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