Exhibit K - HHS FFATA Certification Form.pdf
PDF 121 KB Posted
- Attached to
- Recovery Audit Contractor Services
- Solicitation number
- HHS0017023
- Issued by
- Texas
About this file
This is a Federal Funding Accountability and Transparency Act (FFATA) Certification Form (Form 8040) issued by the Texas Health and Human Services Commission (HHSC) for the Recovery Audit Contractor Services contract opportunity. The form serves as a material certification that HHSC relies upon when reporting contractor information to the federal government in compliance with federal law. Contractors must certify their responses to several key questions regarding federal funding, including whether their organization had gross income of less than $300,000 in the previous tax year, whether they received 80% or more of annual gross revenue from federal awards in the preceding fiscal year, and whether they received $25 million or more in annual gross revenues from federal awards during that same period. The form requires the duly authorized representative of the contractor to sign and certify that all statements made are true, complete, and correct to the best of their knowledge, and obligates the contractor to provide immediate written notice to HHSC if any certification becomes incorrect or changes due to altered circumstances.
If a contractor answers affirmatively to both the federal revenue percentage and amount thresholds, they must additionally certify whether the public has access to information about their highly compensated officers and senior executives through Securities Exchange Act filings or Internal Revenue Code provisions. Should public access not be available, the contractor must provide the names and total compensation of their top five highly compensated officers and senior executives. The form requires contractors to supply their legal name, unique entity identifier, applicable HHSC contract number(s), the signature and title of the authorized representative, and the date of signature. This certification is a mandatory submission requirement for federal awards and contractors who knowingly provide incorrect certifications may face remedies pursued under Texas and U.S. laws.
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Form 8040 December 2024 Federal Funding Accountability and Transparency Act (FFATA) Federal Awards Certification Texas Health and Human Services Commission Logo ..\..\..\MISC\Images\HHSC-Logo Images\HHS_Logo_BW_M.jpg The certifications listed below represent material facts that HHSC relies on when reporting information to the federal government required under federal law. If HHSC later determines that the contractor knowingly rendered incorrect certification, HHSC may pursue all available remedies per Texas and U.S. laws. The signer also 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 wrong when submitted or have since become wrong by reason of changed circumstances. Note: If the signer cannot certify all 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?
Section A – Certification About 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?
Section B – Certification About 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 sections A and B, you must answer section C.
If your answer is No to either sections A or B, skip section C and continue to section D.
Section C – Certification Regarding Public Access to Compensation Information Does the public have access to information about the highly compensated officers or 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?
If no, provide the names and total compensation of the top five highly compensated officers and senior executives.
Name of Officer or Senior Executive Total Compensation 1.
2.
3.
4.
5.
Section 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.
10.0.2.20120224.1.869952.867557 Texas Health and Human Services Form 8040, FFATA Federal Awards Certification
| Yes, the public does have access to information about the highly compensated officers or 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.: |
| No, the public does not have access to information about the highly compensated officers or 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: |
| Signature of Authorized Representative: |
| Date of Signature: |
| Legal Name of Contractor: |
| Title of Authorized Representative: |
| Unique Entity Identifier: |
| Applicable HHSC Contract Number(s): |
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