NC SBIR/STTR Matching Funds Program Soloicitation FY0506

SCRA SBIR/STTR Phase I Matching Grant Program

Application FY 2018

SCRA Small Business Innovation Research (SBIR)

and Small Business Technology Transfer Research (STTR)

Phase I Matching Grant Program

APPLICATION

Section 1

Date: Click or tap to enter a date.

Company Name (referred to as “Applicant”): Click or tap here to enter text.

Company Street Address: Click or tap here to enter text.

City: Click or tap here to enter text.

State: Click or tap here to enter text.

Zip + 4 Digit Code (Look-up code here): Click or tap here to enter text.

Work Phone: Click or tap here to enter text.

Mobile: Click or tap here to enter text.

Company Primary Point of Contact: Click or tap here to enter text.

Company Primary Point of Contact Email: Click or tap here to enter text.

Section 2

Legal Structure (Refer to Solicitation for eligibility):

Choose an item.

If you selected other, please specify: Click or tap here to enter text.

Does this business have its principal place of business in South Carolina and no less than fifty-one percent (51%) of its payroll, as defined in the Solicitation, located in South Carolina?

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Will, at a minimum, fifty-one percent (51%) of the activities conducted under Phase I be performed in South Carolina?

Choose an item.

Does the Company have any overdue tax debts?

Choose an item.

Has the Company received official notification of Phase I award by the Federal SBIR/STTR agency for which Matching Grant funding is sought?

Choose an item.

Program: Choose an item. / Fast-Track? Choose an item.

Section 3

Project Title: Click or tap here to enter text.

Funding Federal Agency: Click or tap here to enter text.

Solicitation Number: Click or tap here to enter text.

Web-Link to Solicitation: Click or tap here to enter text.

Date Awarded: Click or tap to enter a date.

Total Federal SBIR/STTR Award Amount: $

Performance period start date: Click or tap to enter a date. Finish date: Click or tap to enter a date.

Name of Principal Investigator(s) (P.I.): Click or tap here to enter text.

Use of Matching Grant Funds:

Applicant is to submit a Use of Matching Grant Funds attachment (not to exceed 2 pages) that includes:

(1)  Description of the work plan/specific aims for the Matching Grant funds in non-technical terms, including deliverables, metrics for success, and the budget subtotal for each component of the work plan/aim

(2)  Timeline for deliverables by Applicant and all contractors/subcontractors/consultants

(3)  List all contractors/subcontractors/consultants, (including addresses) for the Matching Grant funds; if Matching Grant funds will be distributed to parties outside of South Carolina, justify the need to go outside the state

(4)  Projected impact of the Matching Grant funds on the scope and success of the project

(5)  Description of the benefits that the company may provide to South Carolina

(6)  Description of funds the company is contributing to the project in addition to the Federal award

(7)  Detailed budget for the Matching Grant funds, broken down by equipment, supplies, consultants, contract research organizations, travel, and intellectual property expenses; salaries and rent are not allowable expenses

The Applicant certifies that all statements, representations, and warranties made by the Applicant, or on its behalf, and any materials furnished by the Applicant or on its behalf in connection with this application (referred to as “Application”), are true, accurate and complete in all material respects, and do not contain any material misstatement of fact or omit to state a material fact or any fact necessary to make the statements contained herein or therein not materially misleading, to the best of the Applicant’s knowledge and belief.
The Applicant certifies that it has reviewed and understands the Solicitation for the SCRA SBIR/STTR Phase I Matching Grant Program, and that it meets all the applicable eligibility requirements.
The Applicant certifies that there is no scientific, budgetary, or commitment overlap between this Application and the Applicant’s other support, including all financial resources, whether Federal, non-Federal, commercial or institutional, available in direct support of an individual’s research endeavors, including but not limited to research grants, cooperative agreements, contracts, and/or institutional awards.
The Applicant understands that disbursement of funds is based upon the Applicant’s compliance with the terms outlined in the Solicitation and may be subject to recapture for non-compliance.
The Applicant acknowledges and accepts SCRA’s absolute right in its sole discretion to withhold, discontinue, or retract and recover in part or in full any monies awardedand/or distributed pursuant to the SBIR/STTR Phase I Matching Grant Program if it is determined that the Applicant has engaged in unlawful conduct or conduct which violates the spirit and intent of the Matching Grant Program.

Name of authorized company official (Please type): Click or tap here to enter text.

Title of authorized company official: Click or tap here to enter text.

Signature authorized company official: ______

(please sign)

Date Signed: Click or tap to enter a date.

E-mail address: Click or tap here to enter text.

Section 4

Company Name: Click or tap here to enter text.
List the Company’s management team, Board of Directors/Trustees or members of its governing body (add additional sheets if necessary).
Names (Company Officers, Directors, Trustees, Advisors): / Title (i.e. President, CEO, CFO, CTO, COO, VP, Director, Trustee, Advisor, etc.)
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Please indicate below for which of the research and development focus technology area(s) that the federal award was made. (Click all that apply)

Information Technology
Choose an item. / Life Sciences
Choose an item. / Advanced Materials/Manufacturing
Choose an item.

Please describe briefly other products and or services provided by your company beyond what your company is developing under the SBIR/STTR grant (if any):

Click or tap here to enter text.

Estimated Job Impact - Number of full-time equivalent jobs
Types of employees
If funding is received, what is the number of jobs expected to be created in the following categories, if any? / Current number of employees per category / Current number of employees in South Carolina
(if different from column to left) / Total employees estimated under Phase I
(With SCRA SBIR/STTR Phase I Matching Grant funds) / Total employees estimated under
Phase II
a) Professional / Scientific
b) Management
c) Technical / Technician
d) Skilled labor
e) Unskilled labor
f) Other (please describe)

Section 5

Type(s) of intellectual property protecting the project (you may select more than one):

Trade Secret
Choose an item. / Trademark
Choose an item. / Patent
Choose an item. / None
Choose an item.

Provide listing of pending and issued patent applications:

Does your company plan to manufacture/produce your product/service in South Carolina?

Choose an item.

If you selected “No,” please explain why not: Click or tap here to enter text.

Section 6

Is there a similar product/process on the market today?

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If you selected “Yes,” please detail how your product differentiates from the competition. Click or tap here to enter text.

Section 7

What is your go-to-market funding plan? Click or tap here to enter text.

Is your company actively pursuing other sources of funding?

Choose an item.

If the answer is “Yes,” please describe the nature and approximate dollar value of the funding and its status: Click or tap here to enter text.

Section 8

SUCCESS RATES: The following questions will assist SCRA in determining the overall success rates of South Carolina companies applying for Federal SBIR/STTR awards.

Please supply information for each Federal SBIR/STTR award(s) and or proposal(s) in the table below from the past five (5) years. Attach additional sheets, as needed.

Program / Funding Received? / Year
Award Received
(if applicable) / Project Title / Federal Agency / Score
(if applicable) / Award
Amount
(if applicable)
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REQUIRED: To receive any matching grant for your awarded SBIR/STTR grant, you must also apply to become a SC Launch Client Company. Please fill out a Client Company application as well, if you have not done so yet.

If you have any questions or need assistance regarding this application please contact Holly Unger, SC Launch Program Coordinator at or 843-760-4080.

Thank you for your interest.

By submitting this application, you are authorizing SCRA to perform a background check on the person(s) listed as contact, principals, founders, partners, etc.

If you are approved for funding, SCRA may use your name, company description and/or logo in printed and electronic material, including the SCRA website.

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