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Federal Funding Accountability and Transparency Act Data Collection Form (2-23-2011) <br />This contract is supported by federal funds that require compliance with the Federal Funding Accountability and <br />Transparency Act. The purpose of the Transparency Act is to make information available online so the public can see <br />how federal funds are spent. To comply with the act and be eligible to enter into this contract, your organization must <br />have a Data Universal Numbering System (DUNS®) number. If you do not already have one, you may receive a DUNS® <br />number free of charge by contacting Dun and Bradstreet at www.dnb.com . The Department of Health (DOH) also <br />encourages registration with the Central Contractor Registry (CCR) to reduce data entry by both DOH and your <br />organization. You may register with CCR free of charge at www.ccr.gov . Information about your organization and this <br />contract will be reported by DOH to the federal government as required by P.L. 109-282. This information will then be <br />made available to the public by the federal government on USASpending.gov. <br />CONTRACTOR lQDegal Name 2. DUNS Number <br />Ufl-!'vJ Of ~,+h+a/~ at -02.0 -1SLll <br />3. Principl e Place of Performance <br />tJ Ovt- <br />3a . City 8 [(/\,,'!t;tJ ~ 3b. State <br />\I'M <br />3c. Zlp+4 ~gq2 .~ -l ' q { 3d . Country [}S~ <br />4. Are you registered in CCR? p YES (skip to signature block, Sign, date and return) DNO <br />S. In the preceding fiscal year did your organization : <br />\'JV a. Receive 80% or more of annual gross revenue from federal contracts, subcontracts, grants, loans, <br />subgrants, and/or cooperative agreements; lmI <br />~~ b. $25,000,000 or more in annual gross revenues from federal contracts, subcontracts, grants, loans, <br />subgrants, and/or cooperative agreements; and <br />~ c. The public does not have access to this information about the compensation of the senior executives of <br />your organization through periodic reports filed under section 13(a) or lS(d) of the Securities and <br />Exchange Act of 1934 (15 U.S.c. §§ 78m(a), 78o(d) or section 6104 of the Internal Revenue Code of <br />~: 1986. NO (skip to signature block. Sign, date and return) <br />ES (You must report the names and total compensation of the top 5 highly compensated officials of your <br />organization ). <br />Name Of Offidal Total Compensation <br />1. <br />2. <br />3. <br />4. <br />5. <br />Note: "Total compensation" for purposes of this requirement generally means the cash and non-cash value earned <br />by the executive during the past fiscal year and includes salary and bonus; awards of stock, stock options and stock <br />appreciation rights; and other compensation such as severance and termination payments, and value of life <br />insurance paid on behalf of the emplo'lee, and as otherwise _prov ided by FFATA and applicable OMS guidance. <br />resentative attests to the Information. <br />Print Name Date <br />rli ;}-( IS- <br />The Department of Health will not endorse your subaward until this form is completed and returned.