Form 4040-0001 SBIR/STTR Form

OMB Approval No.:4040-0001
Expiration Date: mm/dd/yyyy

SBIR/STTR Information
• Agency to which you are applying (select only one)
QHHS

!ODoE

QusoA

D Other.

(This 9 digit code is obtained from the Small Business Administration)

• SBC Control ID:
• Program Type (select only one)
SBIR

STIR

Both (See agency-specific Instructions to detennine whether a particular agency allows a single submission for both SBIR and STTR)

• Application Type (select only one)
Phase I

Phase II

Fast-Track

Direct Phase I

Direct Phase II

O Phase 118

Phase IIA

(See agency-specific instructions to detennine whether a particular agency participates in Fast-Track,
Commercialization Readiness Program Second/S uenlial Direct Phase II or Commercialization Pilot Plan.

Phase I Letter of Intent Number:
• Agency Topic/Subtopic:

Questions 1-7 must be completed by all SBIR and STTR Applicants:
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1

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0Yes
0No

0Yes

nNo

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1nNo

LJYes

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• 1a. Do you certify that at the time of award your organization will meet the eligibility criteria for a small business as defined in the funding
opportunity announcement?
• 1b. Anticipated Number of personnel to be employed at your organization at the time of award.

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• 1c. Is your small business majority owned by venture capital operating companies, hedge funds, or private equity firms?

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• 1d. Is your small business a Faculty or Student-Owned entity?

• 2. Does this application include subcontracts with Federal laboratories or any other Federal Government agencies?
• If yes, insert the names of the Federal laboratories/agencies:

• 3. Are you located in a HUBZone? To find out if your business is in a HUBZone, use the mapping utility provided by the Small Business
Administration at its web site: http://www.sba.gov

• 4. Will all research and development on the project be performed in its entirety in the United Stales?
If no, provide an explanatlon in an attached file.

• Explanation:

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• 5. Has the applicant and/or Program Director/Principal Investigator submitted proposals for essentially equivalent work under other
Federal program solicitations or received other Federal awards for essentially equivalent work?
• If yes, insert the names or the other Federal agencies:

• 6. Disclosure Permission Statement: If this application does not result in an award, is the Government permitted lo disclose the title of
your proposed project, and the name, address, telephone number and email address of the official signing for the applicant organization to
state-level economic development organizations that may be interested in contacting you for further information (e.g., possible
collaborations. investment)?

• 7. Commercialization Plan: The following applications require a Commercialization Plan: Phase I (DOE only), Phase II (all agencies),
Phase 1/11 Fast-Track (all agencies). Include a Commercialization Plan in accordance with the agency announcement and/or agency-specific
instructions.
• Attach File:

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 4040-0001. The time required to complete this information collection is estimated to average 1 hour per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200
Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer