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Fiscal Federal Funding Accountability and Transparency Act <br />(FFATA) CERTIFICATION <br />For Fiscal Year (FY14) <br />As the duly authorized representative (Signor) of the Contractor, I hereby certify that <br />the statements made by me in this certification form are true, complete and correct to <br />the best of my knowledge. <br />Did your organization have a gross income, from all sources, of less than $300,000 in <br />your previous tax year? ❑ Yes JZ No <br />If your answer is "Yes ", skip questions "A ", "B ", and "C" and finish the certification. <br />If your answer is "No ", answer questions "A" and "B ". <br />A. Certification Regarding % of Annual Gross from Federal Awards. <br />Did your organization receive 80% or more of its annual gross revenue from federal <br />awards during the preceding fiscal year? ❑ Yes EZINo <br />B. Certification Reeardine Amount of Annual Gross from Federal Awards. <br />Did your organization receive $25 million or more in annual gross revenues from federal <br />awards in the preceding fiscal year? ❑ Yes WNo <br />If your answer is "Yes" to both question "A" and "B ", you must answer question "C ". <br />If your answer is "No" to either question "A" or "B ", skip question "C" and finish the <br />certification. <br />C. Certification Regarding Public Access to Compensation Information. <br />Does the public have access to information about the compensation of the senior <br />executives in your business or organization (including parent organization, all branches, <br />and all affiliates worldwide) through periodic reports filed under section 13(a) or 15(d) <br />of the Securities Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or section 6104 of the <br />Internal Revenue Code of 1986? ❑ Yes ❑ No <br />If your answer is "Yes" to this question, where can this information be accessed? <br />If your answer is "No" to this question, you must provide the names and total <br />compensation of the top five highly compensated officers below. <br />For example: <br />John Blum :500000; Mary Redd :50000; Eric Gan t:400000, Todd Platt :300000; <br />Sally Tom :300000 <br />Provide compensation information here: <br />-2- <br />Department of State Health Services Form 4734 — June 2012 <br />