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eck theSECIION C: Federal and Act <br />ln your preceding fiscal year, did your organization <br />fu flYes El No <br />its gross revenues from federalreceive 8}o/o or more of <br />ln your preceding fiscal year, did your organization <br />Yes x trto <br />000 or more in federalfunding?receive S25,000, <br />top 5 highly compensated officials of your organization. <br />t. <br />2. <br />3. <br />4. <br />5. <br />nd total comPensation of thelf you answered yes to the previous quest ions, you must rePort the names a <br />I hereby certify that I am an individual authorized by the above identified entity (subrecipient) to complete this <br />form. Further, I certifiT that the above information is true and correct, and all material findings contained in the <br />audit report/statement have been disclosed. Additionally, I understand this form is to be submitted every fiscal <br />year for which this entity is a subrecipient of federal award funds from the Department until the grant agreement <br />is closed. <br />gWet +6pn,tce <br />4 l"l X-Laof Authorized Financial Representative:Date' <br />Page2of 2