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<br /> Washington State <br /> Health Care Authority Page 38 of 53 Contract # 2747 <br /> <br />Attachment 2 Federal Funding Accountability and Transparency Act (FFATA) Data Collection Form <br />This Contract is supported by federal funds that require compliance with the Federal Funding Accountability and <br />Transparency Act (FFATA or the Transparency Act). The purpose of the Transparency Act is to make information <br />available online so the public can see how federal funds are spent. <br />To comply with the act and be eligible to enter into this contract, your organization must have a Data Universal <br />Numbering System (DUNS®) number. A DUNS® number provides a method to verify data about your <br />organization. If you do not already have one, you may receive a DUNS® number free of charge by contacting <br />Dun and Bradstreet at www.dnb.com. <br />Required Information about your organization and this contract will be made available on USASpending.gov by <br />the Washington State Health Care Authority (HCA) as required by P.L. 109-282. As a tool to provide the <br />information, HCA encourages registration with the Central Contractor Registry (CCR) because less data entry <br />and re-entry is required by both HCA and your organization. You may register with CCR on-line at <br />https://www.uscontractorregistration.com/. <br />Contractor must complete this form and return it to the Health Care Authority (HCA). <br />CONTRACTOR <br />1. Legal Name <br /> <br />2. DUNS Number <br /> <br />3. Principle Place of Performance <br /> <br />3a. City 3b. State <br />3c. Zip+4 3d. Country <br />4. Are you registered in CCR (https://www.uscontractorregistration.com/)? YES (skip to page 2. Sign, date and <br />return) NO <br /> <br />5. In the preceding fiscal year did your organization: <br />a. Receive 80% or more of annual gross revenue from federal contracts, subcontracts, grants, loans, subgrants, <br />and/or cooperative agreements; and <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 information about the compensation of the executives through periodic <br />reports filled with the IRS or the Security and Exchange Commission per 2 CFR Part 170.330 <br /> <br /> NO (skip the remainder of this section - Sign, date and return) <br /> YES (You must report the names and total compensation of the top 5 highly compensated officials of your <br />organization). <br /> <br />Name Of Official Total Compensation <br />1. <br />2. <br />3. <br />4. <br />5. <br /> <br />Note: “Total compensation” means the cash and noncash dollar value earned by the executive during the <br />sub-recipient’s past fiscal year of the following (for more information see 17 CFR 229.402 (c)(2)). <br />