SAMPLE SUBRECIPIENT INVOICE FORMAT (must be obtained & authorized by the Subrecipient)

SUBMIT INVOICE TO: [email protected] Regents of the University of Minnesota Sponsored Projects Administration - Attn: Subaward Invoice 200 Oak Street SE, STE 450 Minneapolis, MN 55455-2070 Project Title: UMN Subaward Number: UMN Principal Investigator:

Subaward No.:_____________

SUBRECIPIENT Name: Address:

INVOICE DATE: INVOICE No.: INVOICE PERIOD:

to

For Questions, Contact Name: Telephone: Email: Project Period of Performance: *Subrecipient costs must be identified on each invoice by categorical line item in accordance with the approved Cost Share/In-Kind/ Program Income Current Costs

Cumulative

Budget Costs Salaries and Wages Fringe Benefits Materials and Supplies Travel – Domestic Travel – Foreign Other Equipment Patient Care Subawards

Indirect Cost: Rate% of Base TOTAL

USD

$

$

$

$

Amount of Payment Requested: USD $ If receipts are in a foreign language, English translation must be attached.

Certification: By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil, or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code, Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812)

Subrecipient Official Authorized to legally bind non-Federal entity

Date

Make Remittance Payable to: Mail to:

Electronically signed and dated via WorkflowGen system UMN Principal Investigator Signature of Approval

Date DUNS#: