Federal Disclosure Form

Name of Applicant and Spouse: (last, first, middle):


University Telephone Number: Email Address:
Department: Room & Bldg:
Home Address:

Title of Project:

First Disclosure Relating to this Proposal
Change, Renewal, or Extension of Grant or Contract
Change of Financial Interest Status

Agency to which you are applying or from which the grant was received:
DHHS/NIH or NSF

Name of Principal Contact Person at Agency:

Telephone Number: Email Address:

Amount Applied for: For Period:

Significant (reportable) Financial Interests:
I have no reportable financial interests.
I have reportable financial interests declared on the attached pages.

Please list on the attached numbered page(s) each financial interest as follows:

  • Name of Interest
  • Address of Interest
  • Owners of Interest
  • Amount of your combined (applicant and spouse) investment in them
  • The nature and titles used in your participation in them (salary, royalties, etc.)
  • Your intellectual property rights (patents, copyrights) being used by them
  • Any agreement for deferred remuneration, compensation, or financial gain of any kind

I declare under penalty of perjury under the laws of the State of California that I have used all reasonable diligence in preparing this Disclosure and that, to the best of my knowledge and belief, it is true and complete.


(Please print this form and provide the Signature of Grant Applicant and date.)

rev. 7/9/01