Form 1 phs 3734

Approved for use through 06/30/2015 OMB No. 0925-0002
Department of Health and Human Services, Public Health Service Official Statement Relinquishing Interests and Rights in a Public Health Service Research Grant
(Return original to awarding unit)
The PHS estimates that it will take 30 minutes to complete this form. This includes time for reviewing the instructions, gathering needed information and completing and reviewing the form. An agency many not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. If you have comments regarding this burden estimate of any other aspects of this collection of information, including suggestions for reducing this burden, send comments to: NIH, Project Clearance Office, 6705 Rockledge Drive MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0002). Do not return the completed form this address.							     	(date)
Name of Institution		     
Address (city and state)		     
		     
		     
Principal Investigator		     
on Public Health Service grant number			     
has expressed a desire to continue his/her research project at the
     
In view of the fact that we do not wish to nominate another principal investigator or continue the research project at this Institution, this is to signify our willingness to terminate this grant as of       (date) and to relinquish all claims to any unexpended and uncommitted funds remaining in the grant as of that date, as well as to all recommended future support of this project.
Equipment Costing $5,000 or More Transferring with the Project (itemize)				Unexpended Balance — Estimated
1.	     			The unexpended balance on termination date of
2.	     			      calculated on basis of total amount
3.	     			awarded for the grant year, will be approximately
4.	     			$	     	direct cost
5.	     			$	     	indirect cost.
6.	     
Use separate page for additional items.
That portion of the estimated unexpended balance which has been received will be returned to the Public Health Service, upon request, with a final adjustment, if required, to be made after the grant account has been audited.
Official Authorized to Sign Application
Signature
Name and Title (print or type)      

Privacy Act Statement.   The NIH maintains application and grant records as part of a system of records as defined by the Privacy Act:  NIH 09-25-0036, Extramural Awards and Chartered Advisory Committees (IMPAC 2), Contract Information (DCIS), and Cooperative Agreement Information, HHS/NIH:  http://oma.od.nih.gov/ms/privacy/pa-files/0036.htm.

PHS 3734 (Rev. 06/12)