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.  Name:

b.  Address:

c.  Phone:

d.  Email:

4.  Expected period of Subrecipient/Subcontractor participation:

From to

5. Current authorized period of Subrecipient/Subcontract: From to

6. Expected total funding for Subcontractor/Subrecipient: $

7. Current authorized funding for Subcontractor/Subrecipient: $

8. Was this Subrecipient/Subcontractor proposed in the application? yes no

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 yes

If yes, explain and attach a copy of your conflict of interest management plan:

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

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

Page 2 January 2015