Form NIST-1022 Technology Innovation Program

OMB APPROVAL NUMBER: 0693-0050

NIST-1022
DAO 203-26

EXPIRATION DATE: XX-XX-XXXX

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

TECHNOLOGY INNOVATION PROGRAM (TIP)
PROPOSAL INFORMATION SHEET

TIP Ver. ?.?

NOTE: This application/questionnaire contains collection of information requirements subject to the Paperwork Reduction Act (PRA). Notwithstanding any other provisions of the law, no
person is required to respond to, nor shall any person be subject to penalty for failure to comply with, a collection of information subject to the requirements of the PRA. The estimated
response time for this application questionnaire is 37 hours. The response time includes the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Send comments regarding this estimate or any other aspects of this collection of information, including
suggestions for reducing the length of this questionnaire, to the National Institute of Standards and Technology, Attn., Barbara Lambis, via email at [email protected] or
telephone (301) 975-4447.

1. COMPETITION

2. LEGAL NAME OF SUBMITTING ORGANIZATION

NUMBER:
3. PROPOSAL TYPE

4. ORGANIZATION TYPE

SINGLE COMPANY
JOINT VENTURE

5. PROJECT DURATION 6. WILL CONTRACTORS
BE USED ?

7. Does the single company or if a joint venture, any joint venture member, have a parent company outside the United
States? (If yes, complete form NIST-1022G, Foreign Owned Company Questionnaire, for each such company.)
8. Is the single company or if a joint venture, any joint venture member, majority owned by non-U.S. citizens? (If
yes, explain below.)
9. Is the single company or if a joint venture, any joint venture member, subject to control by non-U.S. citizens? (If
yes, explain below.)
10. Will any R&D work be performed outside the United States? (If yes, complete form NIST-1022H, R&D Work
Performed Outside the United States by the Recipient or Contractor Questionnaire.)
11. Is the company or if a joint venture, any joint venture member, delinquent on any federal debt? (If yes, explain
below.)
12. Are there any third party in-kind contributions?
13. NONPROPRIETARY PROPOSAL ABSTRACT

14. In addition to the certification on item 18 of the SF-424 (R&R), I agree with the certification statements in the
instructions to this item 14.

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OMB APPROVAL NUMBER: 0693-0050

NIST-1022A
DAO 203-26

EXPIRATION DATE: XX-XX-XXXX

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

Show Budget Narrative
Add Joint Venture Member
1. LEGAL NAME, ADDRESS, CONTACT INFORMATION & CONGRESSIONAL DISTRICT OF MEMBER #1
Remove
NAME OF CONTACT

TECHNOLOGY INNOVATION PROGRAM (TIP)
OTHER JOINT VENTURE MEMBERS

ORG:

PREFIX:

STREET 1:

FIRST NAME:

STREET 2:

LAST NAME:

CITY:

MIDDLE NAME:

COUNTY:

SUFFIX:

STATE:

ZIP:

POSITION/TITLE:

COUNTRY: UNITED STATES

DEPARTMENT:

PHONE:

DIVISION:

FAX:

CONGRESSIONAL DISTRICT:

EMAIL:
2. ORGANIZATION TYPE
(Pick one)
SMALL-SIZED BUSINESS

(Check if applicable)
NONPROFIT RESEARCH INSTITUTE

MEDIUM-SIZED BUSINESS

INSTITUTION OF HIGHER EDUCATION

LARGE-SIZED BUSINESS

NATIONAL LABORATORY

FOREIGN-OWNED, U.S.-LOCATED
COMPANY

GOVERNMENTAL LABORATORY (not including NIST)
3. EMPLOYER IDENTIFICATION NUMBER:

4. DUN AND BRADSTREET NUMBER:

OMB APPROVAL NUMBER: 0693-0050

NIST-1022B
DAO 203-26

EXPIRATION DATE: XX-XX-XXXX

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

TECHNOLOGY INNOVATION PROGRAM (TIP)
CONTRACTORS

1. LEGAL NAME, ADDRESS, CONTACT INFORMATION OF CONTRACTOR #1

NAME OF CONTACT
NAME:

PREFIX:

STREET 1:

FIRST NAME:

STREET 2:

LAST NAME:

CITY:

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Remove

MIDDLE NAME:

COUNTY:

SUFFIX:

STATE:

ZIP:

POSITION/TITLE:

COUNTRY: UNITED STATES

DEPARTMENT:

PHONE:

DIVISION:

CONTRACTEE:
2. ORGANIZATION TYPE
(Pick one)

(Check if applicable)

SMALL-SIZED BUSINESS

NONPROFIT RESEARCH INSTITUTE

MEDIUM-SIZED BUSINESS

INSTITUTION OF HIGHER EDUCATION

LARGE-SIZED BUSINESS

NATIONAL LABORATORY

FOREIGN-OWNED, U.S.-LOCATED
COMPANY
FOREIGN-LOCATED ENTITY

GOVERNMENTAL LABORATORY (not including NIST)
3. ESTIMATED AMOUNT OF CONTRACT:
4. DESCRIBE SCOPE OF WORK AND IDENTIFY WHICH TASK OR TASKS IN R&D PLAN REQUIRE CONTRACTOR'S
INVOLVEMENT.

5. IS THIS A SOLE SOURCE CONTRACT?
YES (If yes, explain; e.g., is this the only contractor that can perform the work, what is the nature of its unique
NO
capabilities/experience, etc.)

6. DOES THE CONTRACTOR HAVE ANY FINANCIAL OR OTHER INTEREST IN THE SUBMITTING ORGANIZATION?
NO

YES (If yes, briefly explain what type and how much.)

7. DOES THE SUBMITTING ORGANIZATION HAVE ANY FINANCIAL OR OTHER INTEREST IN THE CONTRACTOR?
NO

YES (If yes, briefly explain what type and how much.)

OMB APPROVAL NUMBER: 0693-0050

NIST-1022C
DAO 203-26

EXPIRATION DATE: XX-XX-XXXX

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

TECHNOLOGY INNOVATION PROGRAM (TIP)
BUDGET NARRATIVE

Organization Name:

Year:

A. Personnel
Employee Name

Position Title

Annual Salary

Add Line

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Percentage of
Time

Cost

TOTAL:
B. Travel
Purpose of Travel

Destination

Add Line

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Computation
(Mode of transportation, lodging, and subsistence)

Cost

TOTAL:
Justification for foreign travel and/or foreign conference(s) [include an explanation of how the foreign travel and/or foreign
conference(s) are specifically related to the R&D activities of the TIP project (i.e., how will the information gathered contribute to
funded tasks), why the information cannot be obtained in the United States, and summarize conference agenda or topics for
meeting with key experts (name and expertise) at the conference, etc.]:

Justification for domestic conference(s) [include an explanation of how the conference(s) specifically relates to the R&D activities
of the TIP project (i.e., how will the information gathered contribute to funded task(s), summarize conference agenda or topics for
meeting with key experts (name and expertise) at the conference, etc.]:

C. Equipment
Item

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Computation

Cost

TOTAL:
Justification for each equipment item exceeding $100,000, to be purchased outside the United States, and/or any construction
costs:

D. Materials/Supplies
Item

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Computation

Cost

TOTAL:
E. Contractors
Name of Contractor

Service Provided

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Computation

Cost

SUBTOTAL:
If contractor’s fees are in excess of $550 per day, justify here:

Contractor Expenses
Name of Contractor

Expense

Add Line

Remove Line

Computation

Cost

SUBTOTAL:
TOTAL:
F. Other
Description

Add Line

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Computation

Cost

AUDIT
TOTAL:
Check here if audit is part of indirect costs. (If checked, enter 0 for AUDIT costs above.)
Check here if cognizant federal audit agency will perform audits and provide names of agency:

G. Indirect Costs
Percentage Rate:
Check here if the indirect cost rate has been negotiated and approved by a cognizant federal agency and a copy of
the agreement is included in proposal.
Check here if the indirect cost rate has not been negotiated and approved by a cognizant federal agency.
Total:
H. Cost Sharing
FEDERAL (direct costs only):
NONFEDERAL (direct costs only):
NONFEDERAL (indirect costs only, which must be the same amount in section G.):
Total:
Generate Estimated Multi-Year Budget

OMB APPROVAL NUMBER: 0693-0050

NIST-1022D
DAO 203-26

TECHNOLOGY INNOVATION PROGRAM (TIP)
THIRD PARTY IN-KIND CONTRIBUTIONS

A.

Name of organization to receive in-kind contributions:

B.

