SH18-050 FFY18 HSGP - FFATA Form (2)

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Page 1 of 3 FFATA FORM Subrecipient Agency: Grant and Year: Agreement Number: Completed by: Name Title Telephone Date Completed: STEP 1 Is your grant agreement less than $25,000? YES C h STOP, no further analysis needed, GO to Step 6 NO C h GO to Step 2 STEP 2 In your preceding fiscal year, did your organization receive 80% or more of its annual gross revenues from federal funding? YES C h GO to STEP 3 NO C h STOP, no further analysis needed, GO to Step 6 STEP 3 In your preceding fiscal year, did your organization receive $25,000,000 or more in federal funding? YES C h GO to STEP 4 NO C h STOP, no further analysis needed, GO to Step 6 STEP 4 Does the public have access to information about the total compensation* of senior executives in your organization? YES C h STOP, no further analysis needed, GO to step 6 NO C h GO to STEP 5 STEP 5 Executive #1 Name: Total Compensation amount: $ Executive #2 Name: Total Compensation amount: $ Executive #3 Name: Total Compensation amount: $ Executive #4 Name: Total Compensation amount: $ Executive #5 Name: Total Compensation amount: $ STEP 6 If your organization does not meet these criteria, specifically identify below each criteria that is not met for your organization: For Example: "Our organization received less than $25,000." Signature: ______________________________________________________ Date: * Total compensation refers to: Salary and bonuses Awards of stock, stock options, and stock appreciation rights Other compensation including, but not limited to, severance and termination payments Life insurance value paid on behalf of the employee Additional Resources: http://www.whitehouse.gov/omb/open http://www.hrsa.gov/grants/ffata.html http://www.gpo.gov/fdsys/pkg/FR-2010-09-14/pdf/2010-22705.pdf http://www.grants.gov/