0524-NEW SBIR STTR Funding Form Time of Award

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SBIR/STTR FUNDING AGREEMENT CERTIFICATION
All small businesses that are selected for award of an SBIR/STTR Funding Agreement must
complete this certification at the time of award and any other time set forth in the Funding
Agreement that is prior to performance of work under this award. This includes checking all of
the boxes and having an authorized officer of the Awardee sign and date the certification each
time it is requested.
Please read carefully the following certification statements. The Federal Government relies on
the information to determine whether the business is eligible for a Small Business Innovation
Research (SBIR) program or Small Business Technology Transfer (STTR) program award. A
similar certification will be used to ensure continued 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 Small Business Act, SBA regulations (13 CFR part 121), the
SBIR/STTR Policy Directive and also any statutory and regulatory provisions referenced in
those authorities.
If the Funding Agreement officer believes that the business may not meet certain eligibility
requirements at the time of award, they are required to file a size protest with the U.S. Small
Business Administration (SBA), which will determine eligibility. At that time, SBA will request
further clarification and supporting documentation in order to assist in the verification of any of
the information provided as part of a protest. If the Funding Agreement officer believes, after
award, that the business is not meeting certain Funding Agreement requirements, 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.
The undersigned has reviewed, verified and certifies that (all boxes must be checked unless
otherwise directed):
(1)
The Awardee business concern meets the ownership and control requirements set
forth in 13 C.F.R. §121.702.

Public reporting for collection of information is estimated to average 30 minutes, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless it
displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to NIFA, OGFM, 2312 East Bannister Road, Mail Stop 10,000, Kansas City, MO
64131, Attention Policy Section. Do not return the completed form to this address. National Institute of Food and Agriculture US
Department of Agriculture OMB No. 0524-NEW Form Approved For Use Through xx/xx/xxxx

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(2)

If a corporation – all corporate documents(namely: articles of incorporation and any
amendments, articles of conversion, by-laws and amendments, shareholder meeting
minutes showing director elections, shareholder meeting minutes showing officer
elections, organizational meeting minutes, all issued stock certificates, stock ledger, buy
sell agreements, stock transfer agreements, voting agreements, and documents relating to
stock options, including the right to convert non-voting stock or debentures into voting
stock) must evidence that the corporation meets the ownership and control requirements
set forth in 13 CFR 121.702. (Check one box)
N/A Explain why N/A:____________________________________
Yes

(3)

If a partnership – the partnership agreement evidences that it meets the ownership and
control requirements set forth in 13 C.F.R. §121.702.

(4)

Yes
N/A Explain why N/A:_________________________________________
If a limited liability company – the articles of organization and any
amendments, and operating agreement and amendments, and any other
evidence that it meets the ownership and control requirements set forth in 13
C.F.R. §121.702.
Yes

(5)

N/A Explain why N/A:_________________________________________

The birth certificates, naturalization papers, or passports show that any
individuals that the small business concern relies upon to meet the eligibility
requirements are U.S. citizens or permanent resident aliens in the United
States.
Yes

N/A Explain why N/A:_________________________________________

(6)

The Awardee business concern has no more than 500 employees, including the
employees of its Affiliates.

(7)

SBA has not issued a size determination currently in effect finding that this
business concern exceeds the 500 employee size standard.

(8)

During the performance of the award, the Principal Investigator/Project
Manager will spend more than one half of his/her time (based on a 40 hour
work week) as an employee of the Awardee (or Research Institution – STTR
only) or has requested and received a written deviation from this requirement
from the Funding Agreement officer.
Yes Deviation approved in writing by funding agreement officer:______ %

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(9)

All Essentially Equivalent Work, or a portion of the work, proposed under this
project (check the applicable line):
Has not been submitted for funding to this Agency or another Federal agency.
Has been submitted for funding to this Agency or another Federal agency but
has not been funded under any other grant, contract, subcontract or other
transaction.
A portion has been funded by another grant, contract, or subcontract as
described in detail in the proposal and approved in writing by the Funding
Agreement Officer.

(10)

During performance of award, the Awardee will perform the applicable
percentage of work unless a deviation from this requirement is approved in
writing by the Funding Agreement officer (check the applicable line and fill in
if needed):
SBIR Phase I: at least two-thirds (66 2/3%) of the research.
SBIR Phase II: at least half (50%) of the research.
STTR Phase I or Phase II: at least forty percent (40%) of the research.
Deviation approved in writing by the Funding Agreement officer (SBIR only):_____%

(11)

During performance of award, the R/R&D will be performed in the United
States unless a deviation is approved in writing by the Funding Agreement
officer .
Yes
Waiver has been granted

(12)

During performance of award, the R/R&D will be performed at the
Awardee’s facilities by the Awardee’s employees, except as otherwise
indicated in the SBIR/STTR application and approved in the Funding
Agreement.

(13)

The SBIR Awardee has registered itself on SBA’s database as majorityowned by venture capital operating companies, hedge funds or private
equity firms (check one box).
Yes
No
N/A Explain why N/A:

(14)

The SBIR Awardee is a Covered Small Business Concern (a Small
Business Concern that: (a) was not majority-owned by multiple venture
capital operating companies (VCOCs), hedge funds, or private equity
firms on the date on which it submitted an application in response to an
SBIR solicitation; and (b) on the date of the SBIR award, which is made
more than 9 months after the closing date of the solicitation, is majorityowned by multiple venture capital operating companies, hedge funds, or
private equity firms). (Check one box).
Yes
No

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(15)

I will notify this Agency immediately if all or a portion of the work authorized
and funded under this award is subsequently funded by another Federal
Agency.
Yes
No

(16)

[For STTR only] The Small Business Concern, and not a partnering Research
Institution, is exercising management direction and control of the performance
of the STTR Funding Agreement.
Yes
No

(17)

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

(18)

I am an officer of the business concern authorized to represent it and sign this
certification on its behalf. By signing this certification, I am representing on my
own behalf, and on behalf of the business concern that the information
provided in this certification, the application, and all other information
submitted in connection with this application, is true and correct as of the date
of submission. I acknowledge that any intentional or negligent
misrepresentation of the information contained in this certification may result
in criminal, civil or administrative sanctions, including but not limited to: (1)
fines, restitution and/or imprisonment under 18 U.S.C. 1001; (2) treble
damages and civil penalties under the False Claims Act (31 U.S.C. 3729 et seq.
double damages and civil penalties under the Program Fraud Civil Remedies
Act (31 U.S.C. 3801 et seq.); (3) seq. 170 double damages and civil penalties
under the Program Fraud Civil Remedies Act (31 U.S.C. 3801 et seq.); (4) civil
recovery of award funds, (5) suspension and/or debarment from all Federal
procurement and nonprocurement transactions (FAR subpart 9.4 or 2 CFR part
180); and (6) other administrative penalties including termination of
SBIR/STTR awards.

Signature:
Print Name (First, Middle, Last):
Title:
Business Name:

Date: