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Federal Funding Accountability and Transparency Act Data Collection Form <br />Page 1 of 2 (03/2019) <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 number (DUNS®). 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 System for Award Management (SAM) to reduce data entry by both DOH and your <br />organization. You may register with SAM free of charge at www.sam.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 />SUBRECIPIENT <br />1.Legal Name 2.DUNS Number <br />3.Principle Place of Performance <br />3a. City 3b. State <br />3c. Zip+4 3d. Country <br /> NO 4.Are you registered in SAM? YES (skip to signature block. Sign, date and return) <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, and/ <br />or cooperative agreements; and <br />b.$25,000,000 or more in annual gross revenues from federal contracts, subcontracts, grants, loans, subgrants, and/ <br />or cooperative agreements; and <br />c.The public does not have access to this information about the compensation of the senior executives of your <br />organization through periodic reports filed under section 13(a) or 15(d) of the Securities and Exchange Act of <br />1934 (15 U.S.C. §§ 78m(a), 78o(d) or section 6104 of the Internal Revenue Code of 1986. <br />NO (skip to signature block. 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 />Name of Official 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 by the <br />executive during the past fiscal year and includes salary and bonus; awards of stock, stock options and stock appreciation <br />rights; and other compensation such as severance and termination payments, and value of life insurance paid on behalf of the <br />employee, and as otherwise provided by FFATA and applicable OMB guidance. <br />By signing this document, the Authorized Representative attests to the information. <br />Subrecipient’ s Authorized Representative Sign & Date <br />DOH will not endorse your subaward until this form is completed and returned.