CONFIDENTIAL

Innovation to Protect (I2P) Grant Grant Closure Form

Submission Details

This form must be endorsed by the Applicant, his/her countersigning officer and respective Office of Research / Principal’s or Directors’ Office / Agency Headquarters / ED’s Office / Institutes or equivalent.

This form must be submitted to NHIC through the Research Office of the Applicant’s (PI’s) Healthcare Cluster. Only forms with the following two (2) submissions received by the Grant Secretariat will be accepted:

A. One softcopy submission containing the following documents to be emailed to Grant Secretariat at ip@nhic.sg with the subject header “Grant Closure Form_NHIC Application Number”.

o Grant Closure Form (One word format without signatures and one PDF format with signatures)

o Filed Patent Application (PDF format; if not submitted previously)

B. One hardcopy submission, with signatures, to be sent and received three (3) working days later from the date of softcopy submission, to the following address:

Attn: I2P Grant SecretariatNational Health Innovation Centre61 Biopolis Drive #01-02 ProteosSingapore 138673

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Important! : Relevant privileged or confidential information should be disclosed to help convey a better understanding of the submission. However, such information must be clearly marked in the submission.

CONFIDENTIAL

1. Grant Details

NHIC Reference number

NHIC-I2P-

Institution Reference Number (if any)

Title of Invention

Applicant Details

(Name, Designation, Institution, Telephone & Email address)

Host Institution

Grant Award Date dd Month yyyy

Grant Expiry Date dd Month yyyy

2. Filing Details

Stage(Please select one only)

Details

Stage 1 - First Filing

Stage 2 - PCT Filing

Stage 3 – PCT Prosecution Support

Stage 4 - National Phase (NP) Entry

Stage 5 – NP Prosecution Support

Stage 6 – Grant & Maintenance

Date of filing dd Month yyyy

Filed patent application details

IP OwnershipInformation

(Please mention institutions involved)

Solely owned _____________

Jointly owned _____________

Assigned Innovation & Enterprise Office

ORResearch Office

ETPL NTUitive NUS ILO SHIP Others ______________

3. Budget Details

Approved Budget ($) Expenditure to Date ($) Account Balance ($)

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CONFIDENTIAL

4. Acknowledgement by the Applicant

In submitting the NHIC I2P Grant Closure Form, the Applicant acknowledges that:

All information is accurate and true. All the Grant terms & conditions stipulated by the Letter of Award have been met. All bills and invoices (or certified copies of thereof) pertaining to the Grant have

been forwarded to NHIC for reimbursement. He/she is free from any financial conflicts of interest.

------------------------------------------------------Name and Signature of ApplicantDate:

5. Acknowledgement by Head of Department (HOD) & Host Institution of the Applicant

In submitting the NHIC I2P Grant Closure Form, the Institution acknowledges that:

The submitted information is accurate and complete. The respective offices (e.g. HR, Finance) have been notified of grant closure. Account Balance is clear and is aligned with Host Institution Finance and other

policies. There is no financial conflict of interest.

-----------------------------------------------------------Name and Signature of Head of Department1

Date:

---------------------------------------------------------Name and Signature of Director of Institution2

Date:

1 If the Applicant is the Head of Department, UNDERTAKING by the HOD’s Reporting officer is required.

2 If the Applicant is the Director of the Institution, UNDERTAKING by the Director’s Reporting officer is required.

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