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Subrecipient Commitment Form

FFATA: Yes No

(To be completed by NAU)

Today’s Date:

NAU PI: PRIME SPONSOR:

Section A - Subrecipient Information

1. SUBRECIPIENT: SUBRECIPIENT PRINCIPAL INVESTIGATOR (PI):

2. SUBMITTED PROPOSAL ENTITLED:

3. PERFORMANCE PERIOD: BEGIN: END:

4. Is Subrecipient currently registered in CENTRAL CONTRACTOR REGISTRATION (CCR) database?

Yes (requirement) No

5. DATA UNIVERSAL NUMBERING SYSTEM (DUNS) # (required):

DUNS+4#:

6. SUBRECIPIENT “AWARD”ADDRESS:

Street Address, City, State, Zip Code + 4, Telephone#, Fax#, and Email Address:

Congressional District (not applicable for foreign subrecipients):

SUBRECIPIENT “PLACE OF PERFORMANCE” ADDRESS(Complete if Subrecipient “Place of Performance” address differs from Subrecipient “Award” address):

Street Address, City, State, Zip Code + 4, Telephone#, Fax#, and Email Address:

Congressional District (not applicable for foreign subrecipients):

Subrecipient Contacts
Administrative Contact
Name:
Address:
Telephone:
Fax: Email:
Project Director
Name:
Address:
Telephone:
Fax: Email:
Financial Contact
Name:
Address:
Telephone:
Fax: Email:
A-133 Audit Contact
Name:
Address:
Telephone:
Fax: Email:
Authorized Official
Name:
Address:
Telephone:
Fax: Email:

Section A – Proposal Documents

The following documents are included in Subrecipient subaward proposal submission and covered by certifications in Section B:

STATEMENT OF WORK(REQUIRED)

Include work to be performed, project description, PI, period of performance, deliverables, milestones.

BUDGET and BUDGET JUSTIFICATION (REQUIRED)
Include Annual and Summary detailed budgets and Budget Justification with sufficient detail for cost/price analysis.

This SUBRECIPIENT COMMITMENT FORM(REQUIRED) signed by Subrecipient Authorized Official.

Small/Small Disadvantaged Business Subcontracting Plan, in agency-required format.(required for proposals over $550,000)

OTHER:

Section B – Special Review and Certifications

  1. Facilities and Administrative Rates included in this proposal have been calculated based on:

Subrecipient federally-negotiated F&A rates for this type of work, or a reduced F&A rate that Subrecipient hereby agrees to accept.

(If this box is checked, a copy of Subrecipient’s F&A rate agreement must be furnished to NAU before a subaward will be issued, submit along with this Subrecipient Commitment Form.)

Other rates
(Please specify basis on which rate has been calculated in “Section C Comments” at end of form.)

  1. Fringe Benefit Rates included in this proposal have been calculated based on:

Rates consistent with or lower than Subrecipient’s federally-negotiated rates.

(If this box is checked, a copy of Subrecipient’s Fringe Benefit rateagreement must be furnished to NAU before a subaward will be issued;include with this Subrecipient Commitment Form.)

Other rates. Please attach documentation or specify the basis on which the rate has been calculated:

  1. Cost SharingYes No Amount: $

(Cost sharing amounts and justification should be included inSubrecipient’s budget.).

REGULATORY APPROVALS (Questions 4-10)

  1. Affirmative Action Compliance

In accordance with the rules and regulations of the Secretary of Labor (41 CFR 60-1 and 60-2), if your organization has more than fifty (50) employees and the subaward will be for $50,000 or more, you are required to have a written affirmative action program.

YES, we have a written affirmative action program developed and on file.

NO, we do not have a written affirmative action program.

NOT APPLICABLE, as we have less than 50 employees or anticipate total subaward amount to be less than $50,000.

  1. Human Subjects Yes No

Check Yes if proposal includes surveys, interviews, observations or secondary data.

If "Yes": Copies of theInstitutional Review Board (IRB)Committee approval and approved "Informed Consent" form must be provided before any subaward will be issued. If pending, obtain approval as required and forward these documents to NAU’s Principal Investigator as soon as available.

If "Yes": Have all key personnel involved completed Human Subjects Training? Yes No

  1. Animal SubjectsYes No

If "Yes": A copy of the IACUC Committee approval must be provided before any subaward will be issued. If pending, obtain approval as required and forward these documents to NAU PI as soon as available.

