Subrecipient Letter of Intent or Commitment Form

PASS-THROUGH ENTITY (PTE) INSTITUTION INFORMATION

PTE PI

PTE Institution

Prime Sponsor

Project Title

SUBRECIPIENT INSTITUTION INFORMATION

Institution

FDP Expanded

Clearinghouse Profile url

PI Name eRA Commons

PI Phone PI E-Mail

Project Period

Performance Site

Address

Performance Site Congressional District #

Direct Costs F&A Costs

Total Costs

SUBRECIPIENT CONTACTS

Administrative E-Mail

Phone

Authorized Official E-Mail

Phone

YES/NO APPROVAL DATE OR PENDING YES/NO APPROVAL DATE OR PENDING

Human Subjects

Recombinant dNA

Vertebrate Animals

Program Income

Human Embryonic Stem Cells

Cost Sharing

Select Agents

In signing below and offering to participate in this research program, the Subrecipient Institution certifies that neither they nor their principals are

presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from receiving funds from any federal department

or agency and are not delinquent on any federal debt; they are in compliance with the Drug Free Workplace Act of 1988; they are in compliance with

U.S. Code, Section 1352, restrictions on the use of federal funds for the purpose of lobbying; they have filed annually with the Office of Scientific

Integrity a PHS form 6349 governing Misconduct in Science; they have filed with DHHS compliance offices certification forms governing Civil Rights

(441), Handicapped Individuals (641), Sex Discrimination (639-A), and Age Discrimination (680); they are in compliance with PHS policy governing

Program Income; they have established policies in compliance with 45 CFR Part 46, Subpart A (protection of human subjects); the Animal Welfare Act

(PL-89-544 as amended) and the Health Research Exchange Act of 1985 (Public Law 99-158); and that they are in compliance with NIH guidelines

regarding human pluripotent stem cell research, transplantation of fetal tissue, recombinant DNA and human gene transfer research, and inclusion of

women, children & minorities in research.

This proposal has been reviewed and approved by the appropriate official(s) of Subrecipient and certified to its accuracy and completeness. The

appropriate programmatic and administrative personnel of Subrecipient involved in this application are aware of the prime awarding agency’s policies,

agree to accept the obligation to comply with award terms, conditions, and certifications, and is prepared to establish the necessary inter-institutional

agreement consistent with that policy.

Any terms or rates included in the proposal described herein are not binding upon the Pass-Though Entity. All

terms and conditions between the parties will be outlined in a separate formal Agreement.

SUBRECIPIENT INSTITUTIONAL OFFICIAL:

Name and Title Signature/Date

May 2022

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