Subrecipient Compliance Information Form A. OMB 2 CFR 200 Single Audit Status:

Subrecipient Compliance Information Form
A. OMB 2 CFR 200 Single Audit Status:
Name of Organization:
1. Does the subcontractor receive an annual audit in accordance with OMB Circular 2 CFR 200 (formerly A-133)?
A. If “Yes”, please provide the URL link to the most recent 2 CFR 200 (formerly A-133) single audit report:
Were there any audit findings reported in your most recent single audit report?
If "Yes", provide a description of the findings:
B. If “No”, select the appropriate box indicating why the subcontractor would not be subject to compliance
with OMB 2 CFR 200 certification (check all that apply):
Government Entity
Foreign Entity
Non-Profit Entity (under the federal funding threshold)
For-Profit Entity
Subrecipient receives overall federal funding less than $750,000 per year
In lieu of the single audit report, please provide a copy of your most recent audited financial statements, if your company
or organization is required to issue annual audited financial statements.
B. Federal Funding Accountability and Transparency Act (FFATA):
Northeastern University is required under the Federal Funding Accountability and Transparency Act (FFATA) to collect
subcontractor information for transactions exceeding $25,000.
Please provide your Organization’s DUNS number for FFATA reporting purposes:
Please check the box below for exemption from reporting if, in the preceding fiscal year, all of the following apply:
i)Recipient did not receive more than 80% or more of its annual gross revenues in federal awards (federal
contracts (and subcontracts), loans, grants (and sub-grants) and cooperative agreements); and ii) the recipient did not
receive $25,000,000 or more in annual gross revenue from federal awards; and iii) the public does not have access to
information about compensation of the senior executives through periodic reports filed under section 13(a) or 15(d) of
the Securities Exchange Act of 1934 (15 U.S.C. 78m(a)) or section 6104 of the Internal Revenue Code of 1986.
If applicable, please provide the annual total compensation and names of the subcontractor’s top five executives:
Compensation Amount
C. Conflict of Interest:
Does the subcontractor organization/institution have an active, current, and enforced Financial Conflict of Interest
(FCOI) Policy that is consistent with the provision of 42 CFR Part 50, Subpart F "Responsibility of Applicants for
Promoting Objectivity in Research"?
If "Yes", Certify:
All financial disclosures have been made related to the activities proposed through the subcontract.
If "No", select one of the following:
Agree to abide by Northeastern’s Individual Financial Conflict of Interest Policy, available at: , and follow Northeastern’s FCOI disclosure and
management processes.
Agree to implement the FDP Model Financial Conflict of Interest Policy, available at:
If "No", please list all investigators as defined here: "A project director, a principal investigator of a research project and
any other person, regardless of title or position, who is responsible for the design, conduct or reporting of research or
project results at or involving Northeastern, including employees, sub-grantees, contractors, subcontractors,
collaborators and consultants."
D. Fiscal Responsibility:
The subcontractor certifies that its financial system is in accordance with generally accepted accounting principles and
(check all that apply):
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 in compliance with applicable laws,
regulations, and the provisions of contracts or grants;
Complies with applicable laws and regulations;
Can prepare appropriate financial statements, including the schedule of expenditures of federal awards;
Has written accounting, payroll, accounts payable, accounts receivable, human resources, travel, procurement,
and property management policies;
Has a written policy to track and report the effort of key personnel on research projects;
Has a written policy for cost transfers (moving expenses between accounts).
E. Authorized Signature:
The information, certification, and representations above have been read, signed, and made by an authorized official of
the subcontractor named herein. The appropriate programmatic and administrative personnel involved in this
subcontract are aware of those policies. Any work begun and/or expenses incurred prior to execution of a subcontract
agreement are at the subcontractor's own risk. No work involving human subjects and/or animals may begin until the
subcontractor has obtained registered Institutional Review Board and/or Animal Care and Use Committee review and
Signature of Authorized Official:
Name and Title:
Name of Organization:
Last Updated 12-03-15