SUBRECIPIENT COMMITMENT FORM



SUBRECIPIENT COMMITMENT FORM

UC IRVINE OFFICE OF RESEARCH ADMINISTRATION

INSTITUTE FOR MONEY, TECHNOLOGY & FINANACIAL INCLUSION-INTERNATIONAL

|All subrecipients must complete this form when submitting a proposal to IMTFI at UCI. It provides a checklist of documents and certifications required by sponsors |

|and it must be endorsed by the Subrecipient’s Authorized Official. |

|A. PRIME PROPOSAL INFORMATION |

|1. SPONSOR: GATES FOUNDATION |

|2. RFA/RFP/PAR NO: OPP1031657 |UCI PI NAME: WILLIAM M. MAURER |

|B. SUBRECIPIENT INFORMATION |

|1. SUBRECIPIENT’S LEGAL NAME (ORGANIZATION): |2. SUBRECIPIENT PI : |

| |ADDRESS: |

|ADDRESS: | |

| |PHONE: |

| |FAX: |

| |EMAIL: |

|3. SUBRECIPIENT FINANCIAL CONTACT : |4. SUBRECIPIENT AUTHORIZED OFFICIAL: |

|ADDRESS: |ADDRESS: |

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|PHONE: |PHONE: |

|FAX: |FAX: |

|EMAIL: |EMAIL: |

|5. PROJECT LOCATION (If different from Subrecipient Address): |

|C. PROPOSAL DOCUMENTS (REQUIRED) |

|The following documents are included in our subaward proposal submission and covered by the certification below (check as applicable) |

| ☒ STATEMENT OF WORK |

| ☒ BUDGET AND BUDGET JUSTIFICATION TOTAL AMOUNT REQUESTED: |

| ☒ COMMITMENT TO ATTEND IMTFI ANNUAL CONFERENCE AT UC IRVINE, DEC. 5-7, 2012 |

| ☒ PHOTO IMAGES AND BIOSKETCHES OF PI AND CO-PIS APPROPRIATE FOR DISTRIBUTION |

| ☒ COMMITMENT TO ONE POST REGARDING RESEARCH FOR THE IMTFI BLOG |

| ☐Other: _________________________________________________________________________________________________________ |

|D. SPECIAL REVIEW & CERTIFICATIONS |

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|1. Facilities & Administration Rates (F&A) included in this proposal have been calculated based on the following policy: |

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|Only allowed if your organization charges for F&A Costs. Please note that rates are allowable up to 10% for U.S. universities and up to 15% for all other |

|non-governmental organizations, international organizations and non-U.S. universities. |

| |

|2. Human Subjects: An institutional review board (IRB), also known as an independent ethics committee (IEC) or ethical review board (ERB), is a committee that has |

|been formally designated to approve, monitor, and review behavioral research involving humans. The subcontract will not be issued without IRB approval. |

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|Does your organization have an Institutional Review Board? Yes No Go to next page and if yes, please go to 2A, if no, please go to 2B |

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|2A. My organization has an Institutional Review Board: |

|Determination of Exemption or IRB Approval Date: Expiration Date: IRB number: |

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|2B. My organization does not have an Institutional Review Board and needs to apply with the UCI IRB. |

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|The following is required, please notify IMTFI immediately in order to obtain forms and begin the approval process: |

|Investigator Training |

|IRB application |

|Exhibit G: Investigator Assurance |

|Letter of permission and/or letter of cooperation (as applicable) |

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|E. AUDIT STATUS |

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|UCI requires completion of a Mini-Audit Questionnaire, before a subaward will be issued. The link to the mini-audit is here: |

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|Subrecipient is a: Non-profit entity |

|Foreign entity |

|For-profit entity |

|Government entity |

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|For-Profit/Commercial Entities Please respond to the following: |

|Yes No The goods and/or services we will provide under this transaction will be comparable to the goods and/or services we provide to many |

|different customers during the course of our normal business operations. |

|If “no” please describe how these services and/or goods will differ from those offered to other customers |

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APPROVED FOR SUBRECIPIENT

Your organization has been selected to participate in this project at our discretion. You may not make any statement or otherwise imply to other donors, investors, media or the general public that you are a direct grantee of the Bill & Melinda Gates Foundation and must clearly state that University of California, Irvine is the Foundation's grantee and that you are a subgrantee of the University of California, Irvine.

By signing this form, you are agreeing to these terms and conditions.

The information, certifications, and representations above have been read, signed and made by an authorized official of the subrecipient named herein.

Any work begun and/or expenses incurred prior to execution of a subaward agreement are at the subrecipient’s own risk.

Subrecipient Authorized Official Date

Printed Name and Title

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