CSREES-666 Organizational Information

OM B approved 0524-0026
Expires 08/31/2006

UNITED STATES DEPARTMENT OF AGRICULTURE
COOPERATIVE STATE RESEARCH, EDUCATION AND EXTENSION SERVICE

ORGANIZATIONAL INFORMATION
( No te : Id en tif y a tt ac he d in fo rm a tio n by th e c or re sp o nd in g nu m b er an d it em o f t his fo rm )
1 . L EG A L N AM E O F O RG A NIZ AT IO N

C O N G R E S S IO N A L D IS T R IC T

2. COMPLETE BU SINESS ADD RESS (Including zip code)

3.

K E Y OF F ICIA L

NAME

TITLE

a. C hi ef Exe cu tive

T E L E PH O N E N U M B ER S
Office: ________________________
Fax:___________________________
E-mail:_________________________

b. Authorized Organizational

Office: ________________________

Repre sentative (AOR )
(Individual autho rized to co m m it

Fax: __________________________

the o rga niza tion's res our ce to
propose d projects. Aw ard letters

E-mail: ________________________

will be addressed to the
Authorized Organizational
Representative unless he/she
specifies in writing another
individual (such as the Chief
Executive)
c. Business Officer

Office: ________________________
Fax: __________________________
E-mail: _______________________

4 . O R G AN IZ A T IONA L T Y P E

5.

[

]

Co lleg e/U nivers ity

[

]

Com mercial Organization

[

]

State or Local Government

[

]

Corporation

[

]

No n-P rofit (S ubm it a co py of your c urre nt IRS ta x exem ption letter.)

[

]

Proprietorship (unincorporated)

[

]

Other (Sp ecify):

[

]

Partne rship

ORG ANIZATION AFFILIATIONS - On a separate sheet, describe any relationship of the organization to a parent organization or to subsidiaries of other affiliates. If the
org aniz ation is a s uc ce ss or in intere st to a pred ec es so r or if c han ges in org aniz ation al affilia tion a re an ticip ated , des crib e bri efly. If any key offic ial is affiliate d w ith
another organization in any capacity, describe the relationship.

6.

STAT EMENT OF PU RPOS ES AND PO W ERS - Attach an official published statement of the major purposes of the organization as to the powers which have been
g r a n te d to i t to e n te r in to contr actual relationships and/or to accept grants or other ty pes of fundi ng agr eem ents , ( e.g., ar ti c le of i nc orpor ati on, term s of r e fe re n c e, b y-l aw s ,
etc.).

7.

F IN AN C IA L IN F O RM AT IO N
a. O n a se p ar at e s h ee t, d e sc r ib e th e po li c ie s an d pr oc e du re s of yo u r o rg a ni za ti on fo r th e ad m i ni s tr at ive a nd fi na n ci al m a na g em e n t o f th e pr oj ec t fo r w h ic h U SD A
a ssi sta n ce is b e i ng re quested. This should include details of you r c os t ac c ounti ng s ys tem and audi ti ng ar r angem ents . ( If nec es s ar y you m ay need to o b ta i n ad vi c e
from a C ertifie d Pu blic Ac co unta nt (C PA ) in s etting up you r ac co untin g sys tem .)
b. If yo u r org a n iza ti o n is other than a college or univer sity or a State or loc al gover nm ent, attac h
A ce rti fi e d sta tement of financial condition (e.g. balance sheet, inc om e s tatem ent, etc .) , us uall y pr epar ed by a C PA, c over ing at l eas t the pr ec ed i n g t w o ye a rs .
B a n k o r o th e r re fer ences, including contact per son, telephone num ber and addres s .
c . If indirect costs are requested under this proposal, submit a copy of your current negotiated rate agreement with a cognizant Federal audit agency. If your
org aniz ation doe s no t have a c urre nt ne gotia ted ra te w ith a c ogn izan t Fed era l aud it age nc y, an ind irec t cos t rate p rop os al m us t be s ubm itted for dete rm inatio n of a
bi lli ng ra te ac ce pt ab le for thi s a w ar d o nl y.

8 . R e m a r ks:

CERTIFICATION
1. I certify that ___________________________________________________________ has legal authority
to accept
(Name of organization)

Federal awards and has in place the requisite policies, procedures, and personnel to ensure stewardship
of Federal Funds and management of Federally supported projects, specifically including standards for
financial management, procurement, and property management, which meet those described in USDA
regulations (7 CFR Part 3015, "Uniform Federal Assistance Regulations”, 7 CFR Part 3016, “Uniform
Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments”,
7 CFR 3019, “Uniform Administrative Requirements for Grants and Agreements with Institutions of Higher
Education, Hospitals, and Other Non-profit Organizations”).
2. Each proposal submitted to the Cooperative State Research, Education, and Extension Service will be
consistent with the procedures, policies, and goals of the named organization.
3. In the event that an award is made as a result of any such proposal, the above named organization will:
A.

Make available the necessary facilities, equipment, services, and personnel to conduct the project
funded under the award substantially as outlined in the proposal or such modifications thereof as
may be mutually agreed upon by the above named organization and the Cooperative State
Research, Education, and Extension Service.

B.

Conduct such project oversight as may be appropriate, manage the Federal funding with probity
and prudence, and comply with all the terms and conditions of the award.

C.

Ensure that costs incurred under the award are reasonable, necessary, allocable, and allowable
pursuant to the applicable program legislation, the purpose of the award, the terms and conditions
of the award, and the following Federal cost principles applicable to the above organization as in
effect at the time of award:

D.

1)

OMB Circular A-21, "Cost Principles for Educational Institutions."

2)

OMB Circular A-122, "Cost Principles for Nonprofit Organizations."

3)

OMB Circular A-87, "Cost Principles for State, Local and Indian Tribal Governments."

4)

45 CFR Part 74, Appendix E, "Principles for Determining Costs Applicable to Research
and Development under Grants and Contracts with Hospitals."

5)

48 CFR Part 31 (Federal Acquisition Regulations (FAR)), "Contract Cost Principles
and Procedures."

Comply with all applicable laws and regulations.

T YP E D N A ME A ND T IT L E O F AUT HORIZED ORG ANIZATIONAL RE PR ESEN T AT IVE

S IG N A T U R E

D AT E

According to the Paperwo rk Reduction Act of 1995, an agency may no t c on du ct or sp on so r, a nd a p er so n i s n ot re qu ired to r es po nd to a co lle ct io n o f in fo rm at io n u nl es s i t di sp la ys
a valid O MB c ontro l num ber . Th e valid O MB c ontro l num ber for this inform ation col lec tion is 052 4-0 026 . The time required to complete this information collection is estimated
to average 6.3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the da ta needed, and completing and
reviewing the collection of information.
FOR M CSREES-666 (reverse)