Simons Fellows in Mathematics and Theoretical Physics
Activation and Agreement Form
Grantee:
Institution:
Address:
Grantee Telephone:
Grantee E-mail:
Grantee’s Administrator (if applicable):
Admin Telephone:
Admin E-mail:
Title:
Award Number:
Grant Period:
Total Budget:
Signing Official:
Signing Official Telephone:
Signing Official E-mail:
Financial Officer:
(Person to whom funds will be sent and who will keep a full account of disbursements)
Pay to:
(Cannot be a person)
Address:
Financial Officer Telephone:
Financial Officer E-mail:
Electronic Fund Transfer Payment Information
(* indicates required field)
NOTE: Payments to U.S. institutions will be made by ACH only. Payments to
foreign institutions will be made by WIRE only, except in circumstances where the foreign
institution has a U.S. intermediary bank. U.S. intermediary banks will be paid via ACH and
the ACH section must be completed.
The ACH or Wire Bank Statement will indicate the Amount, the Award Number, Cycle, and PI
Name.
Simons Fellows in Mathematics and Theoretical Physics
Activation and Agreement Form
For grants to U.S. institutions (or involving U.S. intermediary banks), please complete the
following information:
*EIN:
*Bank Name:
*Bank Address:
*Bank ACH Routing Number:
*Bank Account Number:
*Account type:
For grants to foreign institutions, please complete the following information:
*Tax ID, EIN equivalent:
*Bank Name:
*Bank Country:
Bank Country ID:
*Bank Swift ID or IBAN Number (please indicate which):
*Bank Account Number (if using Swift ID):
Any Additional Information:
(instructions normally provided to your bank for international wires)
CERTIFICATION: I certify that the information submitted herein are true, complete, and
accurate to the best of my knowledge, and agree to comply with terms and conditions
outlined in the award letter and with all applicable laws and Simons Foundation policies
(http://www.simonsfoundation.org/funding/policies-and-procedures/#mps).
Signing Official Signature:
Date: