20230214 BAA ITC IPAC Atch 9 Coversheet.pdf

Instructions for Completion

Cover Page Completion If there is information that is not applicable in any of the sections, please indicate that by marking “N/A”

Section 1 Fill out this section with the information of the organization that the contract will be formed with.

Section 2 Fill out this section with the organizations SAM registration information. If your organization is still completing your SAM registration, please select “In Progress.”

Section 3 Fill out this section with the project information.

Section 4 Fill out this section with the information of the individual who can be contacted with questions about this application.

Section 5 Fill out this section with the amount of funding you are requesting from ITC IPAC.

Section 6 Fill out this section with the information of the person authorized to sign the contract.

Section 7 Fill out this section with the projects principal investigator’s information. Complete Section 7 for all principal investigators.

Current & Pending Support Please provide additional information on any additional funding support you are receiving for this project and any other projects. Complete the Current & Pending Support page for all principal investigators.

Privacy Act Completion Please review and complete the “Covered Individual” and “Institution Name” Blocks.

BROAD AGENCY ANNOUNCEMENT Attachment 1

FA520922S0001

PROJECT SUBMISSION COVERSHEET

DATE:

1. APPLICANT INFORMATION

Legal Name/Organization Name:

Department/Division:

Address:

Country:

2. APPLICANT SAM REGISTRATION INFORMATION

SAM Registration Status:

SAM Expiration Date:

SAM UEI:

SAM CAGE:

3. APPLICATION POINT OF CONTACT

First Name:

Last Name:

Telephone Number:

Email:

Organization Affiliation/Position:

4. PROJECT INFORMATION

Descriptive Title of Applicant’s Project:

Proposed Project Start Date:

Proposed Project End Date:

5. ESTIMATED FUNDING INFORMATION

Total ITC IPAC Funds Requested:

6. AUTHORIZED CONTRACT REPRESENTATIVE

First Name:

Last Name:

Telephone Number:

Email:

Organization Affiliation/Position:

7. PRINCIPAL INVESTIGATOR INFORMATION

Prefix: First Name: Last Name:

Organization Name:

Position: Department:

Phone Number: Email:

List Degree(s) Type/Year:

List Previous Employment/Experience (include years):

List last five (5) publications and five (5) most closely related to the proposal:

CURRENT AND PENDING SUPPORT

The following information should be provided for each investigator and other senior personnel. Failure to provide the information may delay consideration of the proposal.

Investigator:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Plannedin Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

* If this project has previously been funded by another agency, please list and furnish information for immediately preceding funding period.

USE ADDITIONAL SHEETS AS NECESSARY

Privacy Act Statement

Army Futures Command or Department of the Army

Application for Federal Assistance

Authority: Government Paperwork Elimination Act (Pub. L. 105-277, 44 U.S.C. 3504); Executive Order 12372, Intergovernmental review of Federal Programs (47 FR 30959); 42 U.S. Code § 6605 – Disclosure of funding sources in applications for Federal research and development awards; Public Law 117-167, CHIPS and Science Act; Public Law 116-92, National Defense Authorization Act for Fiscal Year 2020; 5 U.S.C. 9101, Access to Criminal History for National Security and Other Purposes 5 CFR §1320.8, Agency collection of information Responsibility; 18 U.S.C. § 1001, False Statements, Concealment; E.O. 13478, Amendments to Executive Order 9397 Related to Federal Use of social Security Numbers; NSPM-33, National Security Presidential Memorandum 33 on National Security for United States Research and Development; DoD-D 5240.01, DoD Intelligence Activities; DoD-I 5200.02, Department of Defense Personnel Security Program; Army Regulation 381-10, U.S. Army Intelligence Activities

Purpose: The information collected may be used in processing, investigating, and maintaining records relevant to Federal Assistance awarded by the Department of the Army. Records in these systems will be used to ensure Army sponsored and/or awarded federal grants, assistance, contracts, and/or benefits are awarded to responsible parties, entities, and individuals.

Routine Uses: To contractors, grantees, experts, consultants, students, and others performing or working on a contract, service, grant, cooperative agreement, or other assignment for the Federal Government when necessary to accomplish an agency function.

To the appropriate Federal, State, local, territorial, tribal, foreign, or international law enforcement authority or other appropriate entity where a record, either alone or in conjunction with other information, indicates a violation or potential violation of law, whether criminal, civil, or regulatory in nature.

DoD Blanket Routine Use (http://dpcld.defense.gov/privacy)

Effect of not providing information: Providing information to the Department of the Army is voluntary. However, 42 U.S. Code § 6605, which imposes certain disclosure requirements in connection with Federal research and development awards, provides various enforcement mechanisms for non-compliance. One such mechanism, which the Department of the Army intends to pursue here, is rejection of such applications.

Proposal Title (or grants.gov number):

Acknowledgment of consent:

Covered individual (Signature): Date:

Covered individual (Name print):

Sponsor signature (Signature): Date:

Sponsor signature (Name print):

Institution Name: