First-TierSubcontractorInformationTemplate.xls
XLS spreadsheet 26 KB Posted
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Subcontractor Information form
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| File | Type | Posted |
|---|---|---|
| TemplateJCMntlHlth.doc | DOC document | |
| W9 Form.pdf | ||
| ExecLeve1.xls | XLS spreadsheet | |
| StdSelfCert_Revised.doc | DOC document |
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Sheet1
| Information required if award is $25,000 and over | ||||||
| This form implements section 2 of the Federal Funding Accountability and Transparency Act of 2006 (Pub. L. 109-282), as amended by section 6202 of the Government Funding Transparency Act of 2008 (Pub. L. 110-252), which requires contractors to report subcontract award data and the total compensation of the five most highly compensated executives of the contractor and subcontractor. The public may view first-tier subcontract award data at http://usaspending.gov. | ||||||
| Buyer's responsibility: | Prime Contract number: | |||||
| NAICS Code | Description of Award | Sub award Number | Amount of Sub award | Sub award Date | ||
| 6-digit North American Industry Classification System (NAICS) found in contract | A description of the products or services (including construction) being provided under the subcontract, including the overall purpose and expected outcomes or results of the subcontract. | Prime contractor's identifying number (PO number) | Anticipated total over the life of award | Date award signed. Format: MM/DD/YYYY | ||
| Subcontractor's Information: | ||||||
| DUNS Number | Name of Subcontractor | DUNS Number of Parent Company | Name of Parent Company | |||
| Subcontractor's Data Universal Number System | Name of company | Parent Company's Data Universal Number System | Name of subcontractor's parent company | |||
| Subcontractor's Physical Address | Street Address 2 | City | State | Zip Code + 4 | Congressional District | Country |
| Street address | Additional line for street address | City | 2-digit code | Zip code plus 4 (no dashes) | 2-digit code | 2-digit code |
| Subcontractor's Place of Performance | Street Address 2 | City | State | Zip Code + 4 | Congressional District | Country |
| Street address | Additional line for street address | City | 2-digit code | Zip code plus 4 (no dashes) | 2-digit code | 2-digit code |
| Subcontractor's Indication of Reporting Applicability | If a subcontractor in the previous tax year had gross income from all sources under $300,000, enter "No" because the Contractor does not need to report awards to that subcontractor. If over $300,000, enter "Yes" because the Contractor does need to report awards to that subcontractor. | |||||
| "Yes" or "No" | ||||||
| Subcontractor's Indication of Reporting Highly Compensated Officers (Public will not have access to this information) | Officer's Name | Officer's Compensation | ||||
| "Yes" or "No" | #1 | |||||
| #2 | ||||||
| If in the preceding fiscal year, received 80%+ and $25M annual gross revenue from federal contracts, "Yes" and give names & compensation for the five most highly compensated individuals for the calendar year; if not, "No" | #3 | |||||
| #4 | ||||||
| #5 | ||||||
| I certify that I have checked the appropriate categories for myself or my company. | ||||||
| ______________________________________ | ____________________________ | |||||
| Signature of authorized company representative | Date | |||||
| ______________________________________ | ____________________________ | |||||
| Printed Name | Title |
&C&"-,Bold"&12FAR 52.204-10 First-Tier Subcontractor Information &L6/21/11&C &R
Sheet2
Sheet3
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