Pre-Award-Information-Sheet_ALRD3109_Final.docx

Last Updated July 25, 2023

PRE-AWARD INFORMATION SHEET

Name of Organization Street Address City and County State and Zip + 4 (matches the USPS database)

Name and address must match SAM registration.

Project Title:

Unique Entity Identifier (UEI):

Organization’s Fiscal Year End Date:

A. BUSINESS ASSURANCES AND PAYMENT INFORMATION

1. DISCLOSURE OF POTENTIAL IMPROPRIETIES

Below, please disclose if any of the following conditions exist. If the answer to any question (a) through (g) below is yes, provide a detailed explanation in an attachment to this document.

a. Is the proposed Recipient, Subrecipient(s), or any of the Recipient’s or Subrecipient’s principals[footnoteRef:2] under investigation for or charged with a covered offense[footnoteRef:3]? [2: For this form, “principal” means: (1) An officer, director, owner, partner, technical program manager, or other person (as defined in 2 C.F.R. 180.95) within the project team with management or supervisory responsibilities related to this project and any resulting transaction; or (2) A consultant or other person, whether or not employed by the Recipient, Subrecipient, or their principals, or paid with Federal funds, who (a) is in a position to handle Federal funds, (b) is in a position to influence or control the use of those funds, or (c) occupies a technical or professional position capable of substantially influencing the development or outcome of an activity required to perform the transaction, including but not limited to, any Co-PIs.

] [3: For this form, “covered offenses” include: (1) Commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public or private agreement or transaction; (2) Violation of Federal or State antitrust statutes, including those proscribing price fixing between competitors, allocation of customers between competitors, and bid rigging; (3) Commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, receiving stolen property, making false claims, or obstruction of justice; or (4) Commission of any other offense indicating a lack of business integrity or business honesty that seriously and directly affects the Recipient’s present responsibility.]

b. Has the proposed Recipient, Subrecipient(s), or any of the Recipient’s or Subrecipient’s principals been convicted of a covered offense in the last five-years or had a civil judgment rendered against them for one of those offenses in that time period?

c. Is the proposed Recipient, Subrecipient(s), or any of the Recipient’s or Subrecipient’s principals under investigation for potential violation of U.S. export control laws and regulations, or has the proposed Recipient, Subrecipient(s), or any of the Recipient’s or Subrecipient’s principals been convicted of any violations of U.S. export control laws and regulations?

d. Is the proposed Recipient or Subrecipient(s) under investigation for potential violations of the Drug-Free Workplace Act of 1988, or has the proposed Recipient or Subrecipient(s) been convicted of any violations of the Drug-Free Workplace Act of 1988?

e. Is the proposed Recipient, Subrecipient(s), or any of the Recipient’s or Subrecipient’s principals under investigation for research misconduct, or has the proposed Recipient, Subrecipient(s), or any of the Recipient’s or Subrecipient’s principals been convicted of research misconduct?

f. Has any Federal agency recommended or initiated proceedings against the proposed Recipient, Subrecipient(s), or any of the Recipient’s or Subrecipient’s principals for suspension or debarment, or is the proposed Recipient, Subrecipient(s), or any of the Recipient’s or Subrecipient’s principals debarred, suspended, publicly banned from doing business with the Federal government, or otherwise declared ineligible from receiving Federal contracts, subcontracts or financial assistance?

g. Is the proposed Recipient or Subrecipient(s) delinquent on federal debt or insolvent or at risk of insolvency or have the proposed Recipient or Subrecipient(s) filed for bankruptcy in any domestic or foreign jurisdiction?

2. POTENTIAL CONFLICTS OF INTEREST

a. Financial Conflicts of Interest: The Recipient must disclose in writing any managed or unmanageable financial conflicts of interest involving a member of the project team (i.e., technical project manager) and include sufficient information to enable DOE to understand the nature and extent of the financial conflict, and to assess the appropriateness of the non-Federal entity's management plan. See Section V(b)(3) of the DOE Interim Conflict of Interest Policy. As part of this DOE funded project, does the recipient or any subrecipients have any managed or unmanageable financial conflicts of interest involving a member of the project team?

b. Organizational Conflicts of Interest[footnoteRef:4]: The Recipient must disclose in writing any potential or actual organizational conflict of interest to DOE. See DOE Interim Conflict of Interest Policy Section VI and 2 CFR 200.318 for more information. As part of this DOE funded project, does the recipient or any subrecipients intend to engage in a procurement with a parent, affiliate, or subsidiary organization that is not a state, local government, or Indian tribe? [4: Organizational Conflict of Interest means a situation where because of relationships with a parent company, affiliate, or subsidiary organization, the non-Federal entity is unable or appears to be unable to be impartial in conducting a procurement action involving a related organization. 2 CFR 200.318(c)(2).]

3. PAYMENT INFORMATION AND ASSURANCES

a. Has your organization received any prior DOE awards administered by NETL?

|_| If yes, please list the most recent award number:

|_| No

Questions b through d are reserved for institutions of higher education, hospitals, other non-profit organizations and state and local governments that are not considered for-profit entities.

b. Is the Awardee currently enrolled with the U.S. Department of Treasury/ASAP system (Automated Standard Application for Payment System)?

|_| Yes, please enter Awardee Seven-digit ASAP ID Number:

|_| No

c. Please provide the following contact information for ASAP and/or Payments:

Important: If not currently enrolled in the ASAP system, the person identified below will be contacted by the U.S. Department of Treasury with further instruction on completing the ASAP enrollment process.

ASAP / Payments Contact Person:

Phone No.:

Extension:

E-mail:

NOTE: All Recipient’s will be placed on “ASAP – Payment by Reimbursement”.

d. Indicate the name, phone number, and email address of the Designated Responsible Employee for complying with national policies prohibiting discrimination (see 10 CFR 1040.5 and the Certifications and Assurances SF-424B Assurances for Non-Construction Programs or SF-424D Assurances for Construction Programs found at: http://www.grants.gov/web/grants/forms/sf-424-family.html).

Name/Title

Phone No/Email

B. ACCOUNTING SYSTEM

Your organization should have an accounting system that meets government standards for recording and collecting costs in accordance with 2 CFR 200.302(b)(1). If you have not had prior government awards or a recent accounting system review, the DOE may request the Defense Contract Audit Agency (DCAA) or an independent auditor to verify that the accounting system is acceptable.

Indirect costs are an acceptable cost component of an approved budget if they are adequately supported and properly allocated. Organizations proposing indirect costs will need to demonstrate that the proposed indirect (e.g., overhead, G&A) rates were developed using a methodology acceptable for Government contracting, and in accordance with applicable Federal cost principles. If a current provisional indirect rate agreement has been issued by a Federal agency then that agreement should have been provided with the initial application. If it has not been, or a more current provisional indirect rate agreement has been executed, it needs to be provided as an attachment. In the absence of a provisional indirect rate agreement, the most current final indirect rate agreement should be provided as an attachment to this document.

1. Information for Determining Cognizant Agency/Office

Cognizance related duties (i.e.; negotiating provisional/final indirect rates) are the responsibility of the Cognizant Federal Agency (CFA). The CFA is the Federal agency (e.g., Department of Defense, Department of Energy, etc.) that provided the preponderance (largest amount) of funding for your awards, across all federal agencies. Once a Federal agency assumes cognizance for an organization, it should remain cognizant for at least 5 years to ensure continuity and ease of administration. It is extremely important to confirm that you work with the correct cognizant federal agency/office.

As a rule of thumb, Department of Health & Human Services (DHHS) or the Office of Naval Research (ONR) is usually the CFA for Universities, Cities, States, and Counties. DHHS/ONR cognizance is not usually transferred.

Please identify the CFA by providing the following information:

Agency:

Point-of-Contact:

Phone No.:

E-mail:

To assist our office in validating the CFA, please provide the following information for the five (5) highest dollar award values for current Federal contracts, grants or awards for which the organization receives funding (either as a prime or subcontract) directly from a Governmental agency. (State and Local Governments, Institutions of Higher Education, and Tribal organizations can skip this section if DHHS/ONR is the cognizant agency). The total federal contract/award dollars should include the full project period, not just the incremental funding.

(e.g., NETL) Agency Contact Name/Phone/E-mail

If awardee has current DOE awards, identify Cognizant DOE Office (CDO) (office providing the preponderance of DOE funding), and provide DOE office name, a point-of-contact, phone number, and e-mail (If same as above, proceed to Section F, Financial Management System-Accounting System Survey).

DOE Office:

Point-of-Contact (Contracting Officer):

Phone No.:

E-mail:

To assist our office in validating the CDO, please provide the following information for the 5 highest dollar value awards for current DOE contracts, grants or awards for which the organization receives funding (either as a prime or subcontract) directly from a DOE office. (State and Local Governments, Institutions of Higher Education, and Tribal organizations can skip this section if DHHS/ONR is the cognizant agency). The total DOE contract/award dollars should include the full project period, not just the incremental funding.

Contact Name/Phone/E-mail

C. FINANCIAL MANAGEMENT SYSTEM – ACCOUNTING SYSTEM SURVEY

To qualify for a financial assistance award, compliance with 2 CFR 200 as amended by 2 CFR 910 is required. This includes assurance of an adequate accounting system for estimating, accounting and billing for governmental funding received.

For additional information, please visit https://www.dcaa.mil. Under “CUSTOMERS->checklists and Tools,” click on “Pre-award Accounting System Adequacy Checklist”.

Please complete the checklist below as assurance of this requirement.

a. If yes, please provide a copy of the audit report as an attachment to this document.

c. If yes, have there been any changes to the accounting system since the DCAA audit? If the answer is “yes”, please provide a detailed explanation of the changes.

Use this block to explain the changes or provide an attachment.

