Exhibit M - HHS FFATA Certification Form.pdf
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- Solicitation number
- HHS0016853
- Issued by
- Travis County, Austin City, Texas
About this file
This is a Federal Funding Accountability and Transparency Act (FFATA) Certification Form 8040-A issued by the Texas Health and Human Services Commission (HHSC). The form serves as a material certification document that contractors must complete and submit to HHSC for federal reporting purposes. The document establishes the certifications and representations upon which HHSC relies when reporting contractor information to the federal government as required by federal law. Contractors must certify the accuracy of all statements contained within the form, and any erroneous certifications knowingly provided may result in HHSC pursuing available remedies under Texas and U.S. laws. Signatories agree to provide immediate written notice to HHSC if any certification becomes erroneous due to changed circumstances or if errors are discovered after submission.
The certification addresses four primary areas: organizational gross income from all sources in the previous tax year; the percentage of annual gross revenue derived from federal awards; the total amount of annual gross revenues from federal awards; and public access to compensation information for highly compensated officers and senior executives. Contractors receiving 80 percent or more of annual gross revenue from federal awards and $25 million or more in federal award revenues must provide names and total compensation for their top five highly compensated officers and senior executives if the public does not have access to this information through Securities Exchange Act filings or Internal Revenue Code Section 6104 reports. The form requires signature from a duly authorized representative along with the applicable HHSC contract number(s) and signature date.
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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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