COMPLETE THIS FORM AND UNIVERSITY OF IOWA SUBMIT AT LEAST 2 WEEKS GRANT/CONTRACT PROPOSAL PRIOR TO PROPOSAL EQUIPMENT COST SHARING REQUEST SUBMISSION

TO: Vice President Jordan Cohen Date: FROM:

Title of Proposal:

Funding Agency: Seq. No. Program (DSP will enter) Announcement/Division:

Budget: First 12 Months Total Project Period Total Direct Costs $ $ Indirect Costs $ $

Description of the equipment for which cost sharing is being requested.

Function of the equipment. (What does it do?)

Justification for the equipment. (Why is it needed?)

Include (in the table below) the cost of the equipment, how much of the cost is being requested from the University, and when the funds will be needed.

University Fiscal Year (begins July 1**) in which Funds Will Be Expended FY FY FY FY FY Total Equipment Cost (Agency + University) $ $ $ $ $ Requested from Agency $ $ $ $ $ Requested from University $ $ $ $ $

** For example, FY 1996 begins July 1, 1995 and ends June 30, 1996 Does the funding agency REQUIRE IN WRITING equipment cost sharing for this program/division? YES If YES: (1) Attach a photocopy of the mandatory cost sharing provision, or a letter from the agency program officer confirming that cost sharing is mandatory. (2) indicate what percent of the TOTAL EQUIPMENT COST must be from the University. Give a percent or range, e.g., 33%-50%: %

NO If NO, explain why you do not wish to request this equipment money from the funding agency.

Has space been identified for the equipment? YES NO. If YES, identify the space and other arrangements.

Will the equipment require remodeling or special utility hook-ups for installation? YES NO. If YES, identify the source of funds to be used for this purpose. (University equipment cost sharing funds will not cover these costs.)

______Principal Investigator Department Head Collegiate Dean (Signature) (Signature) (Signature)

Name: Name: Name Dept: Dept: College:

Approved for forwarding proposal to funding agency: ______Jordan Cohen Vice President for Research cc. Collegiate Dean, Department Head, Principal Investigator, Vice President for Finance and University Services, Provost, Facilities Services Group, Division of Sponsored Programs (PI and working file) ------

TO BE COMPLETED BY SPONSORED PROGRAMS AT TIME OF AWARD

Award Confirmation: Date of Award______Budget Begin Date ______Budget End Date______Account Specialist DSP______

Send to Grant Accounting Office for assignment of a C account and distribution of information of Request for Equipment Form. (DSP 10/95)