Certification of Membership for Awards Prior to October 1St 2016 Single Site Reporting

Certification of Membership for awards prior to October 1st 2016 – Single Site reporting

Project Title: I/UCRC forSite X – Phase I – Research Area

Grant No. IIP-xxxxx

Project dates: 09/01/13 - 08/31/18

Today date:

Member / Type / 09/01/13-08/31/14 / 09/01/14-08/31/15 / 09/01/15-08/31/16 / 09/01/16-08/31/17 / 09/01/17-08/31/18
In Cash
Company A / Full / $50,000 / $50,000
Company B / Full/Associate / $50,000 / $25,000*
Company C / Full / $50,000
Company D / Full / $50,000**
Company E / Associate / $25,000 / $25,000
NSF SBIR Phase II Company X / Associate / $5,000
Agency X / Full/MIPR- 1234567 / $50,000 / $100,000***
Agency Y / Full/IAA-1234567 / $100,000 / $100,000
* Company B went from full to associate in Year 2 – 3 payments received to date for $15k
** Company D joined in January 2014, 3 payments received to date for $37.5k
*** Agency X went from one to two memberships in year 2
In Kind
Kind Company X / N/A / $50,000
Annual funds certified towards minimum membership requirement** / $325,000 / $405,000
** Minimum membership requirement is $400K AND 8 full members for a single site center, $150k AND 3 full members per site in a multi-site Phase I center, or $175k AND 3 full members per site in a multi-sites Phase II and III
(OPTIONAL) Others
NSF SBIR Phase II Company X / $20,000
(OPTIONAL) Site Overall Total Funds (sum of annual funds certified and all other funds) / $325,000 / $425,000

Provided by[Name and Title], on [Date]

SRO Signature______

Certification of Membership for awards prior to October 1st 2016 – Multi Site Reporting

Project Title: I/UCRC for Site X – Phase I – Research Area

Grant No. IIP-xxxxx

Project dates: 09/01/13 - 08/31/18

Today date:

Member / Type / 09/01/13-08/31/14 / 09/01/14-08/31/15 / 09/01/15-08/31/16 / 09/01/16-08/31/17 / 09/01/17-08/31/18
In Cash
Company A / Full / $50,000 / $50,000
Company B / Full/Associate / $50,000 / $25,000*
Company C / Full / $50,000
Company D / Full / $50,000**
Company E / Associate / $25,000 / $25,000
NSF SBIR Phase II Company X / Associate / $5,000
Agency X / Full/MIPR- 1234567 / $50,000 / $50,000***
* Company B went from full to associate in Year 2 – 3 payments received to date for $15k
** Company D joined in January 2014, 3 payments received to date for $37.5k
*** Agency X went from one to two memberships in year 2 but only one membership can count towards minimum
In Kind
Nice Company X / N/A / $50,000
Annual funds certified towards minimum membership requirement** / $325,000 / $405,000
** Minimum membership requirement is $400K AND 8 full members for a single site center, $150k AND 3 full members per site in a multi-site Phase I center, or $175k AND 3 full members per site in a multi-sites Phase II and III
(OPTIONAL) Others
Agency X / Full/MIPR- 1234567 / $50,000 / $50,000***
Agency Y / 2-Full/IAA-1234567 / $100,000 / $100,000
NSF SBIR Phase II Company X / $20,000
(OPTIONAL) Site Overall Total Funds (sum of annual funds certified and all other funds) / $325,000 / $425,000

Provided by [Name and Title], on [Date]

SRO Signature______

Certification of Membership for awards after October 1st 2016 – One Site reporting for all (pool memberships)

Project Title: I/UCRC for Site X – Phase I – Research Area

Grant No. IIP-xxxxx

Project dates: 09/01/13 - 08/31/18

Today date:

Member / Type / Site / 09/01/13-08/31/14 / 09/01/14-08/31/15 / 09/01/15-08/31/16 / 09/01/16-08/31/17 / 09/01/17-08/31/18
In Cash
Company A / Full / Univ. A / $50,000 / $50,000
Company B / Full/Associate / Univ. A / $50,000 / $25,000*
Company C / Full / Univ. A / $50,000
Company D / Full / Univ. A / $50,000**
Company E / Associate / Univ. A / $25,000 / $25,000
NSF SBIR Phase II Company X / Associate / Univ. A / $5,000
Univ A Total / $175,000 / 155,000
Company A / Full / Univ. B / $50,000 / $50,000
Company B / Full / Univ. B / $50,000 / $50,000
Company C / Full / Univ. B / $50,000 / $50,000
Univ B Total / $150,000 / $150,000
* Company B went from full to associate in Year 2 – 3 payments received to date for $15k
** Company D joined in January 2014, 3 payments received to date for $37.5k
*** Agency X went from one to two memberships in year 2
In Kind
Kind Company X / Univ A / N/A / $50,000
Kind Company Y / Univ B / N/A / $25,000
Annual funds certified towards minimum membership requirement** / $325,000 / $380,000
** Minimum membership requirement is $400K AND 8 full members for a single site center, $150k AND 3 full members per site in a multi-site Phase I center, or $175k AND 3 full members per site in a multi-sites Phase II and III
(OPTIONAL) Others
NSF SBIR Phase II Company X / Univ A / $20,000
(OPTIONAL) Site Overall Total Funds (sum of annual funds certified and all other funds) / $325,000 / $400,000

Provided by [Name and Title], on [Date]

SRO Signature______

Certification of Membership for awards after October 1st 2016 – One Site reporting for all (pool memberships)

Project Title: I/UCRC for Site X – Phase I – Research Area

Grant No. IIP-xxxxx

Project dates: 09/01/13 - 08/31/18

Today date:

Member / Type / Site / 09/01/13-08/31/14 / 09/01/14-08/31/15 / 09/01/15-08/31/16 / 09/01/16-08/31/17 / 09/01/17-08/31/18
In Cash
Company A / Full / Univ. A / $50,000 / $50,000
Company B / Full/Associate / Univ. A / $50,000 / $25,000*
Company C / Full / Univ. A / $50,000
Company D / Full / Univ. A / $50,000**
Company E / Associate / Univ. A / $25,000 / $25,000
NSF SBIR Phase II Company X / Associate / Univ. A / $5,000
Univ A Total / $175,000 / 155,000
Company A / Full / Univ. B / $50,000 / $50,000
Company B / Full / Univ. B / $50,000 / $50,000
Company C / Full / Univ. B / $50,000 / $50,000
Univ B Total / $150,000 / $150,000
* Company B went from full to associate in Year 2 – 3 payments received to date for $15k
** Company D joined in January 2014, 3 payments received to date for $37.5k
*** Agency X went from one to two memberships in year 2
Annual funds certified towards minimum membership requirement** / $325,000 / $305,000
** Minimum membership requirement is $400K AND 8 full members for a single site center, $150k AND 3 full members per site in a multi-site Phase I center, or $175k AND 3 full members per site in a multi-sites Phase II and III
(OPTIONAL) Others
Kind Company X / Univ A / N/A / $50,000
NSF SBIR Phase II Company X / Univ A / $20,000
Kind Company Y / Univ B / N/A / $25,000
(OPTIONAL) Site Overall Total Funds (sum of annual funds certified and all other funds) / $325,000 / $400,000

Provided by [Name and Title], on [Date]

SRO Signature______