2 Form

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:

OMB No. 0925-0001 (Rev. 08/2023 Approved Through 01/31/2026)

Page 1

STTR Funding Agreement Certification

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.
OMB No. 0925-0001 (Rev. 08/2023 Approved Through 01/31/2026)

Page 2

STTR Funding Agreement Certification

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. 08/2023 Approved Through 01/31/2026

Page 3

STTR Funding Agreement Certification