University of Colorado Colorado Springs
REQUEST FOR SUBRECIPIENT/SUBCONTRACT AGREEMENT
Request for Subrecipient/Subcontract Agreement to:
SECTION A. Project Information:
1.
UCCS Principal Investigator Information:
a. PI Name:
b. UCCS Department:
c. Phone:
d. Email:
2.
Sponsor Information:
a. Sponsor Name:
b. Sponsor’s Award #:
3.
Project Information:
a. Project Title:
b. UCCS Project #:
c. UCCS Speed Type #:
SECTION B. Subrecipient/Subcontractor Information:
1.
Subrecipient/Subcontractor Legal Name:
2.
Subrecipient/Subcontractor Principal Investigator/Project Director Information
(Person responsible for performing, or supervising, the work to be performed under this
subcontract):
a. Name:
b. Address:
c. Phone:
d. Email:
3.
Subrecipient/Subcontractor Contractual/Legal Contact (This is the
Subcontractor/Subrecipient’s Institutional Official, who will be signing the subcontract
and/or who should be notified (in addition to the PI) of any changes to the subcontract):
a.
b.
c.
d.
Name:
Address:
Phone:
Email:
4.
Expected period of Subrecipient/Subcontractor participation:
From
to
5.
Current authorized period of Subrecipient/Subcontract: From
6.
Expected total funding for Subcontractor/Subrecipient: $
7.
Current authorized funding for Subcontractor/Subrecipient: $
8.
Was this Subrecipient/Subcontractor proposed in the application?
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to
yes
January 2015
no
University of Colorado Colorado Springs
REQUEST FOR SUBRECIPIENT/SUBCONTRACT AGREEMENT
If no, have you subsequently obtained approval from the Sponsor for this
Subcontract/Subrecipient?
yes (please attach approval)
no (please explain)
9. Have you worked with the Subrecipient/Subcontractor before?
no
yes or
the Subrecipient/Subcontractor PI/PD?
no
yes
If yes, describe the circumstances and positive and/or negative outcomes/experience:
10. Do you have a financial interest in the proposed Subrecipient/Subcontractor
organization?
no
yes
If yes, attach a copy of your conflict of interest management plan.
11. Are you related to the proposed PI of the Subrecipient/Subcontractor?
no
If yes, explain and attach a copy of your conflict of interest management plan:
yes
SECTION C.
Department Administrator, if applicable, who assists the PI with the administration of
the Subaward/subcontract (such as requesting the Purchase Order):
a. Name:
b. Phone:
c. Email:
SECTION D. Project Information
1. Attach Subrecipient/Subcontractor proposed detailed Statement of Work and
budget.
2. Describe timetable or schedule of the work to be performed:
3. Describe how the work’s progress or results will be measured:
4. Identify deliverables, products, and expected outcomes:
5 Indicate reporting schedule (monthly, interim, final, other) and due dates:
6. Are there any matching/cost-share requirements for the Subrecipient/Subcontractor?
no
yes If yes, describe:
7.
A statement of work and a budget is attached.
PLEASE PROVIDE ANY ADDITIONAL COMMENTS, INCLUDING POTENTIAL CONFLICTS
OF INTEREST, OR SPECIAL INSTRUCTIONS
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University of Colorado Colorado Springs
REQUEST FOR SUBRECIPIENT/SUBCONTRACT AGREEMENT
SECTION E. Signatures/Certifications:
Principal Investigator/Project Director (Initial Each)
____ I certify that the information provided is true, complete, and accurate to the best of my
knowledge and all potential and/or actual conflicts of interest have been identified.
____ I understand that I am responsible for monitoring the subrecipient/subcontractor’s
performance, which includes ensuring receipt and review of required reports, adherence
to timelines, and successful completion of work.
____ I understand I am responsible for financial expenditures against this project and will
review and approve invoices for allowable costs, which are appropriate for the work
completed through the invoice period.
____ I understand no subrecipient/subcontractor invoices will be paid without my written
approval.
__________________________________________
UCCS Principal Investigator/Project Director Date
Department/College/Unit Approvals
I certify that the information has been reviewed. The department, college, and/or unit are
aware of the requirements of this project and the need for the subrecipient/subcontractor. I
confirm I am aware of no undisclosed potential and/or actual conflicts of interest.
___________________________________________
UCCS Department Chair
Date
___________________________________________
UCCS Center Director, if applicable
Date
___________________________________________
UCCS Dean/Vice Chancellor, as applicable
Date
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