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DocuSign Envelope ID: 4166FC64-6496-4305-B555-38A174BDAA73 Attachment 2 Federal Funding Accountability and Transparency Act (FFATA) Data Collection Form This Contract is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the 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. A DUNS® number provides a method to verify data about your organization. If you do not already have one, you may receive a DUNS® number free of charge by contacting Dui') and Bradstre et at www.dn b .. com_ Required Information about your organization and this contract will be made available on USASpending.gov by the Washington State Health Care Authority (HCA) as required by P.L. 109-282. As a tool to provide the information, HCA encourages registration with the Central Contractor Registry (CCR) because less data entry and r~ntry is required by both HCA and your organization. You may register with CCR on-line at hltps://www .uscontractorregislratign.com/. Contractor must complete this form and return it to the Health Care Authority (HCA). CONTRACTOR 1. Lega~ame t'. tr.17£J I 2. DUNS Number et.t, H Qt-0/-0.,1.0 -~~Y7 3. Principle PJ~e of Perfonnance ~5 i.l.1J ·1 .s~ -,SIA.._,tt_ {O S 3a. City b l(t!,~.:>h..._ ir, 3b . Stat JA- 3c. Zip+4 I 3d. Country £i q f1,;.. t., l~·1+: #~s --/,1. f,JJ'tati~1 4. Are you registered in CCR (hllps:/tw....w.uscontraclorreglstraljon.oomO? 001/ES (skip to page 2. Sign, date and return) ONO ' 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; !!llt. 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 information about the compensation of the executives through periodic reports filled with the IRS or the Security and Exchange Commission per 2 CFR Part 170.330 D NO (skip the remainder of this section -Sign, date and return) 0 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" means the cash and noncash dollar value earned by the executive during the sub- recipient's past fiscal vear of the followini:i (for more information see 17 CFR 229.402 (c)(2)). Local Health Jurisdiction Washington State Health Care Authority Page42 of 59 Medicaid Administrative Claiming Contract # K3069