Sponsored Research Office Certificate of Membership

Sponsored Research Office Certificate of Membership

In the table below, please report the Program Income received by the Center from each Member Organization

Please refer to the IUCRC Solicitation for full details on Membership Terms and Definitions

Note: all pre-populated yellow highlighted entries are provided as examples. The tables should be updated with actual data from the IUCRC.

Definition of Program Income (please refer to the NSF's Proposal & Award Policies & Procedures Guide (PAPPG):

https://www.nsf.gov/publications/pub_summ.jsp?ods_key=nsf20001&org=NSF

Definition of Membership

[insert link to 20-XXX]

Membership Fee Details

Member Type

Cost of membership

Full

$50,000

Associate

$25,000

Actual Expenditures

Site 1

Site 2

Site 3

Actual Expenditure of Program Income in reporting period

$150,000

Cumulative expenditures since start of the grant

$390,000

Membership Contributions Received

Organization

Employer Identification Number (EIN)

Year 1

Year 2

Year 3

Year 4

Year 5

Start Date:

Start Date:

Start Date:

Start Date:

Start Date:

End Date:

End Date:

End Date:

End Date:

End Date:

Program Income from Membership Fee

Program Income from Membership Fee

Membership (number of equivalent full Members)

Program Income from Membership Fee

Membership (number of equivalent full Members)

Program Income from Membership Fee

Membership (number of equivalent full Members)

Program Income from Membership Fee

Membership (number of equivalent full Members)

Membership (number of equivalent full Members)

Company A

$50,000

1

Company B

$100,000

1

Company C

$25,000

0.5

Non-profit D

$50,000

1

Company E

$25,000

0.5

Government agency F

$50,000

1

Company G

$50,000

1

Total Program Income from Memberships in reporting period

$350,000

6

Additional Program Income received (over and above Membership Fees)

Source of Program Income

Employer Identification Number (EIN)

Year 1

Year 2

Year 3

Year 4

Year 5

Start Date:

Start Date:

Start Date:

Start Date:

Start Date:

End Date:

End Date:

End Date:

End Date:

End Date:

Program Income

Program Income

Program Income

Program Income

Program Income

Program Income type (Cash or In-kind)

Program Income type (Cash or In-kind)

Program Income type (Cash or In-kind)

Program Income type (Cash or In-kind)

Program Income type (Cash or In-kind)

Company A

$65,500

Cash

Company B

$23,000

Cash

Non-profit D

$314,159

in-kind

Total additional Program Income in reporting period

$402,659

In the tables below, please report the allocation of the Program Income to individual projects within the IUCRC (add additional rows as needed)

Reporting Year 1:

Start date

1/1/2021

End date

12/31/2021

Project title

Institution Name

Program Income Funds allocated

Project A

Site 1

$5,000

Project A

Site 2

$45,000

Project B

Site 1

$10,000

Project B

Site 2

$100,000

Project B

Site 3

$90,000

Reporting Year 2:

Start date

End date

Research Project title

Institution Name

Program Income Funds allocated

Reporting Year 3:

Start date

End date

Research Project title

Institution Name

Program Income Funds allocated

Reporting Year 4:

Start date

End date

Research Project title

Institution Name

Program Income Funds allocated

Reporting Year 5:

Start date

End date

Research Project title

Institution Name

Program Income Funds allocated

Signature and Certifications

Please read carefully the following certification statements. The Federal government relies on the information to ensure 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 IUCRC Program Solicitation. 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.

I certify that at least 90% of the IUCRC Program Income is used to support the direct costs of research, and no more than 10% is used to support indirect costs

⎕

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

⎕

I certify that to the best of my knowledge that the statements herein are true and complete, I understand that the willful provision of false information or concealing a material fact in this report or any other communication submitted to NSF is a criminal offense (U.S. Code, Title 18, Section 1001).

⎕

Authorized Organizational Representative (AOR)

Signature_______________________________________

Date:

AOR Contact information:

Name

Address

Phone Number

Email Address

Principal Investigator (PI) for the Lead Site

Signature_______________________________________

Date:

PI Contact information:

Name

Address

Phone Number

Email Address