This document is considered a working paper of the Office of the Governor, Compliance and Oversight Division. Any unauthorized review, use, disclosure or distribution is prohibited without the express authorization of the Office of the Governor. This template is developed to facilitate the annual reporting process. The Office of the Governor reserves its contractual rights to request any additional information or documentation beyond the inforamtion provided herein, as it deems necessary.
Texas Emerging Technology Fund
[University Name] [Project Name]
Annual Compliance report For Fiscal year ending[August 31, 201X] or [December 31, 2012]
[Annual Compliance Report is due on September 30 each year]
Prepared for
Office of the Governor
P.O. Box 12878
Austin, TX 78711-2878
Prepared by: Name, Title, Organization
Annual Compliance Verification
[Date]
Director
Texas Emerging Technology Fund
Office of the Governor
Dear TETF Director,
This verification is delivered to you pursuant to the reporting section of the Texas Emerging Technology Fund Grant Agreement (the “Agreement”), effective as of __[date]__ between ___[Grantee Name as shown on Agreement]__ (the “Grantee”) and the State of Texas, acting by and through the Office of the Governor Economic Development and Tourism Division (the “OOGEDT”).
The undersigned hereby certifies that the undersigned is the Grantee’s duly authorized representative acting in the capacity of _ [position title] _, and as such representative, the undersigned hereby confirms Grantee’s compliance with each of the Grantee’s agreements, covenants and obligations under this Agreement.
The undersigned hereby certifies that all information provided in this report is true and correct.
Sincerely,
Name
Title
Organization
Executive Summary
[Please provide a brief summary of the activities, achievements, milestone status, matching funds received, commercialization success, etc. during the past reporting year.]
Milestones
Project Milestones
Project Milestone 1: [Enter the milestone as approved by TETF]
Status: [Complete/In-progress/Failed or Abandoned/Not Started]
Description: [Please provide a description of efforts taken and results.]
Reference: [Please attach documentary evidence to support the status and description. Make a reference to the attachment here and explain how the attached document(s) relate to this milestone.]
Project Milestone 2: [Enter the milestone as approved by TETF]
Status: [Complete/In-progress/Failed or Abandoned/Not Started]
Description: [Please provide a description of efforts taken and results.]
Reference: [Please attach documentary evidence to support the status and description. Make a reference to the attachment here and explain how the attached document(s) relate to this milestone.]
Project Milestone 3: [Enter the milestone as approved by TETF]
Status: [Complete/In-progress/Failed or Abandoned/Not Started]
Description: [Please provide a description of efforts taken and results.]
Reference: [Please attach documentary evidence to support the status and description. Make a reference to the attachment here and explain how the attached document(s) relate to this milestone.]
…
Researcher Milestones (Subchapter F Grants Only)
Researcher (name) Milestone 1: [Enter the milestone as approved by TETF]
Status: [Complete/In-progress/Failed or Abandoned/Not Started]
Description: [Please provide a description of efforts taken by the individual researcher and results.]
Reference: [Please attach documentary evidence to support the status and description. Make a reference to the attachment here and explain how the attached document(s) relate to this milestone.]
Researcher (name) Milestone 2: [Enter the milestone as approved by TETF]
Status: [Complete/In-progress/Failed or Abandoned/Not Started]
Description: [Please provide a description of efforts taken by the individual researcher and results.]
Reference: [Please attach documentary evidence to support the status and description. Make a reference to the attachment here and explain how the attached document(s) relate to this milestone.]
Researcher (name) Milestone 3: [Enter the milestone as approved by TETF]
Status: [Complete/In-progress/Failed or Abandoned/Not Started]
Description: [Please provide a description of efforts taken by the individual researcher and results.]
Reference: [Please attach documentary evidence to support the status and description. Make a reference to the attachment here and explain how the attached document(s) relate to this milestone.]
…
Matching Funds
Matching Funds Received
[If Grantee is required to secure matching funds, please use the table below to account for matching funds received.Please attach project fund account summary from university accounting system to show matching funds received to date.]
