BIOMEDICAL AND HEALTH SCIENCES

RESTRICTED FUNDS - DISCRETIONARY AND ENDOWMENT NEW INDEXREQUEST QUESTIONNAIRE

PLEASE ANSWER ALL QUESTIONS COMPLETELY. THE COMPLETED QUESTIONNAIRE AND ALL SUPPORTING DOCUMENTATION SHOULD BE UPLOADED VIA THE “RBHS DISCRETIONARY-NEW INDEX REQUEST PORTAL” FOUND AT http://postaward.rutgers.edu/legacy-umdnj-units/overview-resources

IF INCOMPLETE OR MISSING REQUIRED ATTACHMENTS, THE INDEX OPENING PROCESS WILL BE DELAYED.

Please contact your school’s business office and/or development officer for assistance in completing the questionnaire.

PROPOSED INDEX TITLE:

SCHOOL NAME:

DEPARTMENT NAME:

RESPONSIBLE PERSON OF INDEX:

(Indicate name of Investigator, Chair or Dean/Director)

RESPONSIBLE PERSON OF INDEX EMPLOYEE ID:

PRED-ORG CODE:

DESCRIBE PURPOSE OF INDEX:

PERSONS WHO WILL BE AUTHORIZED TO RECEIVE AND EXPEND FUNDS FROM THE INDEX:

NAME (Print or Type) / SIGNATURE / TITLE
SOURCE OF EXTERNAL FUNDING/DONOR NAME:

Please provide details as to anticipated dollar amounts to be received: ______

______

______

ATTACH DONOR SUPPORT/OTHER DOCUMENTATION:
Without supporting documentation, an INDEX will not typically be opened. Required donor support for restricted gifts related to scholarships, fellowships and student prizes/awards are signed specifications (fund agreements). Ideal support for other restricted INDICES includes fund agreements or written correspondence from the donor(s) which confirms their wishes for the use(s) of the funding, start-up letters, etc. Please note that fund agreements are required for all endowment INDICES.

AVAILABLE FUNDS THAT WILL BE USED TO OPENINDEXAND THEIR CURRENT LOCATION:

An INDEX will not be opened without the receipt of funds at the Rutgers University Foundation (RUF), New Jersey Health Foundation (NJHF) or at Rutgers University (RU). In most cases, contributions should be received at RUF and reside there in a temporary account until a permanent University INDEX is opened.

LOCATED AT RUF: / RUF TEMPORARY ACCOUNT NUMBER
LOCATED AT NJHF: / NJHF AWARD INDICATOR
LOCATED AT RBHS: / RBHS INDEX NUMBER

NOTE: If funding is to be transferred from an existing index, please indicate the amount of funding to be transferred to this new index this current fiscal year: $______

ATTACH AN ANNUAL BUDGET
Please attach a balanced annual budget with appropriate Banner account codes. Annual expenses cannot exceed annual income and the total amounts should coincide with the annual figures provided directly below.
EXPECTED DOLLAR AMOUNT OF ANNUAL INCOME:
*Net of 5% and/or 10% Gift Assessment Fee, if applicable
EXPECTED DOLLAR AMOUNT OF ANNUAL EXPENDITURES:

EXPENDITURES: Please note the following:

Actual fringe benefits incurred by the employment of an employee on this INDEX will be charged to this INDEX.

Will payments for services (including consulting fees) be expended for an existing employee or official (paid or unpaid) of the State of New Jersey (including Rutgers), the county or municipal governments or the Federal Government, in addition to their regular salaries? If yes, please attach a listing of the names and agencies involved. If no, and later it is decided that it is necessary to employ such individuals, you are responsible to notify the RBHS-DGCA department.

YES / NO

INDEX TO COVER OVERDRAFTS:

State appropriationsor sponsored program INDICES cannot be used to cover overdrafts.

INDEX NUMBER:
INDEXTITLE:

COMPLIANCE QUESTIONS:

  1. To the extent known at the time of index establishment, will this index involve any of the following, subjecting it to U.S. Export Control Laws? For assistance, please contact the Export Compliance Officer at

Foreign Nationals involved in research No Yes To be Determined

Funding by an International Sponsor No Yes

Work Outside of USA No Yes

EAR: Export Administration Regulations No Yes

ITAR: International Traffic in Arms Regulations No Yes

  1. Please indicate whether activities funded by this index includes any of the following:

Human Subjects (IRB) No Yes

Animal Subjects (IACUC) No Yes

Biohazards, Toxins, Pathogens, rDNA, Human Tissues/Cells No Yes

Materials, Machines, Lasers (Radiation Safety) No Yes

CONDITIONS AND APPROVALS:

1)I understand that expenditures against this INDEX shall not exceed the available cash balance.

2)I understand that this INDEX shall not be used for sponsored research contracts or grants for specific work or services.

3)I certify that the answers to the above questions and statements are true and correct.

REQUESTOR’S SIGNATURE: / DATE:
REQUESTOR’S NAME (Print or Type):

REQUESTOR’S EMAIL: ______

SCHOOL CFO/BUSINESS OFFICE SIGNATURE: / DATE:
SCHOOL CFO/BUSINESS OFFICE NAME/(Print or Type): / ___
DEAN’S/DIRECTOR’S SIGNATURE: / DATE:
DEAN’S/DIRECTOR’S NAME (Print or Type):

FOR ACCOUNTING USE ONLY: AUTHORIZATIONS

DIRECTOR OF FINANCIAL AID (For Scholarships, Fellowships, Student Prizes/Awards)
SIGNATURE: / DATE:
DGCA/MANGER-RESTRICTED FUNDS
SIGNATURE: / DATE:
DGCA/ASSOCIATE CONTROLLER
SIGNATURE: / DATE:

DIRECTOR OF COMPLIANCE

SIGNATURE: ______DATE: ______

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