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FEDERAL FT'NDING ACCOLNTABILITY AND TRANSPARENCY ACT <br />Data Collection Form <br />The office of Management and Budget (oMB) has created a searchabre, no-cost-publicly accessiblewebsite that includes the following information for each new federal award and/or first tier subawards equalto or greater than $25,000. As of october l, 2}ll,recipients of federal grants and conhacts must complywith subrecipient reporting requirements under the Federal Funding Acc-ountability and Transparency Act(P,L. t09-2E2). <br />NAccHo, as a recipient of federal funding, is required to collect the information below and input thisinfonnation into the FFATA website (www.fsrs.gov). <br />Please complete the inforrnation requested below and submit this form to: <br />Ade Hutapea LL.M,, CFCM <br />Lead Contracts Administrator <br />National Association of Counfy & City Health Officials <br />!?01 (I) Eye Sreet NW 4th H:, Washington, DC 20005 <br />Direct Liue: e02) 507-4272 - <br />Email: ahutapea@naccho.org <br />www.naccho.org <br />Please answer the foilowing questions: <br />l ' Is the total value ofthis conlract (including any option periods) expocted to exceed $25,000.00? <br />lS "o No <br />3. If you answered yes to euestion 1 and 2, ptease provide the following infonnation below: <br />Name ofEntity: <br />Address of Entity: <br />b <br />Congressional District of Entity Location:tq <br />Unique Identifier (DUNS #):'01-b' <br />CCR/Cage Code #;1 ApplicableNAICS <br />2' If you answered Yes toQuesti-on I' in the previous ta,r year, was your gross income from all sourcesgreater than or equal to $300,000? (If you answered No tL afur# i;i"u do not need to complete theremainder of this information,equ"sq. <br />($ "" O*, <br />Award Title Describing Purpose:'il <br />ht-,h6 <br />\Amount of Award:A <br />L <br />l\0ortti;_