Fillable Form Nifa-666 - Organizational Information printable pdf download

OMB approved 0524-0026

Expires 07/31/2015

UNITED STATES DEPARTMENT OF AGRICULTURE

NATIONAL INSTITUTE OF FOOD AND AGRICULTURE

ORGANIZATIONAL INFORMATION

(Note: Identify attached information by the corresponding number and item of this form)

1. LEGAL NAME OF ORGANIZATION

CONGRESSIONAL DISTRICT

2. COMPLETE BUSINESS ADDRESS (Including zip code)

KEY OFFICIAL

NAME

TITLE

TELEPHONE NUMBERS

a. Chief Executive

Office: ________________________

Fax:___________________________

E-mail:_________________________

b. Authorized Representative (AR)

Office: ________________________

(Individual authorized to commit the

organization’s resource to proposed

Fax: __________________________

projects. Award letters will be

addressed to the Authorized

E-mail: ________________________

Representative unless he/she specifies

in writing another individual (such as

the Chief Executive)

c. Business Officer

Office: ________________________

Fax: __________________________

E-mail: _______________________

4. ORGANIZATIONAL TYPE

[ ] College/University

[ ] Commercial Organization

[ ] State or Local Government

[ ] Partnership

[ ] Public Secondary or Post-Secondary School

[ ] Proprietorship (unincorporated)

[ ] Other (Specify):

[ ] Corporation

[ ] For-Profit

[ ] Non-Profit (submit a copy of your current IRS tax exempt letter)

ORGANIZATION AFFILIATIONS – On a separate sheet, describe any relationship of the organization to a parent organization or to subsidiaries of other affiliates. If the organization is

a successor in interest to a predecessor or if changes in organizational affiliation are anticipated, describe briefly. If any key official is affiliated with another organization in any capacity,

describe the relationship.

STATEMENT OF PURPOSES AND POWERS - Provide the organization’s Articles of Incorporation, By-Laws, or, if not a corporation, a statement of the organization’s major

purposes.

FINANCIAL INFORMATION

a. On a separate sheet, describe the policies and procedures of your organization for the administrative and financial management of the project for which USDA assistance is being

requested. This should include details of your cost accounting system and auditing arrangements. (If necessary you may need to obtain advice from a Certified Public Accountant

(CPA) in setting up your accounting system.)

b. If your organization is other than a college or university or a State or local government, attach:

- Certified financial records for the preceding two years consisting of audit reports prepared by a CPA or year-end balance sheets and income statements.

- Documentation on the organization’s policy on salary compensation.

- Certification that the organization is not delinquent in the payment of Federal taxes.

- Provide a listing of previous Federal grants received to include the Federal awarding agency, amount received and the date awarded.

c. If indirect costs are requested under this proposal, submit a copy of your current negotiated rate agreement with a cognizant Federal audit agency. If your organization does not have

a current negotiated rate with a cognizant Federal audit agency, an indirect cost rate proposal must be submitted for determination of a billing rate acceptable for this award only.

8. Remarks:

Form NIFA-666 Page 1

Form Nifa-666 - Organizational Information

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