Yale

SCHOOL OF MEDICINE

YSM Non-Sponsored Assessment Reduction or Waiver Request

This form is to request a waiver or reduction of the university and/or YSM assessment on non-sponsored revenue. The form is valid for up to two years from the date of approval or when the deposit amount has been met, whichever occurs first. Department Business Offices are responsible for submitting the approved form to the YSM Controller’s Office at ysmcontroller@yale.edu so that an adjustment can be processed. For requests related to sponsored projects, use 1306 FR.02 Facilities and Administrative ("F&A") Rate Reduction/Waiver Request | It's Your Yale

Deposit Details

Contractor Name

Current Amount ($)

Deposit Date

Expected Future Deposits ($)

Full COA

Non-Sponsored Funds Assessment Information

Assessment Type

Applicable Assessment %**

Rate Being Requested %

Yale Medicine***	0.0 to 100.0 as a decimal.	0.0 to 100.0 as a decimal.
Dean's/Other	0.0 to 100.0 as a decimal.	0.0 to 100.0 as a decimal.

** See YSM Revenue Assessment Chart at Finance & Administration < MyYSM (yale.edu)

*** Yale Medicine recommendation & approval is required.

Yale Medicine Approval

Please note the date approved and attach an approval email documentation from the Director of Yale Medicine Finance prior to submitting this request.

Approved On

Documentation Submitted Filename

Documentation Of Approval

Documentation Of Approval (submitted)

Documentation Of Approval (resubmit)

Explanation/Justification

In the box below, provide an explanation/justification and attach documents as necessary, including but not limited to a copy of the contractor/donor's F&A policy, copy of contract, copy of budget:

Supporting Document

Requestor Information

Submitter's Name

Submitter's Email

Department

Faculty Name

Status

Request is being processed.