  1. Debarment, Suspension, Proposed Debarment

Is the Principal Investigator or any other employee or student participating in this project debarred, suspended or otherwise excluded from or ineligible for participation in Federal assistance programs or activities?

Yes No

Subrecipientcertifies that they: (answer all questions below)

Are Are Notpresently debarred, suspended, proposed fordebarment, or declared ineligible for award of Federal Contracts.

Are Are Notpresently indicted for, or otherwise criminally or civilly charged by a governmental entity.

Have Have Notwithin 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 or 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.

Have Have Notwithin three (3) years preceding this offer, had one or more contracts terminated for default by any Federal Agency.

  1. Conflict of Interest

Subrecipient hereby certifies that it has an active and enforced conflict of interest policy that is consistent with the provisions 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 or though a resulting agreement, and required by its conflict of interest 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 agreement.

Subrecipient does not have an active and/or enforced conflict of interest policy and hereby agrees to abide by NAU’s policy. The undersigned certifies that to the best of his/her knowledge there is no officer or employee of NAU who has, or whose relative has, a substantial interest in any contract resulting from this request.

  1. Responsible Conduct in Research (RCR) (applicable to NSF and NIH)

Not applicable because this project is not being funded by NSF nor NIH.

Not applicable because the Subrecipient is not an educational institution.

By checking this box, Subrecipient certifies,if applicable, that it maintains anInstitutional Planto meet NSF’sEducational Requirements for the Responsible Conduct of Research, as required under the “America COMPETES Act” PUBLIC LAW 110-69-August 9, 2007. Subrecipient certifies that it has a training program in place and will train all undergraduate and graduate students and postdocs in accordance with NSF’s RCR training requirements.

By checking this box, Subrecipient certifies, if applicable, that for NIH Grants for Training and Fellowship awards, that Subrecipient will monitor and maintain records for the individual training plans as proposed by Subrecipient, in accordance with NIH’s RCR training requirements.

  1. Fiscal Responsibility

Subrecipient certifies that its financial system is in accordance with generally accepted accounting principles and:

has the capability to identify, in its accounts, all Federal awards received and expended and the Federal programs under which they were received

maintains internal controls to assure that it is managing Federal awards in compliance with applicable laws, regulations and the provision of contracts or grants

complies with applicable laws and regulations

can prepare appropriate financial statements, including the schedule of expenditures of Federal awards

there are no outstanding audit findings which would impact contract costs. If there are findings, submit a copy of the most report that describes the finding and steps to be taken to correct the finding.

  1. A-133 Audit and Financial Status

We have completed our A-133 audit for the most recent period to . The audit disclosed no material weaknesses, no material instances of noncompliance with federal laws or regulations, no reportable conditions, no findings, and there are no unresolved prior year findings.

We have completed our A-133 audit for the most recent period to . The audit report noted material weaknesses, material instances of noncompliance with federal laws or regulations, reportable conditions, findings or unresolved prior year findings. The link to our A-133 audit report is:

We have not completed our A-133 audit for the fiscal year ending in 20. Our fiscal year ended and we expect the audit to be completed by . Within thirty days of completion, we will provide you with written certification and will send a copy of the audit report, including relevant findings, our responses and corrective action plan if the audit discloses any material weaknesses, material instances of noncompliance with federal laws or regulations, reportable conditions, findings or unresolved prior year findingscomplies with applicable laws and regulations

Subrecipient is not subject to the audit requirements of the OMB Circular A-133 because it is a:

Non-profit entity expending less than $500,000 in Federal and Sub-Federal funds in the most recent Fiscal Year

Foreign (non-U.S.) entity

For-profit entity

Other:

Note: If Subrecipient is not subject to OMB Circular A-133, Subrecipient is required to complete the attached Audit Certification and the Financial Status Questionnaire, and Subrecipient may be required to provide a limited scope audit, before subaward will be issued.

Section C – Comments

APPROVED FOR SUBRECIPIENT:

The information, certifications and representations above 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 establish the necessary inter-institutional agreements consistent with those policies.

Any work begun and/or expenses incurred prior to execution of a subaward agreement are at the subrecipient’s own risk.

Revised 11/2012Page 1 of 5

______

(Signature of Subrecipient’s Authorized Official)

(Name and Title of Authorized Official)

(Name and EIN of Subrecipient’s Organization/Institution)

(Address)

(City, State, Zip)

(Phone) (Fax)

(Email)

Revised 11/2012Page 1 of 5

Revised 11/2012Page 1 of 5