Laserfiche WebLink
Attachment 3 <br />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 <br />information 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 Nww.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 />htti2s://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 />2. DUNS Number <br />3. Principle Place of Performance <br />3a. Congressional District <br />3b. City <br />3c. State <br />3d. Zip+4 <br />3e. Country <br />4. Are you registered in CCR (https://www.uscontractorregistration.com! ? ❑ YES (skip to page 2. Sign, date <br />and return) ONO <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, <br />subgrants, 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 <br />periodic reports filled with the IRS or the Security and Exchange Commission per 2 CFR Part 170.330 <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 />_14aβ€”me Of Official_ ota ompensation <br />1. <br />2. <br />Washington State Page 55 HCA Contract No. K3924 <br />Health Care Authority <br />