Date: ______________

MEMORANDUM

TO: Kara Shibata, Controller University of Hawaii Foundation

FROM: ___________________________, Principal Investigator (Email: ____________________) John A. Burns School of Medicine

SUBJECT: Request for New ORS Agreement

Project Title: UHF Support –

Dept/Prgm:

Address:

Type: (intentionally left blank)

Purpose:

UHF Account:

UH Fiscal Admin: UH FA Code:

UH Org Code: UH Campus: MA

Requesting the following budget period and amount: Requesting Budget Period: Start: End: Requesting Budget Amount: $

The John A. Burns School of Medicine respectfully requests your office’s assistance with

preparing a new ORS Agreement for budget period __________________ - __________________ and

budget amount $__________________.

NEW MEMO TEMPLATE: SAMPLE

Kara Shibata Page 2 of 2

Scope of Work:

Budget Justification:

Budget Spreadsheet: See attached

Approved by:

___________________________ __________ ___________________________ __________ Account Administrator #1 Date Account Administrator #2 Date

___________________________ ___________________________ Name Name

Note to UHF: Please contact/email the individual below for the following matters. Mahalo!

1. Inquiries related to this request2. Email a copy of the half-executed agreement for UH myGRANT processing3. Email a copy of the monthly ORS Invoice for UHF Account Administrator approval

___________________________ __________ ___________________________ Name Phone # Email Address

Kara Shibata Page 2 of 2

Budget Spreadsheet:

Category Description Amount Salaries & Wages TBD: $44,112 annual x 0.50 FTE = $22,056 Salaries & Wages Subtotal: $22,056 Fringe Benefits TBD: $22,056 x 0.6249 = $13,783 Fringe Benefits Subtotal: $13,783 Services n/a $0 Services Subtotal: $0 Materials & Supplies

Medical/Office Supplies $14,161

Materials & Supplies Subtotal: $14,161 Travel n/a $0 Travel Subtotal: $0 Others n/a $0 Others Subtotal: $0 Equipment n/a $0 Equipment Subtotal: $0 Indirect Costs n/a $0 Indirect Costs Subtotal: $0 TOTAL: $50,000