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FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT <br />Data Collection Form <br />The Office of Management and Budget (OMB) has created a searchable, no -cost -publicly accessible <br />website that includes the following information for each new federal award and/or first tier subawards equal <br />to or greater than $25,000. As of October 1, 2010, recipients of federal grants and contracts must comply <br />with subrecipient reporting requirements under the Federal Funding Accountability and Transparency Act <br />(P.L. 109-282). <br />NACCHO, as a recipient of federal funding, is required to collect the information below and input this <br />information into the FFATA website (www.fsrs.gov). <br />Please complete the information requested below and submit this form to: <br />Ade Hutapea, LL.M., CFCM <br />Lead Contracts Administrator <br />National Association of County & City Health Officials <br />1201 (I) Eye Street NW 4th Fl., Washington, DC 20005 <br />Direct Line: (202) 507-4272 <br />Email: ahutapea@naccho.org <br />www.naccho.org <br />Please answer the following questions: <br />1. Is the total value of this contract (including any option periods) expected to exceed $25,000.00? <br />© Yes O No <br />2. If you answered Yes to Question 1, in the previous tax year, was your gross income from all sources <br />greater than or equal to $300,000? (If you answered No to Question 1, you do not need to complete the <br />remainder of this information request). <br />© Yes 0 No <br />3. If you answered Yes to Question 1 and 2, please provide the following information below: <br />Name of Entity: _ <br />Address of Entity: <br />Congressional District of Entity Location: <br />Unique Identifier (DUNS ft <br />CCR/Cage Code #: <br />Award Title Describing Purpose: <br />Amount of Award: <br />Applicable NAICS Code <br />