PHS 2590 (Rev. 9/07), Checklist, Form Page 6

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Program Director/Principal Investigator (Last, first, middle):
     


GRANT NUMBER
     

CHECKLIST
1.  PROGRAM INCOME  (See instructions.)
All applications must indicate whether program income is anticipated during the period(s) for which grant support is requested.  If program income is anticipated, use the format below to reflect the amount and source(s).
Budget Period
Anticipated Amount
Source(s)
     
     
     
     
     
     
     
     
     
2.  ASSURANCES/CERTIFICATIONS (See instructions.)
In signing the application Face Page, the authorized organizational representative agrees to comply with the following policies, assurances and/or certifications when applicable. Descriptions of individual assurances/certifications are provided in Part III of the PHS 398.  If unable to certify compliance, where applicable, provide an explanation and place it after the Progress Report (Form Page 5).

3.  FACILITIES AND ADMINSTRATIVE (F&A) COSTS
Indicate the applicant organization’s most recent F&A cost rate established with the appropriate DHHS Regional Office, or, in the case of for-profit organizations, the rate established with the appropriate PHS Agency Cost Advisory Office.

F&A costs will not be paid on construction grants, grants to Federal organizations, grants to individuals, and conference grants.  Follow any additional instructions provided for Research Career Awards, Institutional National Research Service Awards, Small Business Innovation Research/Small Business Technology Transfer Grants, foreign grants, and specialized grant applications.
  DHHS Agreement dated:
     
  No Facilities and Administrative Costs Requested.
  No DHHS Agreement, but rate established with
     
Date
     
CALCULATION*
Entire proposed budget period:
Amount of base $
     
x Rate applied
     
% = F&A costs  $
     
Add to total direct costs from Form Page 2 and enter new total on Face Page, Item 8b.
*Check appropriate box(es):
  Salary and wages base
  Modified total direct cost base
  Other base  (Explain)
  Off-site, other special rate, or more than one rate involved  (Explain)
Explanation  (Attach separate sheet, if necessary.):
     
PHS 2590 (Rev. 09/07)	Page     	Form Page 6