0524-NEW SBIR/STTR Lifecycle Certification Form

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Appendix A
SBIR/STTR Certification Statement
USDA SBIR/STTR Award Number:

Project Title:

Date:

Period covered by this report:

Company Name:

PI Name:

Telephone Number:

Email Address:

Company Address:

USDA SBIR/STTR National Program Leader:

Please check as appropriate:
Phase I Award Interim Report
Phase I Award Final Report
Plan to submit Phase II Proposal
Phase II Award Interim Report
Phase II Award Final Report
Check if report contains Proprietary Information
Acknowledgement of USDA support and disclaimer:
“This material is based upon work supported by the US Department of Agriculture (USDA)
under Award Number:______________________. Any opinions, findings, and conclusions or
recommendations expressed in this publication are those of the author(s) and do not necessarily
reflect the views of the USDA.”
SBIR/STTR Funding Agreement Certification – Life Cycle Certification
All USDA SBIR/STTR Phase I and Phase II Awardees must complete this certification at all
times set forth in the Funding Agreement (see § 8(j) of the SBIR/STTR Policy Directive) and the
grant terms and conditions. This includes checking all the boxes and having an authorized officer
of the Awardee sign and date the certification each time it is requested.
Please carefully read 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
Public reporting for collection of information is estimated to average 15 minutes, 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 current 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 NIFA, OGFM, 2312 East Bannister Road, Mail
Stop 10,000, Kansas City, MO 64131, Atention Policy Section. Do not return the completed form to this address. National
Institute of Food and Agriculture US Department of Agriculture OMB No. 0524-NEW Form Approved For Use Through xx/xx/xxxx

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Small Business Act, the SBIR/STTR Policy Directive, and any statutory and regulatory
provisions referenced in those authorities.
If the USDA SBIR/STTR National Program Leader or Authorized Departmental Officer (ADO)
believes 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 (one box must be checked for each):
(1) The Principal Investigator is/was "primarily employed" by the Awardee (or Research
Institution – STTR only) as defined in the solicitation during the term of the Funding
Agreement, or the Awardee has requested and received a written deviation from this
requirement from USDA.
Yes
No
Deviation approved in writing by the USDA.
(2) All Essentially Equivalent Work, or a portion of the work, performed 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 USDA.
(3) Upon completion of the award, the Awardee will have performed the applicable
percentage of work, unless a deviation from this requirement is approved in writing by
the USDA (check the applicable line and fill in if needed):
SBIR Phase I: at least two-thirds (66.66 %) of the research performed by the
awardee.
SBIR Phase II: at least half (50%) of the research by the awardee.
STTR Phase I or Phase II: at least 40% of the research by the small business and
at least 30% of the research by the non-profit research institution.
Deviation approved in writing by the USDA.
(4) The work is completed and the small business Awardee has performed the applicable
percentage of work, unless a deviation from this requirement is approved in writing by
the USDA (check the applicable line and fill in if needed):
SBIR Phase I: at least two-thirds (66.66 %) of the research performed by the
awardee.
SBIR Phase II: at least half (50%) of the research by the awardee.
STTR Phase I or Phase II: at least 40% of the research by the small business and
at least 30% of the research by the non-profit research institution.
Deviation approved in writing by the USDA.
Not applicable because the work has not been completed at this time.

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(5)

[For STTR only] The Small Business Concern, and not a partnerting Research
Institution, is exercising management direction and control of the performance of the
STTR Funding Agreement
Yes
No
(6) The research/research and development is/was performed in the United States unless a
deviation is approved in writing by the USDA.
Yes
No
Waiver has been granted
(7) The research/research and development is/was performed at the awardee's facilities
described in the proposal by the awardee's employees, except as otherwise indicated in
the SBIR application and approved in the funding agreement.
Yes
No
(8) I will notify USDA immediately if all or a portion of the work proposed is subsequently
funded by another Federal Agency.
(9) I understand that the information submitted may be given to Federal, State and local
agencies for determining violations of law and other purposes.
(10) I am an officer of the Awardee business concern authorized to represent it and sign this
certification on its behalf. 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 the
award, 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 CFR part 180); and (6) other administrative penalties including termination of
SBIR/STTR awards.
Signature:
Print Name (First, Middle, Last):
Title:
Business Name:

Date: