5700-54 Key Contacts Form

OMB Control No. 2030-0020
Approval expires MM/DD/YYYY

EPA KEY CONTACTS FORM

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2030-0020). Responses to this collection of information
are required to obtain an assistance agreement (40 CFR Part 30, 40 CFR Part 31, and 40 CFR Part 33 for awards made prior to December 26, 2014, and 2 CFR 200, 2 CFR 1500, and 40 CFR
Part 33 for awards made after December 26, 2014). 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. The public reporting and recordkeeping burden for this collection of information is estimated to be 0.5 hours per response. Send comments on the Agency’s need
for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S.
Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed
form to this address.

Authorized Representative: Original awards and amendments will be sent to this individual for review and acceptance, unless
otherwise indicated.
Name: Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:
Complete Address:
Street1:
Street2:
City:

State:

Zip / Postal Code:

Country:

Phone Number:

Fax Number:

E-mail Address:

Payee: Individual authorized to accept payments.
Name: Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:
Complete Address:
Street1:
Street2:
City:

State:

Zip / Postal Code:

Country:

Phone Number:
E-mail Address:

EPA Form 5700-54 (Rev 4-02)

Fax Number:

EPA KEY CONTACTS FORM
Administrative Contact: Individual from Sponsored Programs Office to contact concerning administrative matters (i.e., indirect cost
rate computation, rebudgeting requests etc).
Name: Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:
Complete Address:
Street1:
Street2:
City:

State:

Zip / Postal Code:

Country:

Phone Number:

Fax Number:

E-mail Address:

Project Manager: Individual responsible for the technical completion of the proposed work.
Name:

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:
Complete Address:
Street1:
Street2:
City:

State:

Zip / Postal Code:

Country:

Phone Number:
E-mail Address:

EPA Form 5700-54 (Rev 4-02)

Fax Number: