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Kentucky State University Office of Research and Innovation 4th Floor, Academic Services Building Frankfort, KY 40601 (502) 597-5997 ori@kysu.edu

SUBRECIPIENT COMMITMENT FORM

PI Name: Dept.:

Prime Sponsor:

Proposal Title:

Performance Start: Performance End:

To be completed by the subrecipient institution:

Institution Name:

Institution Address:

City: State: Zip (+4):

Subrecipient PI:

EIN: UEI:

Congressional District:

Subrecipient registered in SAM: Yes No

Institution Type (if applicable):

HBCU Large Business Small Business Tribal

Woman-owned Veteran-Owned Minority Institution/Owned

Other (describe):

Sponsored Programs Administrative Name:

Sponsored Programs Administrative Email:

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Performance Site Location:

Same as above: Yes No (if no, provide performance site information below) Address:

City:

State: Zip (+4):

Subrecipient Budget Request:

Total funds requested: $

Direct Cost: Indirect Cost Rate %:

Cost Sharing: Yes No (If yes, please ensure that the budget and budget justification include cost-sharing amounts and an explanation of the sources of the cost share.)

Human Subjects Research: Yes No (If yes, copies of the IRB approval and approved “Informed Consent” form must be provided prior to the subaward being officially issued.)

Animal Subjects Research: Yes No (If yes, a copy of the IACUC approval must be provided prior to the subaward being officially issued.)

Checklist of Required Proposal Documents:

Scope of Work	IRB/IACUC, if applicable
Budget and budget justification	IDC rate agreement
This form signed by AOR	Financial audit or link
Other (describe):

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Certifications:

We are required to comply with OMB Uniform Guidance Subpart F - Audit Requirements

Yes No

Audit Contact Name and Title:

Audit Contact Phone:

Audit Contact Email:

Signature:

With the signature below, the Authorized Official certifies that the information, certifications, and representations are true and correct, and that the appropriate programmatic and administrative personnel involved in this application are aware of sponsoring agency policies in regard to subawards and are prepared to establish an inter-institutional agreement 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.

Authorized Official Signature

Date Signed

Authorized Official Name/Title

This institution is an equal opportunity employer, lender and provider.