ORSA INTERNAL USE ONLY

University of Oregon/ORSA-Agreement Request Form

NEW CONTRACT AMENDMENT TO CURRENT CONTRACT(Complete

(Complete all information except Section E) Section A and ifinformationhas changed Section B or go directly to

Amendment sections C, E & D)

Type of Agreement:(Please Check One):

MOA Services Agreement Other:

SECTION A – University of Oregon Information

UO PI Name:
Telephone:
E-mail: / Administering DGA:
Telephone: Fax:
E-mail:
Administering Unit:
EPCS # / Grant #
Funding Agency (check appropriate box):
Federal Name: Federal#:
Non-Federal Name: Non-Federal #:
Project Title:

SECTION B –AgencyInformation

Name:
Administrative/Business Contact person: (Name and Title)
Address:
Phone: Fax:
Email: / Technical/PI Contact : (Name and Title)
Address:
Phone: Fax:
Email:
Authorized Signer: (Name & Title)
Total Agreement Dates: Start Date End Date
Select Agreement Invoicing:Cost Reimbursement Fixed Price (Must Fill out Report Deliverable/Task/Phases box below)
MonthlySingle Payment Upon Final Delivery
Quarterly Schedule of Deliverables or Milestones
Report/Deliverable/Tasks/Phase / Due Date / Amount
Description of Deliverable such as interim or final report; completion of data collection, meeting or even such as sponsored institute (a unit at which a portion of the work is completed and payment would be due). / Insert Date / Insert Amount
Total

SECTION C - Other

Provide purpose of the agreement and any special terms to be included in the contract such as any information which you feel will be useful to the person preparing this agreement, i.e., unusual reporting requirements, publications, intellectual property, invoicing address, etc., or any specific requirements you wish to have set forth in the document.

SECTION E – Amendments Only (please fill in all appropriate blanks)

Amendment Number:
Please Check All That Apply:
No-Cost Extension:
Increase funding by $ to a new total of $.
Decrease funding by $ to a new total of $.
Amended End date:
Other (explain):
Please Read and Check All the Boxes Below (Required Information):
Yes No Has the recipient been satisfactorily performing the work?
Yes NoHas the recipient delivered all required reports and/or data?
Yes NoHas the recipient’s institution been invoicing in a timely manner?
Yes NoAre dollar amounts of invoices reasonable for work performed and technical progress made to date?

SECTION D - PI Verification

By signing below, I certify that I have read the following statements and certify that they are accurate and truthful to the best of my knowledge and belief.This request and its attachments have been reviewed and approved by the undersigned:

Principal InvestigatorSignature Date
Typed/Printed Name:

PLEASE FORWARD THIS COMPLETED FORM WITH THE BUDGET AND STATEMENT OF WORK ATTACHED TO ORSA

Note: Our Receipt of your Request for Agreement or an Amendment to an Agreement does not automatically indicate an emergency/expedited situation. Our prioritization for contract preparation is done based on order of receipt. If this is a request that needs expedited preparation of an Agreement based on unusual and exceptional circumstances, please provide a detailed explanation of the circumstances. We will try and expedite emergency requests as we are able. Thank you.

Send to: ORSA 1600 Millrace Dr. Ste 106Eugene, OR97403 Phone: (541) 346-5131 Fax: (541) 346-5138 Website: