FSRS_Reporting_Form.pdf

Contractor Verification fSRS Reporting Requirement

Contract #:____________________________

Contractor Name: _____________________________________________________________________________________

Please note that the reporting of Subcontract awards (Section A) and Compensation of Executives (Section B) are independent of each other. Any of the questions could result in a reporting requirement.

Additionally, any changes to your gross income or subcontract awards throughout the period of performance of your contract may cause a reporting requirement not initially required. If so, this document must be revised and provided to the Contracting Officer.

Confirmation that you understand and will comply with FAR 52.204-10, Reporting Executive Compensation and First-Tier Subcontract Awards, of your contract.

Yes No

Section A: Award(s) of a first-tier subcontract with a value of $25,000 or more:

1. Did you, in the previous tax year prior to award, have gross income, from all sources, under $300,000?

Yes No

- If yes, you are not required to report subcontractor awards.

- If no, please answer below:

Did your subcontractor, in the previous tax year prior to award, have gross income, from all sources, under

$300,000?

Yes No

- If yes, you are not required to report subcontractor award(s).

- If no, you are required to report the subcontractor award(s) to www.fsrs.gov.

http://www.fsrs.gov/

Section B: Reporting of Total Compensation Five Most Highly Compensated Executives:

1. In the preceding fiscal year prior to award did you receive the below:

- 80 percent or more of annual gross revenues from Federal contracts (and subcontracts), loans, grants (and subgrants) and cooperative agreements;

and

- $25,000,000 or more in annual gross revenues from Federal contracts (and subcontracts), loans, grants (and subgrants) and cooperative agreements;

and

- the public does not have access to information about the compensation of the executives 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. (To determine if the public has access to the compensation information, see the U.S. Security and Exchange Commission total compensation filings at http://www.sec.gov/answers/execomp.htm)

- If yes, you are required to report the names and total compensation of each of the five most highly compensated executives to www.fsrs.gov.

2. Will you award a first-tier subcontract over $25K? Yes No

- If no, reporting is not required.

- If yes, answer below.

In the preceding fiscal year prior to award did the first-tier subcontractor receive the below:

- 80 percent or more of its annual gross revenues from Federal contracts (and subcontracts), loans, grants

(and subgrants) and cooperative agreements;

and

- $25,000,000 or more in annual gross revenues from Federal contracts (and subcontracts), loans, grants and subgrants) and cooperative agreements;

and

- the public does not have access to information about the compensation of the executives 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. (To determine if the public has access to the compensation information, see the U.S. Security and Exchange Commission total compensation filings at http://www.sec.gov/answers/execomp.htm)

- If yes, you are required to report the names and total compensation of each of the five most highly compensated executives for each first-tier subcontractor to www.fsrs.gov

X Contractor Representative http://www.sec.gov/answers/execomp.htm http://www.fsrs.gov/ http://www.sec.gov/answers/execomp.htm http://www.fsrs.gov/ http://www.fsrs.gov/