UNIVERSITY OF CALIFORNIA

UC PROCUREMENT SERVICES
FFATA REPORTING FORM

For purchases funded by a federal contract ≥ $30,000

Suppliers must complete Section II of this form, to be issued a purchase order ($30,000 or greater) when the fund source is using a federal contract, to comply with the Federal Funding Accountability and Transparency Act (FFATA).

I. UC TRANSACTION INFORMATION (To be completed by UC)

Requisition or PO #:

Dollar Amount:

UC Campus:

Department:

Prime Agency:

Prime Contract #:

UC Administrative/Financial Contact:

Phone & Email:

II. SUPPLIER INFORMATION & CERTIFICATION (To be completed by Supplier)

Name:

Address:

City:

State:

Zip Code + 4:

Congressional District:

DUNS:

Parent DUNS:

DUNS registration current in SAM.gov

All recipients of federal funds must have an active DUNS.

Brief Description of Goods and/or Services:

Executive Compensation Criteria Question

In the preceding fiscal year, has Supplier received:

80 percent or more of its annual gross revenues in Federal awards (federal contracts (and subcontracts), loans, grants (and subgrants) and cooperative agreements); AND
$25,000,000 or more in annual gross revenues from Federal awards; AND
the public does not have access to information about the compensation of the senior executives of Subcontractor 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.

Has Supplier met all three criteria above?

YES

If No, Supplier is exempt from reporting executive compensation. If Yes, the names and total compensation of the five most highly compensated officers of Supplier must be listed below:

Highest Compensated Officers

Officer 1 Name:

Officer 1 Compensation ($):

Officer 2 Name:

Officer 2 Compensation ($):

Officer 3 Name:

Officer 3 Compensation ($):

Officer 4 Name:

Officer 4 Compensation ($):

Officer 5 Name:

Officer 5 Compensation ($):

Supplier Verification & Signature

Name of Supplier Preparer:

Title:

Signature (Type Full Legal Name):

Date:

Rev 09-2026

UC FFATA Reporting Form