Sponsored Research Office Certificate of Membership

Grantee Reporting Requirements for Industry/University Cooperative Research Center (I/UCRC)

Copy of Membership Certification Form.xlsx

Sponsored Research Office Certificate of Membership

OMB: 3145-0088

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Sponsored Research Office Certificate of Membership
























In the table below, please report the Program Income received by the Center from each Member Organization











Please refer to the IUCRC Solicitation for full details on Membership Terms and Definitions
























Note: all pre-populated yellow highlighted entries are provided as examples. The tables should be updated with actual data from the IUCRC.
























Definition of Program Income (please refer to the NSF's Proposal & Award Policies & Procedures Guide (PAPPG):






https://www.nsf.gov/publications/pub_summ.jsp?ods_key=nsf20001&org=NSF
























Definition of Membership [insert link to 20-XXX]




































Membership Fee Details











Member Type Cost of membership










Full $50,000










Associate $25,000




































Actual Expenditures












Site 1 Site 2 Site 3








Actual Expenditure of Program Income in reporting period $150,000










Cumulative expenditures since start of the grant $390,000




































Membership Contributions Received











Organization Employer Identification Number (EIN) Year 1 Year 2 Year 3 Year 4 Year 5

Start Date:
Start Date:
Start Date:
Start Date:
Start Date:

End Date:
End Date:
End Date:
End Date:
End Date:



Program Income from Membership Fee
Program Income from Membership Fee Membership (number of equivalent full Members) Program Income from Membership Fee Membership (number of equivalent full Members) Program Income from Membership Fee Membership (number of equivalent full Members) Program Income from Membership Fee Membership (number of equivalent full Members)


Membership (number of equivalent full Members)

Company A
$50,000 1








Company B
$100,000 1








Company C
$25,000 0.5








Non-profit D
$50,000 1








Company E
$25,000 0.5








Government agency F
$50,000 1








Company G
$50,000 1









































































Total Program Income from Memberships in reporting period
$350,000 6


































Additional Program Income received (over and above Membership Fees)











Source of Program Income Employer Identification Number (EIN) Year 1 Year 2 Year 3 Year 4 Year 5

Start Date:
Start Date:
Start Date:
Start Date:
Start Date:

End Date:
End Date:
End Date:
End Date:
End Date:



Program Income
Program Income
Program Income
Program Income
Program Income


Program Income type (Cash or In-kind) Program Income type (Cash or In-kind) Program Income type (Cash or In-kind) Program Income type (Cash or In-kind) Program Income type (Cash or In-kind)

Company A
$65,500 Cash








Company B
$23,000 Cash








Non-profit D
$314,159 in-kind








Total additional Program Income in reporting period
$402,659



































In the tables below, please report the allocation of the Program Income to individual projects within the IUCRC (add additional rows as needed)





































Reporting Year 1:











Start date 1/1/2021










End date 12/31/2021























Project title Institution Name Program Income Funds allocated




Project A Site 1 $5,000




Project A Site 2 $45,000




Project B Site 1 $10,000




Project B Site 2 $100,000




Project B Site 3 $90,000

















Reporting Year 2:











Start date











End date
























Research Project title Institution Name Program Income Funds allocated

























































Reporting Year 3:











Start date











End date
























Research Project title Institution Name Program Income Funds allocated






































































Reporting Year 4:











Start date











End date
























Research Project title Institution Name Program Income Funds allocated

























































Reporting Year 5:











Start date











End date
























Research Project title Institution Name Program Income Funds allocated



















































































Signature and Certifications
























Please read carefully the following certification statements. The Federal government relies on the information to ensure compliance with specific program requirements during the life of the funding agreement. The definitions for the terms used in this certification are set forth in the IUCRC Program Solicitation.

The agency may request further clarification and supporting documentation in order to assist in the verification of any of the information provided.

Even if correct information has been included in other materials submitted to the Federal government, any action taken with respect to this certification does not affect the Government’s right to pursue criminal, civil or administrative remedies for incorrect or incomplete information given in the certification. Each person signing this certification may be prosecuted if they have provided false information.
















I certify that at least 90% of the IUCRC Program Income is used to support the direct costs of research, and no more than 10% is used to support indirect costs














I understand that the information submitted may be given to Federal, State and local agencies for determining violations of law and other purposes.














I certify that to the best of my knowledge that the statements herein are true and complete, I understand that the willful provision of false information or concealing a material fact in this report or any other communication submitted to NSF is a criminal offense (U.S. Code, Title 18, Section 1001).








































Authorized Organizational Representative (AOR)











Signature_______________________________________

Date:





















AOR Contact information:











Name











Address











Phone Number











Email Address


















































Principal Investigator (PI) for the Lead Site











Signature_______________________________________

Date:





















PI Contact information:











Name











Address











Phone Number











Email Address























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