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Attachment 3 <br />Federal Funding Accountability and Transparency Act (FFATA) <br />Data Collection Form <br />This Contract is supported by federal funds that require compliance with the Federal Funding <br />Accountability and Transparency Act (FFATA or the Transparency Act). The purpose of the Transparency <br />Act is to make 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 <br />Universal Numbering System (DUNS®) number. A DUNS® number provides a method to verify data <br />about your organization. If you do not already have one, you may receive a DUNS® number free of <br />charge by contacting Dun and Bradstreet at www.dnb.com . <br />Required Information about your organization and this contract will be made available on <br />USASpending.gov by the Washington State Health Care Authority (HCA) as required by P.L. 109-282 . As <br />a tool to provide the information, HCA encourages registration with the Central Contractor Registry (CCR) <br />because less data entry and re-entry is required by both HCA and your organization. You may register <br />with CCR on-line at hHo s ://www.usc onlractorregistra tion .com/. <br />Contractor must complete this form and return it to the Health Care Authority (HCA). <br />CONTRACTOR <br />1. Legaa ame <br />Ou n./ y (5-F £<~~--rA.-S <br />2 . DUNS Number <br />0 I , 0 ;;i. o -:i 5 1/'1 <br />3. Principle Place of Performance u/v< Jul /. ;J-u s {))e,) r 5 ~" /u <br />3a . City£/ /el'\, bu v'j l~ 3b . State uJ A- <br />3c. Zip+4 . 3d . Country 18 /.-L~ '1A _J _ A--;:.2 ,' '7 / <br />4 . Are you registered in CCR (https://WWS'{.u scont.ractorreg istrallon .comt)? ~Y ES (sl<ip to page <br />2. S lim d ate and return ) O NO <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, <br />loans, subgrants , and/or cooperative agreements; and <br />b. $25,000,000 or more in annual gross revenues from federal contracts, subcontracts, <br />grants, loans, subgrants, and/or cooperative agreements; and <br />C. The public does not have access to information about the compensation of the executives <br />through periodic reports filed with the IRS or the Security and Exchange Commission per 2 <br />CFR Part 170.330 <br />0 NO (skip the remainder of this section -Sign , date and return) <br />0 YES (You must report the names and total compensation of the top 5 highly compensated <br />officials of your organization). <br />Name Of OffiC!llal Total Comoensation <br />1. <br />2 . <br />3 . <br />4. <br />5. <br />Washington State <br />Health Care Authority Page 51 of90 HCA Contract No. K3924