Exhibit K - HHS FFATA Certification Form.pdf
PDF 113 KB Posted
- Attached to
- Video Directly Observed Therapy (“VDOT”)
- Solicitation number
- HHS0015558v2
- Issued by
- Texas
About this file
Exhibit K - HHS FFATA Certification Form
This document is an HHS FFATA (Federal Funding Accountability and Transparency Act) Certification Form related to the Video Directly Observed Therapy (VDOT) contract opportunity for the State of Texas. The form serves as a federal compliance certification required for contractors receiving federal funding through HHS programs. The certification typically applies to prime contractors and subcontractors that will receive federal awards or subawards exceeding the federal threshold for FFATA reporting requirements. This form establishes the contractor's commitment to comply with federal transparency and accountability requirements regarding federal funding disclosure.
The FFATA Certification Form requires the contractor to acknowledge obligations related to federal funding transparency, including the registration and maintenance of accurate data in the System for Award Management (SAM) and compliance with applicable federal regulations. Contractors must certify their understanding of reporting requirements for executive compensation and other federal transparency mandates. As part of the VDOT contract for Texas, completion and submission of this certification form is a mandatory prerequisite for contract award, ensuring that all awarded entities maintain compliance with federal funding transparency standards throughout the contract term.
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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): |
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