Attachment 5: Additional Info

Institution/Firm:

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Proposal Title:

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Type of Business (profit, non-profit):

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Size (check all that apply):

FORMCHECKBOX Small Business FORMCHECKBOX Small Disadvantaged Business FORMCHECKBOX 8(a) Business FORMCHECKBOX Woman Owned Business FORMCHECKBOX HUBZone Business FORMCHECKBOX Veteran Owned Business

FORMCHECKBOX SDVOB FORMCHECKBOX Large Business

UEI Number:

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Taxpayer/Federal Identification Number:

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Contractor/Team Project Officials
Contractor/Team Program Manager / Principal Investigator Name:

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Address:

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E-Mail:

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Telephone:

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Fax:

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Contractor/Team Program Financial Administrator
Name:

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Address:

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E-Mail:

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Telephone:

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Fax:

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Contractor/Team Technical Coordinator
Name:

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Address:

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E-Mail:

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Telephone:

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Fax:

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System for Award Management (SAM)
Is your organization registered in www.SAM.gov? Yes FORMCHECKBOX No FORMCHECKBOX If you answered Yes above, please indicate the date of your latest SAM update:

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Cost-Share Certification
Please certify that the proposed cost-share for this project is in accordance with 2 CFR 200 - Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Section 306, Cost Sharing or Matching. Name of Person Certifying:

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Signature:

Date:

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