SBIR-STTR Form Cover Page 01-14-2020.pdf

SBIR/STTR Information OMB Number: 4040-0001 Expiration Date: 10/31/2019

* Agency to which you are applying (select only one)

DOE HHS USDA Other:

* SBC Control ID: (This 9 digit code is obtained from the Small Business Administration)

* Program Type (select only one)

SBIR STTR

Both (See agency-specific instructions to determine whether a particular agency allows a single submission for both SBIR and STTR)

* Application Type (select only one)

Phase I Phase II Fast-Track Direct Phase II Phase IIA Phase IIB

Commercialization Readiness Program (See agency-specific instructions to determine application type participation.)

Phase I Letter of Intent Number:

* Agency Topic/Subtopic:

Questions 1-7 must be completed by all SBIR and STTR Applicants:

Yes No

* 1a. Do you certify that at the time of award your organization will meet the eligibility criteria for a small business as defined in the funding opportunity announcement?

* 1b. Anticipated Number of personnel to be employed at your organization at the time of award.

* 1c. Is your small business majority owned by venture capital operating companies, hedge funds, or private equity firms?

Yes No

* 1d. Is your small business a Faculty or Student-Owned entity?

Yes No

Yes

No

* 2. Does this application include subcontracts with Federal laboratories or any other Federal Government agencies?

* If yes, insert the names of the Federal laboratories/agencies:

Yes

No

* 3. Are you located in a HUBZone? To find out if your business is in a HUBZone, use the mapping utility provided by the Small Business Administration at its web site: http://www.sba.gov

Yes

No

* 4. Will all research and development on the project be performed in its entirety in the United States?

If no, provide an explanation in an attached file.

* Explanation:

Yes

No

* 5. Has the applicant and/or Program Director/Principal Investigator submitted proposals for essentially equivalent work under other Federal program solicitations or received other Federal awards for essentially equivalent work?

* If yes, insert the names of the other Federal agencies:

Yes

No

* 6. Disclosure Permission Statement: If this application does not result in an award, is the Government permitted to disclose the title of your proposed project, and the name, address, telephone number and email address of the official signing for the applicant organization to state-level economic development organizations that may be interested in contacting you for further information (e.g., possible collaborations, investment)?

* 7. Commercialization Plan: The following applications require a Commercialization Plan: Phase I (DOE only), Phase II (all agencies), Phase I/II Fast-Track (all agencies). Include a Commercialization Plan in accordance with the agency announcement and/or agency-specific instructions.

* Attach File:

* 8. Have you received SBIR Phase II awards from the Federal Government? If yes, provide a company commercialization history in accordance with agency-specific instructions using this attachment.

* Attach File:

* 9. Will the Project Director/Principal Investigator have his/her primary employment with the small business at the time of award?

* 10. Please indicate whether the answer to BOTH of the following questions is TRUE:

(1) Does the Project Director/Principal Investigator have a formal appointment or commitment either with the small business directly (as an employee or a contractor) OR as an employee of the Research Institution, which in turn has made a commitment to the small business through the STTR application process; AND

(2) Will the Project Director/Principal Investigator devote at least 10% effort to the proposed project?

* 11. In the joint research and development proposed in this project, does the small business perform at least 40% of the work and the research institution named in the application perform at least 30% of the work?

SBIR-Specific Questions:

STTR-Specific Questions:

SBIR/STTR Information

Questions 8 and 9 apply only to SBIR applications. If you are submitting ONLY an STTR application, leave questions 8 and 9 blank and proceed to question 10.

Questions 10 - 12 apply only to STTR applications. If you are submitting ONLY an SBIR application, leave questions 10 - 12 blank.

Yes

No

Yes No

Yes

No

Yes

No

* 12. Provide DUNS Number of non-profit research partner for STTR.

SBIR/STTR Information D:20061211100558- 05'00' D:20061211100558- 05'00' SBIR/STTR Information OMB Number: 4040-0001 Expiration Date: 10/31/2019

* Agency to which you are applying (select only one) Program Type: If you are applying under the SBIR program, check the SBIR box. If you are applying under the STTR program, check the STTR box. If a particular agency allows a single submission for both STTR & SBIR, check the Both box. A selection is required.

Agency to which you are applying is required.

* SBC Control ID:

(This 9 digit code is obtained from the Small Business Administration)

* Program Type (select only one) Program Type: If you are applying under the SBIR program, check the SBIR box. If you are applying under the STTR program, check the STTR box. If a particular agency allows a single submission for both STTR & SBIR, check the Both box. A selection is required.

