Instructions for phs 398 and sf 424(R&R) Form Approved Through 08/31/2015




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2.18 Small Business Concern SBIR Verification Statement


Grant Application Number: ___________________________________________________________
Organization: ______________________________________________________________________
Program Director(s)/Principal Investigator(s) (PD(s)/PI(s)): _________________________________

The Small Business Innovation Research (SBIR) program legislation requires that the applicant small business concern (SBC) be eligible at the time of the award. As the responsible Federal staff for administering NIH grant funds, Grants Management Officials of the NIH Institutes and Centers (ICs) must verify eligibility prior to issuing a Notice of Award. If the SBC is affiliated with any other organization (domestic or foreign), see www.sba.gov/size.

If an application is selected for funding under the SBIR program, no award will be issued until the NIH IC receives and accepts the following information, which may be provided in a format of your choosing or by completing a checklist as in the example below:

 1 The above-named organization is a for-profit United States SBC that is at least 51% owned and controlled by one or more individuals who are citizens of, or permanent resident aliens in, the United States, or in the case of a publicly-owned business, at least 51% of its voting stock is owned by United States citizens or lawfully admitted permanent resident aliens.



or
The above-named organization is a for profit business concern that is at least 51% owned and controlled by another (one) for-profit business concern that is at least 51% owned and controlled by one or more individuals who are citizens of, or permanent resident aliens in, the United States.
Complete the following part of (1) if relevant: If the above-named applicant organization has been determined by the Small Business Administration (SBA) to be “other than small” for a size standard of not more than 500 employees or for purposes of the SBIR program:
Have you been recertified by SBA?  Yes  No

If not recertified, have you requested a recertification by SBA for eligibility under the


SBIR program?  Yes  No

 2 The above-named organization is independently owned and operated, is not dominant in the field of operation in which it is proposing, has its principal place of business located in the United States, has, including its affiliates, 500 or fewer employees, is not involved in a merger/acquisition that is near complete, and meets the other regulatory requirements found in Title 13, Code of Federal Regulations (CFR), part 121. (Note that the SBA considers “agreements to merge (including agreements in principle) to have present effect on the power to control a concern” [Section 121.103(d)(1) of 13 CFR 121]).

 3 The research space occupied by the above-named organization is available to and under the control of the above-named organization for the conduct of its portion of the proposed project.

 4 All research on the above-referenced grant will be performed in its entirety in the United States, unless otherwise approved by the Grants Management Officer prior to issuance of an award.

 5 The above-named PD’s/PI's primary employment is with the above-named organization and more than one-half of the above-named PD’s/PI’s time will be in the employ of the above-named organization at the time of award and for the duration of the project, unless otherwise approved by the Grants Management Officer prior to issuance of an award. For Multiple PD/PI projects, the Contact PD/PI meets the primary employment requirement.

 6 It is understood that the Public Health Service will not support any market research under its SBIR program (see definition of Market Research) or literature searches that will lead to a new or expanded statement of work, and that if an award is made, any such costs, if requested in the application, will be removed prior to award.

 7 It is understood that if this project is funded, drawing NIH award funds from the DHHS Payment Management System serves as certification that the above-named organization has in place written policies and procedures for financial and business management systems that comply with 45 CFR 74 and the NIH Grants Policy Statement and will follow those policies and procedures.

My signature is verification that the statements checked () above are true and complete. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.

__________________________________________________ _____________________

(Official Authorized to Sign for the Organization) (Date)


2.19 Small Business Concern STTR Verification Statement


Grant Application Number: ___________________________________________________________
Organization: ______________________________________________________________________
Program Director(s)/Principal Investigator(s) (PD(s)/PI(s)): _________________________________

The Small Business Technology Transfer (STTR) program legislation requires that the applicant small business concern (SBC) be eligible at the time of the award. As the responsible Federal staff for administering NIH grant funds, Grants Management Officials of the NIH Institutes and Centers (ICs) must verify eligibility prior to issuing a Notice of Award. If the SBC is affiliated with any other organization (domestic or foreign), see www.sba.gov/size.

If an application is selected for funding under the STTR program, no award will be issued until the NIH IC receives and accepts the following information, which may be provided in a format of your choosing or by completing a checklist as in the example below:

 1 The above-named organization is a for-profit United States SBC that is at least 51% owned and controlled by one or more individuals who are citizens of, or permanent resident aliens in, the United States, or in the case of a publicly-owned business, at least 51% of its voting stock is owned by United States citizens or lawfully admitted permanent resident aliens.


Complete the following part of (1) if relevant: If the above-named applicant organization has been determined by the Small Business Administration (SBA) to be “other than small” for a size standard of not more than 500 employees or for purposes of the STTR program:
Have you been recertified by SBA?  Yes  No

If not recertified, have you requested a recertification by SBA for eligibility under the


STTR program?  Yes  No

 2 The above-named organization is independently owned and operated, is not dominant in the field of operation in which it is proposing, has its principal place of business located in the United States, has, including its affiliates, 500 or fewer employees, is not involved in a merger/acquisition that is near complete, and meets the other regulatory requirements found in Title 13, Code of Federal Regulations (CFR), part 121. (Note that the SBA considers “agreements to merge (including agreements in principle) to have present effect on the power to control a concern” [Section 121.103(d)(1) of 13 CFR 121]).

 3 The research space occupied by the above-named organization is available to and under the control of the above-named organization for the conduct of its portion of the proposed project.

 4 All research on the above-referenced grant will be performed in its entirety in the United States, unless otherwise approved by the Grants Management Officer prior to issuance of an award.

 5 The above-named PD(s)/PI(s) has (have) a formal appointment with or commitment to the above-named organization, which is characterized by an official relationship between the organization and the PD(s)/PI(s), whose effort on this project will be not less than 10% of his or her total professional effort. For Multiple PD/PI projects, each PD/PI must commit a minimum of 1.2 calendar months (10% effort) to the project.

 6 It is understood that the Public Health Service will not support any market research under its STTR program (see definition of Market Research) or literature searches that will lead to a new or expanded statement of work, and that if an award is made, any such costs, if requested in the application, will be removed prior to award.

 7 In conducting the joint research and development proposed in this project, the above-named applicant SBC will conduct not less than 40% of the work and the single “partnering” research institution named in the application will perform not less than 30% of the work.

 8 It is understood that if this project is funded, drawing NIH award funds from the DHHS Payment Management System serves as certification that the above-named organization has in place written policies and procedures for financial and business management systems that comply with 45 CFR 74 and the NIH Grants Policy Statement and will follow those policies and procedures.

My signature is verification that the statements checked () above are true and complete. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.

__________________________________________________ _____________________



(Official Authorized to Sign for the Organization) (Date)
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