28 STTR Funding Agreement Certification

STTR Funding Agreement Certification

Grant Application Number:      

Program Director(s)/Principal Investigator(s) (PD(s)/PI(s)):      

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0001). Do not return the completed form to this address.

All small businesses that are selected for award of an STTR funding agreement must complete this certification at the time of award and any other time set forth in the Notice of Award that is prior to performance of work under this award. This includes checking all of the boxes and having an authorized officer of the awardee sign and date the certification each time it is requested.

Please read carefully the following certification statements. The Federal government relies on this information to determine whether the business is eligible for a Small Business Technology Transfer (STTR) Program award. A similar certification will be used to ensure continued compliance with specific program requirements during the life of the funding agreement. The definitions for the terms used in this certification are set forth in the Small Business Act, SBA regulations (13 C.F.R. Part 121), the SBIR Policy Directive and also any statutory and regulatory provisions references in those authorities.

If the Grants Management Officer believes that the business may not meet certain eligibility requirements at the time of award, they are required to file a size protest with the U.S. Small Business Administration (SBA), who will determine eligibility. At that time, SBA will request further clarification and supporting documentation in order to assist in the verification of any of the information provided as part of a protest. If the Grants Management Officer believes, after award, that the business is not meeting certain funding agreement requirements, the agency may request further clarification and supporting documentation in order to assist in the verification of any of the information provided.

Even if correct information has been included in other materials submitted to the Federal government, any action taken with respect to this certification does not affect the Government’s right to pursue criminal, civil, or administrative remedies for incorrect or incomplete information given in the certification. Each person signing this certification may be prosecuted if they have provided false information.

The undersigned has reviewed, verified and certifies that (all boxes must be checked):

1. The business concern meets the ownership and control requirements set forth in 13 C.F.R. § 121.702.

Yes No

2. If a corporation, all corporate documents (articles of incorporation and any amendments, articles of conversion, by-laws and amendments, shareholder meeting minutes showing director elections, shareholder meeting minutes showing officer elections, organizational meeting minutes, all issued stock certificates, stock ledger, buy-sell agreements, stock transfer agreements, voting agreements, and documents relating to stock options, including the right to convert non-voting stock or debentures into voting stock) evidence that it meets the ownership and control requirements set forth in 13 C.F.R. § 121.702.

Yes No N/A Explain why N/A:      

3. If a partnership, the partnership agreement evidences that it meets the ownership and control requirements set forth in 13 C.F.R. § 121.702.

Yes No N/A Explain why N/A:      

4. If a limited liability company, the articles of organization and any amendments, and operating agreements and amendments, evidence that it meets the ownership and control requirements set forth in 13 C.F.R. § 121.702.

Yes No N/A Explain why N/A:      

5. The birth certificates, naturalization papers, or passports show that any individuals it relies upon to meet the eligibility requirements are U.S. citizens or permanent resident aliens in the United States.

Yes No N/A Explain why N/A:      

6. It has no more than 500 employees, including the employees of its affiliates.

Yes No

7. SBA has not issued a size determination currently in effect finding that this business concern exceeds the 500 employee size standard.

Yes No

8. During the performance of the award, the principal investigator will spend more than half of his/her time as an employee of the awardee or the research institution, or the principal investigator has requested and received a written deviation from this requirement from the Grants Management Officer.

Yes No Deviation approved in writing by Grants Management Officer:      %

9. All, essentially equivalent work, or a portion of the work proposed under this project (check the applicable line):

Has not been submitted for funding by another Federal agency

Has been submitted for funding by another Federal agency but has not been funded under any other Federal grant, contract, subcontract, or other transaction.

A portion has been funded by another grant, contract, or subcontract as described in detail in the proposal and approved in writing by the Grants Management Officer.

10. During the performance of award, it will perform the applicable percentage of work unless a deviation from this requirement is approved in writing by the Grants Management Officer (check the applicable line and fill in if needed):

STTR Phase I: at least forty percent (40%) of the research

STTR Phase II: at least forty percent (40%) of the research

Deviation approved in writing by the Grants Management Officer:      %

11. During performance of award, the research/research and development will be performed in the United States unless a deviation is approved in writing by the Grants Management Officer.

Yes No

12. During the performance of award, the research/research and development will be performed at my facilities with my employees, except as otherwise indicated in the STTR application and approved in the Notice of Award.

Yes No

13. It has registered itself on SBA’s database as majority-owned by venture capital operating companies, hedge funds or private equity firms.

Yes No N/A Explain why N/A:      

14. The small business concern has provided satisfactory evidence that it will exercise management direction and control of the performance of the STTR funding agreement.

Yes No

15. It will notify the Federal agency immediately if all or a portion of the work proposed is subsequently funded by another Federal agency.

Yes No

I understand that the information submitted may be given to Federal, State and local agencies for determining violations of law and other purposes.

I am an officer of the business concern authorized to represent it and sign this certification on its behalf. By signing this certification, I am representing on my own behalf, and on behalf of the business concern that the information provided in this certification, the application, and all other information submitted in connection with this application, is true and correct as of the date of submission. I acknowledge that any intentional or negligent misrepresentation of the information contained in this certification may result in criminal, civil or administrative sanctions, including but not limited to: (1) fines, restitution and/or imprisonment under 18 U.S.C. § 1001; (2) treble damages and civil penalties under the False Claims Act (31 U.S.C. § 3729 et seq); (3) double damages and civil penalties under the Program Fraud Civil Remedies Act (31 U.S.C. §3801 et seq); (4) civil recovery of award funds; (5) suspension and/or debarment from all Federal procurement and nonprocurement transactions (FAR Subpart 9.4 or 2 C.F.R. part 180; and (6) other administrative penalties including termination of SBIR/STTR awards.

     
Date

Signature

     
Printed Name (First, Middle, Last)

     
Title

     
Organization Name

OMB No. 0925-0001 (Rev. 08/12 Approved Through 8/31/2015) Page 2 STTR Funding Agreement Certification