Program Type is required.

* Application Type (select only one) SBIR/STTR Type: See agency-specific instructions to determine application type participation. This field is required.

Application Type is required: See agency-specific instructions to determine application type participation.

(See agency-specific instructions to determine application type participation.)

Phase I Letter of Intent Number:

* Agency Topic/Subtopic:

Questions 1-7 must be completed by all SBIR and STTR Applicants:

Question 1a: If you certify that at the time of award, your organization will meet the eligibility criteria for a small business as defined in the funding opportunity announcement, check the Yes box. Otherwise, check the No box. A selection is required.

Question 1a is required.

* 1a. Do you certify that at the time of award your organization will meet the eligibility criteria for a small business as defined in the funding opportunity announcement?

* 1b. Anticipated Number of personnel to be employed at your organization at the time of award.

* 1c. Is your small business majority owned by venture capital operating companies, hedge funds, or private equity firms?

SBIR/STTR Type: If you are submitting a Phase I application, check the Phase I box. If you are submitting a Phase II application, check the Phase II box. When submitting a Phase II application, please include the Phase I SBIR/STTR grant number in item #4 (Federal Identifier) on the SF424 (R&R) Cover Component. If you are submitting a Fast-Track application, check the Fast-Track box. A selection is required.

Question 1c is required.

* 1d. Is your small business a Faculty or Student-Owned entity?

SBIR/STTR Type: If you are submitting a Phase I application, check the Phase I box. If you are submitting a Phase II application, check the Phase II box. When submitting a Phase II application, please include the Phase I SBIR/STTR grant number in item #4 (Federal Identifier) on the SF424 (R&R) Cover Component. If you are submitting a Fast-Track application, check the Fast-Track box. A selection is required.

Question 1d is required.

Question 2: If this application includes subcontracts with Federal laboratories or any other Federal Government agencies, check the Yes box and insert the name of the Federal laboratories/agencies in the space provided. Otherwise, check the No box. A selection is required.

Question 2 is required.

* 2. Does this application include subcontracts with Federal laboratories or any other Federal Government agencies?

* If yes, insert the names of the Federal laboratories/agencies:

Question 3: If you are located in a HUBZone, check the Yes box. Otherwise, check the No box. A selection is required.

Question 3 is required.

* 3. Are you located in a HUBZone? To find out if your business is in a HUBZone, use the mapping utility provided by the Small Business Administration at its web site: http://www.sba.gov Question 4: If all research and development on the project will be performed in its entirety in the United States, check the Yes box. Otherwise, check the No box and use the Add Attachment button below, to attach an explanation. A selection is required.

Question 4 is required.

* 4. Will all research and development on the project be performed in its entirety in the United States?

If no, provide an explanation in an attached file.

* Explanation:

Question 5: If the applicant and/or Program Director/Principal Investigator has submitted proposals for essentially equivalent work under other Federal program solicitations or received other Federal awards for essentially equivalent work, check the Yes box and insert the names of the other Federal agencies in the space provided. Otherwise, check the No box. A selection is required.

Question 5 is required.

* 5. Has the applicant and/or Program Director/Principal Investigator submitted proposals for essentially equivalent work under other Federal program solicitations or received other Federal awards for essentially equivalent work?

* If yes, insert the names of the other Federal agencies:

Question 6: If this application does not result in an award, and the Government is permitted to disclose the title of your proposed project, and the name, address, telephone number and e-mail address of the official signing for the applicant organization, to organizations that may be interested in contacting you for further information (e.g., possible collaborations, investment), check the Yes box. Otherwise, check the No box. A selection is required.

Question 6 Disclosure Permission Statement is required.

* 6. Disclosure Permission Statement: If this application does not result in an award, is the Government permitted to disclose the title of your proposed project, and the name, address, telephone number and email address of the official signing for the applicant organization to state-level economic development organizations that may be interested in contacting you for further information (e.g., possible collaborations, investment)?

* 7. Commercialization Plan: The following applications require a Commercialization Plan: Phase I (DOE only), Phase II (all agencies), Phase I/II Fast-Track (all agencies). Include a Commercialization Plan in accordance with the agency announcement and/or agency-specific instructions.

* Attach File:

* 8. Have you received SBIR Phase II awards from the Federal Government? If yes, provide a company commercialization history in accordance with agency-specific instructions using this attachment.

* Attach File:

* 9. Will the Project Director/Principal Investigator have his/her primary employment with the small business at the time of award?