In-kind contributions will consist of the following as noted:

Add Line
Type of Personnel
Service

Add Line

Employee Name & Position Title

Cost

Percentage
of Use

Method of Valuation

Cost

Percentage
of Use

Method of Valuation

Cost

Percentage
of Use

Method of Valuation

Cost

Percentage
of Use

Method of Valuation

Cost

Percentage
of Use

Method of Valuation

Cost

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Other

C.

Method of Valuation

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Materials/Supplies

Add Line

Percentage
of Time

Remove Line

Software

Add Line

Project Year:

Remove Line

Research Tools

Add Line

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Equipment

Add Line

EXPIRATION DATE: XX-XX-XXXX

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

Total value of third-party in-kind contributions:

By submitting this form, the donor of the in-kind contributions certifies that it is authorized to legally commit the in-kind
contributions listed above for the proposed Technology Innovation Program proposal, if funded, entitled:
Print Name and Title:

Name of Organization Donating In-Kind Contributions:

NIST-1022E
DAO 203-26

OMB APPROVAL NUMBER: 0693-0050

EXPIRATION DATE: XX-XX-XXXX

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

TECHNOLOGY INNOVATION PROGRAM (TIP)
ESTIMATED MULTI-YEAR BUDGET - SINGLE COMPANY
YEAR 1

YEAR 2

YEAR 3

TOTAL

Remove Source Line

Add Source Line

Remove Task Line

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1. OBJECT CLASS CATEGORY
A. Personnel salaries/wages
B. Travel
C. Equipment
D. Materials/supplies
E. Contractors
F. Other
G. Total direct costs (lines A thru F)
H. Total direct costs requested from TIP
I. Total direct costs shared by proposer (if any)
J. Total indirect costs absorbed by proposer
K. Total costs (lines G + J)
2. SOURCES OF FUNDS
A.

TIP (same as H)

A.
A.
B1.
C. Total of all sources of funds (same as line K)
3. TASKS
A1
B. Total of all tasks (same as line K)

OMB APPROVAL NUMBER: 0693-0050

NIST-1022F
DAO 203-26

EXPIRATION DATE: XX-XX-XXXX

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

TECHNOLOGY INNOVATION PROGRAM (TIP)
ESTIMATED MULTI-YEAR BUDGET - JOINT VENTURE
YEAR TOTAL
ALL JV MEMBERS

YEAR:

1. OBJECT CLASS CATEGORY
A. Personnel salaries/wages
B. Travel
C. Equipment
D. Materials/supplies
E. Contractors
F. Other
G. Total direct costs (lines A thru F)
H. Total direct costs requested from TIP
I. Total direct costs shared by proposer (if any)
J. Total indirect costs absorbed by proposer
K. Total costs (lines G + J)
2. SOURCES OF FUNDS
A.

Remove Source Line

Add Source Line

Remove Task Line

Add Task Line

TIP (same as H)

A.
A.
B1.
C. Total of all sources of funds (same as line K)
3. TASKS
A1
B. Total of all tasks (same as line K)

OMB APPROVAL NUMBER: 0693-0050

NIST-1022F
DAO 203-26

YEAR:

TECHNOLOGY INNOVATION PROGRAM (TIP)
ESTIMATED MULTI-YEAR BUDGET - JOINT VENTURE

ALL

1. OBJECT CLASS CATEGORY
A. Personnel salaries/wages

$0

$0

B. Travel

$0

$0

C. Equipment

$0

$0

D. Materials/supplies

$0

$0

E. Contractors

$0

$0

F. Other

$0

$0

H. Total direct costs requested from TIP

$0

$0

I. Total direct costs shared by proposer (if any)

$0

$0

J. Total indirect costs absorbed by proposer

$0

$0

$0

$0

$0

$0

$0

$0

G. Total direct costs (lines A thru F)

K. Total costs (lines G + J)
2. SOURCES OF FUNDS
A.

EXPIRATION DATE: XX-XX-XXXX

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

TIP (same as H)

A.
A.
A.
B1.
C. Total sources of funds (same as line K)
3. TASKS
A1
B. Total of all tasks (same as line K)

Update Budget Summary
YEAR TOTAL
ALL JV MEMBERS

OMB APPROVAL NUMBER: 0693-0050

NIST-1022G
DAO 203-26

EXPIRATION DATE: XX-XX-XXXX

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

TECHNOLOGY INNOVATION PROGRAM (TIP)
FOREIGN OWNED COMPANY QUESTIONNAIRE

Add Questionnaire
Remove Questionnaire

Complete answers to all questions must be provided for each foreign-owned company participating in the proposed TIP project.
Submit additional documentation if necessary. [See Chapter 1, section 4 in the TIP Proposal Preparation Kit for explanation.]
Title of Proposal:

Submitting Organization:

1. Is the foreign-owned company incorporated in the United States, or is the LLC, partnership, or sole proprietorship with foreign
ownership organized in the United States? (NOTE: A company, LLC, partnership, or sole proprietorship is considered foreign
owned if it is majority owned or controlled by a non-U.S. entity, or its ultimate parent, if any, is incorporated outside the United
States.)
No. You are ineligible to continue.
Yes. Please continue.
2. Name of foreign-owned company and U.S. address where research for the project will be conducted.

3. Name of ultimate foreign parent, address, and country of incorporation. Also provide percentage of ownership.

4. What is the type of participation of the foreign-owned company?
Single Company
Joint Venture Lead
Joint Venture Participant
5. What is the role of the foreign-owned company? (Check all that apply.)
Key contributor to the high-risk tasks of the project.
Minor contributor to the high-risk tasks of the project.
Supplier of materials, equipment, or software services.
Manufacturer.
Other. Please explain.

6. What skills, capabilities, and resources does the foreign-owned company bring to the project? How will the company's role
affect project milestones and plans, if any, for commercialization?

7. Provide a brief description of:
a. Facility or facilities where project activities will be carried out;
b. Location, including address;
c. Square footage; and
d. Special equipment.

8. How many employees will be dedicated to the project?

9. Provide the names, titles, and main responsibilities of key project staff.

10. Will there be any activities performed outside the United States?
No.
Yes. If yes, a completed NIST-1022H TIP R&D Work Performed Outside the United States by the Recipient or Contractor
Questionnaire must be submitted.
11. Does the foreign-owned company expect to develop any new products or apply any new processes to its product lines
incorporating the TIP supported technology?
No.
Yes. If yes, provide the following:
a. For each new product or process, when will it first occur?
b. Where?
c. If in the United States, which facility?
d. Which U.S. product line?
e. Other? Please explain.

12. a. Provide investments that the foreign-owned company has made in research, development, manufacturing, distribution,
sales, and marketing in the United States in the past 3 years.

b. State approximate dollar value.

13. Describe the relationship between the foreign-owned company and its ultimate foreign parent. Include financial arrangements,
intercompany research agreements, and intellectual property arrangements.

OMB APPROVAL NUMBER: 0693-0050

NIST-1022H
DAO 203-26

Title of Proposal:

EXPIRATION DATE: XX-XX-XXXX

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

TECHNOLOGY INNOVATION PROGRAM (TIP)
R&D WORK PERFORMED OUTSIDE THE UNITED STATES BY THE
RECIPIENT OR CONTRACTOR QUESTIONNAIRE

Add Questionnaire
Remove Questionnaire

Submitting Organization:

Name of Company To Perform R&D Work Outside the United States:
Country Where Work Will Be Performed:

1. Is the work to be performed outside the United States less technically challenging and lower risk relative to the work carried
out in the United States?
Yes.
No. If no, explain.

2. Describe the impact on U.S. economic interests with and without the R&D being performed outside the United States.

3. What is the percentage of the total TIP project for R&D performed outside the United States?

4. What are the total dollars by organization for R&D performed outside the United States?

5. a. Explain how your organization made a good faith effort to identify alternatives to have this particular work performed outside
the United States.

b. Explain why those alternatives were not considered adequate to meet the R&D plan needs (e.g., cost, schedule,
insufficient interest, or commitment).

6. Would the project be less likely to generate substantial benefits to the United States if the work outside the United States were
not carried out at all, or if TIP insisted that the work be performed in the United States?
Yes.
No.
Explain why:

7. Does the facility proposing to carry out the work outside the United States bring to the project special expertise, extra
resources, or other factors that would represent a substantial loss to the project were they not present?
Yes.
No.
Explain why:

8. a. Is the entity proposing to do work outside the United States U.S. owned?
Yes.
No.
b. Does the entity also have R&D and manufacturing facilities in the United States that would benefit from the project?
Yes. If yes, describe the facilities and benefits:
No.

c. Who else would benefit?