Entity / Date of Receipt / Amount$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
Total / $ -
Matching Funds Committed Not Yet Received
[Please use the table below to account for matching funds committed but not yet received.Please attach copies of letters of intent and encumbrances to date.]
Entity / Date of Commitment / Amount$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
Total / $ -
Use of Award Proceeds
[Please use the table below to account for TETF funds spent or encumbered to date. Please attach project fund account summary from university accounting system to show TETF award spent to date.]
Expenditure Category / Current Year Encumbrance / Current YearExpense / Cumulative Encumbrance / Cumulative Expense
Salaries & Benefits / $ - / $ - / $ - / $ -
Consumable Supplies / $ - / $ - / $ - / $ -
Travel / $ - / $ - / $ - / $ -
Capital Equipment / $ - / $ - / $ - / $ -
Leasehold/Building Improvement (Construction or Renovation) / $ - / $ - / $ - / $ -
Professional Services - R&D / $ - / $ - / $ - / $ -
Professional Services - Legal / $ - / $ - / $ - / $ -
Professional Services - Accounting / $ - / $ - / $ - / $ -
Please enter additional expenditure categories as needed / $ - / $ - / $ - / $ -
$ - / $ - / $ - / $ -
$ - / $ - / $ - / $ -
$ - / $ - / $ - / $ -
$ - / $ - / $ - / $ -
Total / $ - / $ -
[Please also attach copies of invoices for individual expenses excluding payroll expenses that are $100,000 or more.]
Other Funds
[Excluding TETF and matching funds reported in previous sections please use the table below to account for other funds applied for or received from federal, private, or other* entities received.]
Entity / Date of Award / Multi/Single -Year Award?** / Amount$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
Total / $ -
Note:
** For multi-year awards, the total award amount should be reported in the year it was awarded.
* Funds from other entities include but are not limited to other state agencies such as CPRIT, THECB, and University Systems, university investments that are not included in matching funds.
Top researchers and Other personnel (subchapter F grants only)
ETF Funded Top Research Talents
[Please list the ETF-approved, funded top researchers by name, title, hire date, termination date (if terminated) and their current employment status. Please attach applicable HR records.]
Name / Title / Hire Date / Termination Date / Avg. Salary / Current StatusOther Project Employees
[Please also include a roster of other project employees’ names, titles, hire dates, termination dates (if terminated) and their current employment status. Please attach applicable HR records.]
Name / Title / Hire Date / Termination Date / Avg. Salary / Current StatusAdditional Job(s) Created
[As a direct result of the TETF funded project, “spin-off” companies or industry partners might have also created jobs in Texas. Please include the number of job(s) created by “spin-off” companies or industry partners as of August 31 of the reporting year as well.]
Commercialization Efforts
Patents and Invention Disclosures
[Please include a brief description and a list of patents and invention disclosure filed during the past reporting year. Please include patent numbers. Copies of the filing receipts are required if it is related to a contractual milestone.]
Licensing Agreement and Assignments
[Please include a brief description and a list of licensing agreements and patent assignments executed during the past reporting year. Please include information such as the industry partners who are the licensees or assignees. Copies of the agreements are required if it is related to a contractual milestone.]
“Spin-off” Companies
[Please include a brief description and a list of “spin-off” companies formed as a direct result of this TETF Agreement, including direct involvement by a TETF funded researcher serving as a member on the board or management team, or througha licensing or assignment agreement of the patent filed by a TETF funded researcher. Copies of company’s Texas Secretary of State filing record are required if it is a related to a contractual milestone. ]
Advisory Board (if applicable)
[Please include a brief description and a list of companies for which a TETF funded researcher serves in the capacity of an advisory board member. Additional documents are required if it is required under a contractual milestone.]
Other Required Information
Attachments
[Please label and append supporting documents.]
1 / Attachments | [Type the project name]