* 10. Please indicate whether the answer to BOTH of the following questions is TRUE:

(1) Does the Project Director/Principal Investigator have a formal appointment or commitment either with the small business directly (as an employee or a contractor) OR as an employee of the Research Institution, which in turn has made a commitment to the small business through the STTR application process; AND

(2) Will the Project Director/Principal Investigator devote at least 10% effort to the proposed project?

* 11. In the joint research and development proposed in this project, does the small business perform at least 40% of the work and the research institution named in the application perform at least 30% of the work?

SBIR-Specific Questions:

STTR-Specific Questions:

SBIR/STTR Information Questions 8 and 9 apply only to SBIR applications. If you are submitting ONLY an STTR application, leave questions 8 and 9 blank and proceed to question 10.

Questions 10 - 12 apply only to STTR applications. If you are submitting ONLY an SBIR application, leave questions 10 - 12 blank.

Question 8: If you have received SBIR Phase II awards from the Federal Government, check the Yes box and use the Add Attachment button below, to attach a company commercialization history in accordance with agency-specific instructions. Otherwise, check the No box.

Question 8 is required for Program Type SBIR or Both.

Question 9: If the Project Director/Principal Investigator will have his/her primary employment with the small business at the time of award, check the Yes box. Otherwise, check the No box.

Question 9 is required for Program Type SBIR or Both.

Question 10: Check the "Yes" box ONLY if BOTH of the following conditions is TRUE: (1) the Project Director/Principal Investigator has a formal appointment or commitment either with the small business directly (as an employee or a contractor) OR as an employee of the Research Institution, which in turn has made a commitment to the small business through the STTR application process; and (2) the Project Director/Principal Investigator will devote at least 10% effort to the proposed project. Check the "No" box if EITHER of these two conditions (or both) is false.

Question 10 is required for Program Type STTR or Both.

Question 11: If in the joint research and development proposed in this project, the small business performs at least 40% of the work and the research institution named in the application performs at least 30% of the work, check the Yes box. Otherwise, check the No box.

Question 11 is required for Program Type STTR or Both.

* 12. Provide DUNS Number of non-profit research partner for STTR.

DOE: Check if you are applying to DOE.:

Agency to which you are applying: This field is required.

HHS: Check if you are applying to HHS.:

Agency to which you are applying: This field is required.

USDA: Check if you are applying to USDA.:

Agency to which you are applying: This field is required.

Other: Check if other.:

SBIR: If you are applying under the SBIR program, check the SBIR box. If you are applying under the STTR program, check the STTR box. If a particular agency allows a single submission for both STTR & SBIR, check the Both box.:

No: If in the joint research and development proposed in this project, the small business performs at least 40% of the work and the research institution named in the application performs at least 30% of the work, check the Yes box. Otherwise, check the No box.:

Yes: If your small business is majority owned by venture capital operating companies, hedge funds, or private equity firms, check the Yes box. Otherwise, check the No box. :

Question 1c: This field is required.

No: If your small business is majority owned by venture capital operating companies, hedge funds, or private equity firms, check the Yes box. Otherwise, check the No box. :

Question 1d: This field is required.

Yes: If your small business is a Faculty or Student-Owned entity, check the Yes box. Otherwise, check the No box.:

Question 1d: This field is required.

No: If your small business is a Faculty or Student-Owned entity, check the Yes box. Otherwise, check the No box.:

Question 2: This field is required.

Yes: If this application includes subcontracts with Federal laboratories or any other Federal Government agencies, check the Yes box and insert the name of the Federal laboratories/agencies in the space provided. Otherwise, check the No box.:

Question 2: This field is required.

No: If this application includes subcontracts with Federal laboratories or any other Federal Government agencies, check the Yes box and insert the name of the Federal laboratories/agencies in the space provided. Otherwise, check the No box.:

Yes: If this application does not result in an award, and the Government is permitted to disclose the title of your proposed project, and the name, address, telephone number and email address of the official signing for the applicant organization to state-level economic development organizations that may be interested in contacting you for further information (e.g., possible collaborations, investment), check the Yes box. Otherwise, check the No box.:

Question 6 Disclosure Permission Statement: This field is required.

No: If this application does not result in an award, and the Government is permitted to disclose the title of your proposed project, and the name, address, telephone number and email address of the official signing for the applicant organization to state-level economic development organizations that may be interested in contacting you for further information (e.g., possible collaborations, investment), check the Yes box. Otherwise, check the No box.:

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