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Federal Funding Accountability and Transparency Act Data Collection Form This contract is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act. The purpose of the Transparency Act is to make information available online so the public can see how federal funds are spent. To comply with the act and be eligible to enter into this contract, your organization must have a Data Universal Numbering System (DUNS®) number. If you do not already have one, you may receive a DUNS® number free of charge by contacting Dun and Bradstreet at www.dnb.coni. The Department of Health (DOH) also encourages registration with the System for Award Management (SAM) to reduce data entry by both DOH and your organization. You may register with SAM free of charge at federalcontractorregistry.com. Information about your organization and this contract will be reported by DOH to the federal government as required by P.L. 109-282. This information will then be made available to the public by the federal government on USASpending.gov. SUBRECIPIENT 1. Legal Name 2. DUNS Number 3. Principle Place of Performance 3a. City 3b. State 3c. Zip+4 3d. Country 4. Are you registered in SAM? ❑YES (skip to signature block. Sign, date and return) ❑NO 5. In the preceding fiscal year did your organization: a. Receive 80% or more of annual gross revenue from federal contracts, subcontracts, grants, loans, subgrants, and/or cooperative agreements; and b. $25,000,000 or more in annual gross revenues from federal contracts, subcontracts, grants, loans, subgrants, and/or cooperative agreements; and c. The public does not have access to this information about the compensation of the senior executives of your organization through periodic reports filed under section 13(a) or 15(d) of the Securities and Exchange Act of 1934 (15 U.S.C. §§ 78m(a), 78o(d) or section 6104 of the Internal Revenue Code of 1986. ❑NO (skip to signature block. Sign, date and return) ❑YES (You must report the names and total compensation of the top 5 highly compensated officials of your organization). Name Of Official Total Compensation 1. 2. 3. 4. 5. Note: "Total compensation" for purposes of this requirement generally means the cash and non-cash value earned by the executive during the past fiscal year and includes salary and bonus; awards of stock, stock options and stock appreciation rights; and other compensation such as severance and termination payments, and value of life insurance paid on behalf of the employee, and as otherwise provided by FFATA and applicable OMB guidance. iiy signing this document the Authorized Representative attests to the information. Signature of Authorized Representative Print Name Date The Department of Health will not endorse your sub -award until this form is completed and returned. 11Pagc (5, 2 01 6)