Key Contacts Form
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1
2Form Approved OMB No: 2030-0020 Approval Expires
06/30/2017
U.S. ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460
KEY CONTACTS FORM
Authorized Representative:
Original awards and amendments will be sent to this individual for review
and acceptance, unless otherwise indicated.
Name: __________________________________________________________________________
Title: ___________________________________________________________________________
Complete Address: ________________________________________________________________
________________________________________________________________
Phone Number: ___________________________________________________________________
Payee:
Individual authorized to accept payments.
Name: __________________________________________________________________________
Title: ___________________________________________________________________________
Mail Address: ____________________________________________________________________
________________________________________________________________________________
Phone Number: ___________________________________________________________________
Administrative Contact:
Individual from Sponsored Program Office to contact concerning
administrative matters (i.e., indirect cost rate computation, rebudgeting requests etc.)
Name: __________________________________________________________________________
Title: ___________________________________________________________________________
Mailing Address: __________________________________________________________________
________________________________________________________________________________
Phone Number: ___________________________________________________________________
FAX Number: ____________________________________________________________________
E-Mail Address: __________________________________________________________________
Principal Investigator:
Individual responsible for the technical completion of the proposed work.
Name: __________________________________________________________________________
Title: ___________________________________________________________________________
Mailing Address: __________________________________________________________________
________________________________________________________________________________
Phone Number: ___________________________________________________________________
FAX Number: ____________________________________________________________________
E-Mail Address: __________________________________________________________________
Web URL: _______________________________________________________________________
The public reporting and recordkeeping burden for this collection of information is estimated to average 30 minutes per response. Send comments
on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden,
including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T),
1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
EPA Form 5700-54 (Rev
)
06/2014
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