NAU SUBRECIPIENT COMMITMENT FORM (COMPELTED).PDF

NAU SUBRECIPIENT COMMITMENT FORM
Any organization planning to enter into a subrecipient relationship with Northern Arizona University (NAU)
must complete this form at the proposal stage. Please email the completed form and required proposal
documents to the NAU PI and the Office of Sponsored Projects (OSP) contact listed below.
SECTION A. NAU Information to be completed by NAU PI.
Proposal Title:
Prime Sponsor: Solicitation #:
NAU Principal Investigator (PI): PI Phone: PI Email:
OSP Contact: Phone: Email:
SECTION B. Subrecipient Information
Subrecipient Legal Name: Subrecipient Principal Investigator:
Maricopa County John Townsend
Address: 3800 N Central Ave Suite 300 Address:
Phoenix AZ 85021
DUNS: 029569238 Email: Jtownsed@mail.maricopa.gov
EIN: 86-6000472 Phone:
Administrative Contact Name:
(responsible for subaward processing)
Gus Martinez
Address: 3800 N Central Ave Suite 300 Email: gmartinez@mail.maricopa.gov
Phoenix AZ 85021 Phone: 602-506-6703
Is the subrecipient organization, its Principal Investigator, officials, or any other employee
☐Yes ☐No or student participating in this project presently debarred, suspended, proposed for
debarment, declared ineligible or voluntarily excluded from participation in any federal
department or agency?
☐Yes ☐No Subrecipient is currently registered in System for Award Management (SAM) and will keep
registration current throughout the life of the award.
If “No” and Federal Funding: Organizations that have not registered with SAM will need to obtain a DUNS
number first and then access the SAM online registration through SAM home page at
https://www.sam.gov/portal/SAM/#1. Subrecipient must maintain their current information in SAM. No
subaward will be issued until SAM registration is complete.
Revised 04/26/2018

SECTION C. Required Documents
The following documents are included in subrecipient subaward proposal submission and covered by
certifications in SECTION D.
☐STATEMENT OF WORK (REQUIRED – Please attach to this form with submission) Includes work
to be performed, project description, PI, period of performance, reports, deliverables, milestones.
☐DETAILED BUDGET and BUDGET JUSTIFICATION (REQUIRED – Please attach to this form with
submission) Includes budget for entire length of project and broken down by budget period; and
budget justification with reasonable level of detail.
SECTION D. Certifications
1. Facilities and Administrative Rates included in this proposal have been calculated based on
(check as applicable):
☐Our federally-negotiated F&A rate for this type of work is (Enter F&A rate)
(If this box is checked, attached a copy of your F&A rate agreement or provide a link to the
agreement below)
URL:
☐My organization has used the Sponsor’s published limited F&A cap.
☐My organization is not requesting any F&A
☐My organization does not have a federally negotiated
F&A rate and is requesting an F&A rate of 21.4%
IMPORTANT: If your organization is receiving funding under a federal award and you do not
have a federally negotiated F&A rate, your organization can only include a maximum rate of
10% on Modified Total Direct Costs.
2. Conflict of interest (applicable to PHS funded sponsors or those that have adopted the federal
financial disclosure requirements as defined in 42 CFR part 50 Subpart F and 42 CFR part 94)
☐ I Not applicable because this project is not being funded by PHS (NIH, CDC, AHRQ, etc), or any other
sponsor that has adopted the federal financial disclosure requirements
☐Subrecipient is registered in the FDP Clearinghouse indicating compliance with the provision of 42
CFR part 50, Subpart F “Responsibility of Applicants for Promoting Objectivity in Research and 42
CFR part 94
☐Subrecipient is not registered in the FDP Clearinghouse, but certifies that is has an active and
enforced Conflict of Interest policy that is consistent with the provision of 42 CFR Part 50, Subpart F
“Responsibility of Applicants for Promoting Objectivity in Research” and 45 CFR Part 94
“Responsible Prospective Contractors.”
o Register policy on FDP website OR
o Provide to NAU a copy of the policy for NAU’s review
☐Subrecipient does not have an active and/or enforced Conflict of Interest policy, but will have a PHS
compliant policy in place and published at the time of award. (A sample Conflict of Interest policy can
be found at: http://sites.nationalacademies.org/PGA/fdp/PGA_061001 ).
☐Subrecipient does not have an active and/or enforced Conflict of Interest policy and agrees to adopt
NAU’s policy. NAU’s COISP policy can be found at: https://nau.edu/Research/Sponsored-
Projects/Resources/Policies-and-Procedures/
Revised 04/26/2018

SECTION E. Project-Specific Requirements
1. Human Subjects: ☐Yes ☐No
☐If Yes: Copies of the Institutional Review Board (IRB) or Ethics Committee approval and approved
"Informed Consent" form must be provided before any subaward will be issued. If pending, obtain
approval as required and forward these documents to NAU’s Principal Investigator as soon as
available.
☐If Yes and NIH funding is involved: Have all key personnel involved completed ☐Yes ☐No
Human Subjects Training?
Note: All key personnel engaged in human subject research must take the NIH human subjects training
or human subjects research training (http://grants.nih.gov/grants/policy/hs_educ_faq.htm)
2. Animal Subjects: ☐Yes ☐No
If Yes: A copy of the IACUC Committee approval must be provided before any subaward will be issued.
If pending, obtain approval as required and forward these documents to NAU’s PI as soon as available.
SECTION F. Audit (A-133)
1. Single Audit Report Link:
☐We have completed our A-133 Single Audit for fiscal year ending
☐Our A-133 Single Audit for fiscal year ending
Is not anticipated to be complete until
Within thirty days of completion, we will amend and resubmit this certification with any required
documentation.
☐ We are not subject to the provisions of OMB Circular A-133 because our organization:
☐Expends less than $750,000 in federal awards annually
☐Is a non-U.S. entity
☐Is a for-profit entity
☐Other:
SUBRECIPIENT AUTHORIZED APPROVER: THIS SECTION MUST BE COMPLETED
The information, certifications, and representations above have been read, signed, and made by an
authorized official of the subrecipient named herein. The appropriate programmatic and administrative
personnel involved in this application are aware of agency policy in regard to subawards and are prepared
to establish the necessary inter-institutional agreements consistent with those policies.
Any work begun and/or expenses incurred prior to execution of a subaward agreement are at the
subrecipient's own risk.
(Signature of Subrecipient's Authorized Official) DATE
(Type or print name and title of Authorized Official)
Phone: Email:
Revised 04/26/2018