Exhibit K, HHS FFATA Certification Form.pdf
PDF 113 KB Posted
- Solicitation number
- HHS0016585v2
- Issued by
- Texas
About this file
This is a Federal Funding Accountability and Transparency Act (FFATA) Certification Form (Form 8040-A) issued by the Texas Health and Human Services Commission (HHSC) in August 2022 for contractors seeking to work on state and local contract opportunities in Texas. The form requires contractors to certify material facts regarding their federal funding and compensation structures, which HHSC relies upon when reporting information to the federal government. Contractors must provide immediate written notice to HHSC if any certifications become erroneous due to changed circumstances or if they cannot certify all statements in the form. The certification process does not establish a specific contract term, response deadline, or award date, as it functions as a prerequisite compliance document rather than a solicitation for services.
The form contains four primary certification sections addressing federal funding thresholds and compensation disclosure requirements. Contractors must certify whether their organization had gross income below $300,000 in the previous tax year, whether they received 80% or more of annual gross revenue from federal awards, and whether they received $25 million or more in annual federal revenues. If contractors answer affirmatively to both the 80% and $25 million thresholds, they must disclose whether the public has access to highly compensated officer and senior executive compensation information through Securities Exchange Act filings or Internal Revenue Code Section 6104 reports. If public access is not available, contractors must provide the names and total compensation of their top five highly compensated officers or senior executives on an attached FFATA Reporting Template. The authorized representative must sign and date the certification form and provide applicable HHSC contract numbers.
View the file
Other files
Show all 18
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Please wait...
If this message is not eventually replaced by the proper contents of the document, your PDF viewer may not be able to display this type of document.
You can upgrade to the latest version of Adobe Reader for Windows®, Mac, or Linux® by visiting http://www.adobe.com/go/reader_download.
For more assistance with Adobe Reader visit http://www.adobe.com/go/acrreader.
Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries. Mac is a trademark of Apple Inc., registered in the United States and other countries. Linux is the registered trademark of Linus Torvalds in the U.S. and other countries.
Texas Health and Human Services Logo O:\WHS\Work\MISC\Images\HHSC-Logo Images\HHS_Logo_BW_M.jpg Form 8040-A August 2022-E Federal Funding Accountability and Transparency Act (FFATA) Certification Form 10.0.2.20120224.1.869952.867557 Form 8040-A, Federal Funding Accountability and Transparency Act (FFATA) Certification Form Texas Health and Human Services Form 8040-A, Federal Funding Accountability and Transparency Act (FFATA) Certification Form The certifications enumerated below represent material facts upon which HHSC relies when reporting information to the federal government required under federal law. If HHSC later determines that the contractor knowingly rendered an erroneous certification, HHSC may pursue all available remedies in accordance with Texas and U.S. laws. The signer further agrees that they will provide immediate written notice to HHSC if at any time they learn that any of the certifications provided for below were erroneous when submitted or have since become erroneous by reason of changed circumstances. Note: If the signer cannot certify all of the statements contained in this section, they must provide written notice to HHSC detailing which of the below statements they cannot certify and why.
Did your organization have a gross income, from all sources, of less than $300,000 in your previous tax year?
A. Certification Regarding Percent of Annual Gross from Federal Awards Did your organization receive 80% or more of its annual gross revenue from federal awards during the preceding fiscal year?
B. Certification Regarding Amount of Annual Gross from Federal Awards Did your organization receive $25 million or more in annual gross revenues from federal awards in the preceding fiscal year?
If your answer is Yes to both questions A and B, you must answer question C.
If your answer is No to either question A or B, skip question C and continue to section D.
C. Certification Regarding Public Access to Compensation Information Does the public have access to information about the highly compensated officers/senior executives in your business or organization (including parent organization, all branches and all affiliates worldwide) through periodic reports filed under Section 13(a) or 15(d) of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or Section 6104 of the Internal Revenue Code of 1986?
Name of Officer or Senior Executive Total Compensation 1.
2.
3.
4.
5.
D. Signatures As the duly authorized representative (signer) of the contractor, I hereby certify that the statements made by me in this certification form are true, complete and correct to the best of my knowledge.
| Section C, yes.: |
| Section C, no. Provide the names and total compensation of the top five highly compensated officers/senior executives using the attached FFATA Reporting Template.: |
| Name of Officer or Senior Executives, line 5 of 5.: |
| Total Compensation, line 5 of 5.: |
| Signature of Authorized Representative: |
| Date of Signature: |
| Applicable HHSC Contract Number(s): |
File details come from the government source that posted it. Updated .