsored Programs
SUBRECIPIENT ASSURANCE FORM
As a potential recipient of a subaward from the University of Alabama at Birmingham (UAB), provide the
information requested below in Sections A-C and return the form signed by an authorized official to the
UAB Principal Investigator (PI).
Preamble: To be completed by the UAB PI
Subrecipient Institution: ________________________________ Subrecipient PI:________________
Proposal Title: ___________________________________________________________________
Period of Performance: ______________________ Proposed Amount: _____________________
UAB PI: ______________________ Prime Sponsor: _______________________________________
OSP Assigned Number (if available): _______________________
Section A: Documents to be Provided by Subrecipient
The Subrecipient should attach the following documents to this form.
 Statement of Work
 Budget and Budget Justification
 Other proposal documents as required by the solicitation
 Contact Information (Federal Demonstration Partnership Template Attachment 3B form)
Section B: Representations and Certifications Relevant to Application
For each of the topics below, select the response that most accurately describes your entity. Attach any
additional documentation requested.
1. Facilities and Administrative Rates (F&A) Status:
 The F&A rate included in this subward is the entity’s federally negotiated rate for this type of
work or the rate allowed by the sponsor for this program. A copy of the entity’s F&A rate
agreement is attached or may be accessed at the following URL link:
____________________________________.
 The F&A rate included in this subaward is the de minimus 10% as the entity does not have a
federally negotiated rate for this type of work.
2. Fringe Benefit Rate: The fringe benefit rate included in the budget has been calculated on:
 Rates consistent with or lower than our federally negotiated rates. A copy of the entity’s
federally negotiated rate agreement or the entity’s composite employee rate projections are
attached or may be accessed at the following URL link: ________________________________.
 Other rates. The description of the basis on which these rates are calculated is attached or may
be accessed at the following URL link: _______________________________________.
3. Cost Share/Matching/In-Kind (amount and justification must be reflected in the budget):
 Not Applicable
 Cost Share/Matching
 In-Kind funding
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4. Audit Status/Fiscal Responsibility :
 Subrecipient entity receives an annual Single Audit (A-133) in accordance with OMB Uniform
Guidance. A complete copy of the most recent audit report is attached or may be accessed at
the following URL link: ____________________________________________________.
 Subrecipient entity is not subject to Single Audit requirements because it is a:
 non-profit entity with federal expenditures less than or equal to $750,000
 for-profit organization
 governmental entity
 foreign entity (not formed under U.S. laws)
If not subject to a Single Audit complete the attached Financial Questionnaire.
5. ‘Whistleblower’ Protection:
Subrecipient entity certifies that it has a written institutional policy informing their employees of the
rights and remedies provided under 41 U.S.C. § 4712, as amended by P.L. 112-239.
6. Financial Conflict of Interest (42 CFR Part 50 and 45 CFR Part 94):
 Subrecipient entity certifies that it has an active and enforced conflict of interest policy that is
consistent with the provisions of 42 CFR Part 50 and 45 CFR Part 94 as applicable. Subrecipient
also certifies that, to the best of the entity’s knowledge, 1) all financial disclosures have been
made related to the activities that may be funded by or through a resulting agreement as
required by its conflict of interest policy; and, 2) all identified financial conflicts of interest have
or will be satisfactorily managed, reduced, or eliminated in accordance with the subrecipient’s
conflict of interest policy prior to the expenditures of any funds under any resultant agreement.
 Subrecipient entity does NOT have an active and enforced financial conflict of interest policy
that is consistent with the provisions of 42 CFR Part 50 and 45 CFR Part 94 and certifies it will
comply with UAB’s Financial Conflict of Interest policy and procedures prior to the expenditure
of funds under any resultant agreement.
Section C: Review/Approval Subject to Institutional Oversight Body
1. Work Subject to Review/Approval by an Institutional Review Board (IRB) for Human Studies or
comparable oversight body:
 Not Applicable – Subrecipient’s part of the project does not include research involving human
subjects
 Subrecipient entity certifies that it complies with all applicable regulations and training per the
Prime Sponsor solicitation in regard to human subjects. (Documentation of review and
approval by an IRB or comparable institutional oversight body must be supplied upon request.)
2. Work Subject to Review/Approval by an Institutional Animal Care and Use Committee (IACUC) or
comparable oversight body:
 Not Applicable – Subrecipient’s part of the project does not include research involving
vertebrate animal subjects.
 Subrecipient entity certifies that it complies with all applicable regulations and training per the
Prime Sponsor solicitation in regard to animal use and care. (Documentation of review and
approval by an IACUC or comparable institutional oversight body must be supplied upon
request.)
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3. Work Subject to Review/Approval by an Institutional Safety Committee or comparable oversight
body including work involving select agents and stem cells:
 Not Applicable – Subrecipient’s part of the project does not include research requiring review
and approval by an Institutional Biosafety Committee (IBC), Radiation Safety Committee, or
other institutional safety oversight body.
 Subrecipient entity certifies that it complies with all applicable regulations and training per the
Prime Sponsor solicitation in regard to safety issues.
4. Work Subject to International Traffic in Arms Regulations (ITAR), Export Administration
Regulations (EAR), and Office of Foreign Asset Control (OFAC) Regulations:
 Not Applicable
 Covered work being performed at subrecipient location
 Subrecipient accessing work done at pass through entity
5. Work Subject to Dual Use Research of Concern (DURC) Regulation:
 Not Applicable
 Subrecipient entity certifies that it complies with all applicable regulations and training per the
Prime Sponsor solicitation in regard to Dual Use issues.
6. Research Training for undergraduates, graduate students, and post-doctoral researchers:
 Not Applicable
 Subrecipient entity certifies that all undergraduates, graduate students, and post-doctoral
researchers to be supported by the subaward will be provided training on the responsible and
ethical conduct of research. Also that any graduate students and post-doctoral researchers
supported by the subaward will be provided guidance/training in order to prepare Individual
Development Plans (IDPs).
SECTION D: Signature of Authorized Subrecipient Representative
The appropriate programmatic and administrative personnel of the subrecipient entity certify they are
aware of agency policy in regard to Prime Sponsor’s solicitation guidelines, that the entity is in
compliance with all relevant rules and regulations relating to the conduct of this project, are prepared to
establish the necessary inter-institutional agreements consistent with those rules, regulations and
policies and that the information, certifications, and representations above have been read, signed, and
made by an authorized organizational representative of the subrecipient.
Any work done and/or expenses incurred prior to execution of a subaward agreement are at the
subrecipient’s own risk.
By signature below, subrecipient entity certifies that neither the subrecipient entity nor the project
principal(s) are presently debarred, suspended, or otherwise excluded from or ineligible for participation
in federal department, agency, or assistance programs or activities.
_____________________________________
Signature of Subrecipient’s Authorized Official
____________________________________
Type or Print Name and Title of Authorized Official
_____________________________________
Name of Subrecipient Institution
_____________________________________
Address of Subrecipient Institution
____________________________________
Date
_____________________________________
Email
(03/15)
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