Office of Grant and Contract Administration
http://www.umass.edu/research/
SUBRECIPIENT COMMITMENT FORM
Complete form when submitting as a subrecipient in a UMass proposal
Subrecipient Legal Name:
Address:
Phone:
City:
_ Email:
Fax:
Congressional District
EIN #:
Institution Type: __________________________________________
Registered in SAM? Yes______ No _____
DUNS #:
Subrecipient PI Name:
Email:
Phone:
State:
Address where research will be performed: _________________________________________
Proposal Title:
Period of Performance:
Total Funds Requested:
Start date:
End date:
Cost Share Commitment:
Administrator Name:
_
Phone:
Email:
SECTION A: PROPOSAL DOCUMENTS
The following documents are included in our proposal and covered by the certification below (check as applicable)
* required
STATEMENT OF WORK *
BUDGET *
BUDGET JUSTIFICATION *
BIO SKETCHES of Key Personnel *
INDIRECT COST RATE AGREEMENT * (see section B. 1)
FRINGE BENEFIT RATE AGREEMENT/DOCUMENTATION * (see section B.2)
OTHER: _______________________________________________
SECTION B: CERTIFICATIONS
1) Facilities and Administrative 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. (Please attach copy or provide internet URL link in Section D, Comments, below)
_____ Di Minimis indirect cost rate of 10% MTDC - to be applied when a non federal entity does not
have a negotiated indirect cost rate (F&A)
2) Fringe Benefit Rates included in this proposal have been calculated based on:
Rates consistent with or lower than our federally-negotiated rates (Please attach copy or provide
internet URL link in Section D, Comments, below)
Other rates (please specify the basis on which the rate has been calculated in Section D
Comments below).
3) Human Subjects: Yes___No ___
Institutional Assurance ID: ______________________
A copy of the IRB approval must be provided before any subaward will be issued. Please forward this
document to UMASS Amherst Office of Grant & Contract Administration: ogca@research.umass.edu
4) Animal Subjects: Yes ___ No ___ Institutional Assurance ID: ______________________
A copy of the IACUC approval must be provided before any subaward will be issued. Please
forward this document to UMASS Amherst Office of Grant & Contract Administration:
ogca@research.umass.edu
5) F i n a n c i a l C o n f l i c t of Interest in Research: (applicable to PHS and other sponsors that have
adopted the federal financial disclosure requirements)
Not applicable because this project is not being funded by NIH, NSF, or other sponsor that has
adopted the federal financial disclosure requirements
Subrecipient certifies that it has an active and enforced conflict of interest in research policy that is
consistent with the provision of 42 CFR Part 50, Subpart F “Responsibility of Applicants for Promoting
Objectivity in Research.” Subrecipient also certifies that, to the best of Institution’s knowledge, (1) all financial
disclosures have been made related to the activities that may be funded by a resultant subaward as required by its
conflict of interest in research policy; and, (2) all identified conflicts of interest have or will have been
satisfactorily managed, reduced or eliminated in accordance with subrecipient’s conflict of interest policy prior
to the expenditures of any funds under any resultant subaward .
Subrecipient does not have an active and/or enforced conflict of interest policy but will abide by UMASS’
policy and related procedures:
http://www.umass.edu/research/system/files/NSF%20Conflict%20of%20Interest%20Policy.pdf
6) Debarment and Suspension
Is the PI, or any employee or student participating in this project debarred, suspended or otherwise excluded
from or ineligible for participation in federal assistance programs or activities?
Yes _______
(provide explanation in Section D.)
No ________
The Subrecipient hereby certifies that it:
is ____is not
presently debarred, suspended, proposed for debarment, or declared ineligible for
award of federal contracts
is
is not presently indicted for, or otherwise criminally or civilly charged by a government
entity
has
has not within three (3) years preceding this offer, been convicted of or had a civil judgment
rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to
obtain, or performing a public (federal, state or local) contract of subcontract; violation of Federal or State
antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery,
falsification or destruction of records, making false statements or receiving stolen property
has
has not within three (3) years preceding this offer, had one or more contracts terminated for
default by any federal agency
7. Responsible Conduct of Research (RCR)
____ Not applicable because this project is not being funded by NSF or NIH Subrecipient
____ Subrecipient hereby certifies that it will ensure that all undergraduate students, graduate
students, and postdoctoral researchers who will be supported by this NSF/NIH funded proposal will
be trained on the oversight in the responsible and ethical conduct of research.
8. Prior Award Experience
____Yes _____ No Subrecipient Organization is currently in receipt of federal funding or has received
federal funding in the past.
___Yes _____ No Subrecipient Organization has had a contract, grant, and/or agreement terminated
for cause or material breach. (If “yes” explain in the comments section below.)
9. Fiscal Responsibility The Subrecipient Organization certifies that its financial system complies
with generally accepted accounting principles and certifies to the statements below:
____Yes ____ No Subrecipient Organization has outstanding audit findings that would impact contract
cost. (If “yes” submit a copy of the most recent report that describes the findings and the steps to be
taken to correct the findings.)
___Yes ___ No Subrecipient Organization has completed an audit in compliance with 2 CFR § 200.501
(Subpart F – Audit Requirements) If “yes” latest audit was completed for period ending
___________________
___ Yes ___No Subrecipient Organization’s financial system has the capability to identify, in its accounts,
all federal awards received and expended, and the federal programs under which they were received.
___ Yes ___ No Subrecipient Organization maintains internal controls to assure that it is managing federal
awards in compliance with applicable laws, regulations, and the provision of contracts, grants, and
agreements.
___ Yes ___ No Subrecipient Organization and its financial system comply with applicable laws and
regulations.
___ Yes ___No -- Subrecipient Organization and its financial system can prepare appropriate financial
statements, including the schedule of expenditures of federal awards.
Section C- Audit Status:
Subrecipient receives an annual audit in accordance with OMB Circular A-133.
Most recent fiscal year completed: FY _________
Please provide the URL link to your most recent A-133 audit report
Were any audit findings reported? Yes _____
No ______
(If yes, please note the applicable pages in the audit report and provide an update on the status of the
corrective action in Section D.)
___ If Subrecipient did not undergo a single audit, please attach the most recently completed fiscal year audit
report for your organization including independent auditor’s letter, and update on management’s corrective
action on any findings.
Section D Comments:
Approved for Subrecipient
The information, certifications and representations contained herein 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 subawards and are prepared to enter into a
subaward agreement consistent with those policies and the applicable flow-down requirements of the Prime
Award.
To the best of my knowledge, the enclosed represents a true, complete and accurate representation of work to be
performed and costs to be incurred in the performance of the proposed project.
______________________________
_______________________________
Signature of Subrecipient’s Authorized Official
Date
_______________________________________
Name and Title of Authorized Official
_________________________________________
Email
_______________________________________
Phone
_________________________________________
Fax