7. Is your organization’s accounting system ready for a DCAA or independent Certified Public Accountant audit?

Please provide the type of accounting system utilized (manual or electronic) and if electronic, provide the software system implemented. In addition, if you checked “No” to any of the boxes above, please provide a detailed explanation here or as an attachment.

D. ANNUAL AUDIT REQUIREMENTS )

1. Single Audit – A non-Federal entity that expends $750,000 or more during the non-Federal entity’s fiscal year in Federal awards must have a single audit conducted in accordance with 2 CFR 200.514.

a. Has your organization had an independent single audit performed?

b. Has your organization undergone a financial audit within the last 3 years?

Use this block to explain why a financial audit was not completed or performed or provide an attachment.

E. REPRESENTATION/CERTIFICATION

Important: Certification of the information is required by the organization’s authorized representative.

|_| I certify that I have an active System for Award Management (SAM) registration.

|_| I certify that I have registered in FedConnect.net to receive award documentation.

|_| I certify that all cost information contained in the budget justification has been reviewed and that all costs are reasonable, allowable and allocable subrecipient/contractor cost information, and that all subrecipient/contractor costs are reasonable, allowable and allocable in accordance with the applicable cost principles. Any additional supporting budget documents should be available upon DOE request.

|_| I certify that all direct costs proposed in the application (under the personnel, travel, equipment, supplies, contractual, construction, and/or other direct costs categories) are direct to the project and are not duplicated in the proposed indirect costs.

|_| I certify that the processes undertaken to solicit any subrecipients, subawards, subcontracts and vendors comply with our organization’s written procurement procedures as outlined in “Procurement Standards” 2 CFR 200.317 through 2 CFR 200.328 inclusive.

|_| I certify the Recipient:

(6) Has in effect, an up-to-date, written, and enforced policy and process for effective internal controls over, and accountability for, all funds, property, and other assets to ensure they are used solely for authorized purposes; and

(7) Shall comply with applicable State or Federal well plugging and abandonment standards and regulations.

F. SIGNATURES

Title:

Signature of Authorized Official:

Date:

|_| I, the Technical Program Manager named below, certify to the best of my knowledge and belief that the information contained in this Pre-Award Information Sheet is true, complete, and accurate. I understand that false, fictitious, or fraudulent information, misrepresentations, half-truths, or omissions of any material fact may subject me to criminal, civil, or administrative penalties for fraud, false statements, false claims or otherwise. (18 U.S.C. 1001 §§ 1001 and 287, and 31 U.S.C. 3729-3730 and 3801-3812). I further understand and agree that (1) the statements and representations made herein are material to DOE’s funding decision, and (2) I have a responsibility to update the disclosures during the period of performance of the award should circumstances change which impact the responses provided above.

Name:

Title:

Signature of Techncial Program Manager:

Date:

G. MISCELLANEOUS INFORMATION

1. Does your organization anticipate utilizing foreign nationals (FNs) in the performance of the award?

|_| No

|_| Yes (If yes, follow instructions below).

If your organization, including any subrecipient or contractor, anticipates involving foreign nationals (FNs) in the performance of the award, your organization is required to provide a list of all FNs planned to participate on the award along with basic information about each. You must download and complete the “Foreign National Participation Document” located at https://www.netl.doe.gov/business/business-forms/financial-assistance under Post Selection Forms/Information and submit the completed document to basicinfo@netl.doe.gov with a courtesy copy to the assigned Project Manager (PM) and Contract Specialist.

Upon receipt of the completed “Foreign National Participation Document,” we will create a secured file sharing drop box folder(s) for FNs in Technical Program Manager / Co-Technical Program Manager roles and for FNs from countries identified on the U.S. Department of State’s list of State Sponsors of Terrorism located at https://www.state.gov/state-sponsors-of-terrorism/ for submission of additional information. The additional information will NOT be required for any of the other FNs planned to participate on the award, and therefore, a folder(s) will not be created.

As part of the requirement to submit additional information for the Technical Program Manager / Co-Technical Program Manager(s) and for FNs from countries identified as State Sponsors of Terrorism, your organization must ensure completion of the “Foreign National Participation Data Document” also located at https://www.netl.doe.gov/business/business-forms/financial-assistance.

The document and all required attachments must be uploaded to the secured file sharing drop box folder(s) provided by DOE’s FN Request Coordinator. The assigned PM will contact the appropriate FN Data Entry POC in the event there are issues with the submission.

Please note that all FNs identified on the “Foreign National Participation Document,” except for FNs from countries identified on the U.S. Department of State’s list of State Sponsors of Terrorism, are authorized to commence work as of the award effective date unless determined otherwise by DOE. FNs from countries identified on the U.S. Department of State’s list of State Sponsors of Terrorism are NOT permitted to participate on the award until written authorization is received from the Contracting Office.

The Contracting Officer will notify your organization of DOE’s decision regarding participation of FNs from countries identified on the U.S. Department of State’s list of State Sponsors of Terrorism. The DOE reserves the right to request additional information or deny participation of any FN at any time.

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