Exhibit K - HHS FFATA Certification Form.pdf
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- Attached to
- Video Directly Observed Therapy (“VDOT”) RFO
- Solicitation number
- HHS0015558v3
- 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. The form serves as a material certification document that contractors must complete when bidding on or executing contracts with HHSC. The form requires contractors to certify their organizational financial information and federal funding relationships, with the understanding that HHSC will rely on these certifications when reporting required information to the federal government. Contractors must provide immediate written notice to HHSC if any certification becomes inaccurate at any time during the contract period.
The certification requires contractors to answer specific questions regarding their gross income and federal funding dependency. Contractors must disclose whether their organization had less than $300,000 in gross income from all sources 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. If a contractor answers affirmatively to both the 80% federal revenue and $25 million thresholds, they must provide public access certification regarding highly compensated officers and senior executives or supply the names and total compensation of their top five highest-paid executives. The form must be signed by a duly authorized representative of the contractor and include the applicable HHSC contract number(s), with false certifications subject to pursuit of all available remedies under Texas and U.S. law.
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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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