Document
FNS-775

ICR 202605-0584-001 · OMB 0584-0686 · Object 171962100.
Document Viewer [pdf]

Status: Original and derived artifacts are available for this document.
Download: pdf
Primary: pdfSource: application/pdf
Loading document viewer…
Document Metadata

Record metadata
File Type	application/pdf
File Title	FNS-775
Author	LLaurato
Last Modified By	Designer 6.5
File Modified	2026-08-25
File Created	2026-08-25
Conversion State	complete
Extracted Text

(PSRZ+53HUVRQ0RGHO
121EMPLOYEE '$7$ SHEET
3ULYDF\$FW6WDWHPHQW7KHIROORZLQJLQIRUPDWLRQLVSURYLGHGLQDFFRUGDQFHZLWK86&D H  DQG
0
$XWKRULW\7KLVLQIRUPDWLRQLVEHLQJFROOHFWHGXQGHUWKHDXWKRULW\86&DQGDQG([HFXWLYH2UGHU
3XUSRVH7KLVLQIRUPDWLRQLVFROOHFWHGWRFRQGXFWEDFNJURXQGLQYHVWLJDWLRQVZKLFKLVDSUHUHTXLVLWHIRUDOOQRQ)1A
HPSOR\HHV FRQWUDFWRULQWHUQYROXQWHHUVHWF WREHJUDQWHGDVHFXULW\FOHDUDQFHIRUHPSOR\PHQWDWDOO)1AORFDWLRQV
5RXWLQH8VHV7KHLQIRUPDWLRQ\RXSURYLGHRQWKLVIRUPPD\EHVKDUHGZLWKRWKHUIHGHUDOVWDWHORFDODQGIRUHLJQ
JRYHUQPHQWDJHQFLHVDQGDXWKRUL]HGRUJDQL]DWLRQVIROORZLQJDSSURYHGURXWLQHXVHVGHVFULEHGLQWKHDVVRFLDWHG
SXEOLVKHGV\VWHPRIUHFRUGVQRWLFH>86'$236HFXULW\5HFRUGVIRU86'$(PSOR\HHVZKLFKFDQEHIRXQGDW
KWWSVZZZXVGDJRYKRPHSULYDF\SROLF\V\VWHPUHFRUGVQRWLFHV@
'LVFORVXUH'LVFORVLQJWKHLQIRUPDWLRQLVYROXQWDU\+RZHYHULI\RXGRQRWSURYLGHWKHLQIRUPDWLRQUHTXHVWHGZH
FDQQRWSURFHVVWKHUHTXHVWIRUDIILOLDWLRQZLWKRXUDJHQF\

20%&RQWURO1XPEHU0686
([SLUDWLRQ'DWH[[[[[[[[

7KHGDWDFROOHFWHGRQWKLVVKHHWLVXVHGWRLQSXWWKH86'$,)RRGDQG1XWULWLRQAdministrationQRQHPSOR\HH
FRQWUDFWRULQWHUQYROXQWHHUHWF LQIRUPDWLRQLQWR(PSRZ+53HUVRQ0RGHO7KHGDWDFROOHFWHGLVIRUWKH
VSHFLILFSXUSRVHRIVSRQVRUVKLSIRUWKHDJHQF\ V3,9FUHGHQWLDODQGEDFNJURXQGLQYHVWLJDWLRQUHTXLUHGIRU
DFFHVVWRDJHQF\IDFLOLWLHVV\VWHPVDQGLQIRUPDWLRQ:KHQFRPSOHWHGWKLVIRUPFRQWDLQV3HUVRQDOO\
,GHQWLILDEOH,QIRUPDWLRQ6DIHJXDUGDFFRUGLQJWRDJHQF\SROLF\
3XEOLFUHSRUWLQJEXUGHQIRUWKLVFROOHFWLRQRILQIRUPDWLRQLVHVWLPDWHGWRDYHUDJHPLQXWHVSHUUHVSRQVH
LQFOXGLQJWKHWLPHIRUUHYLHZLQJLQVWUXFWLRQVVHDUFKLQJH[LVWLQJGDWDVRXUFHVJDWKHULQJDQGPDLQWDLQLQJWKH
GDWDQHHGHGDQGFRPSOHWLQJDQGUHYLHZLQJWKHFROOHFWLRQRILQIRUPDWLRQ$QDJHQF\PD\QRWFRQGXFWRU
VSRQVRUDQGDSHUVRQLVQRWUHTXLUHGWRUHVSRQGWRDFROOHFWLRQRILQIRUPDWLRQXQOHVVLWGLVSOD\VDFXUUHQWO\
YDOLG20%FRQWUROQXPEHU6HQGFRPPHQWVUHJDUGLQJWKLVEXUGHQHVWLPDWHRUDQ\RWKHUDVSHFWRIWKLV
FROOHFWLRQRILQIRUPDWLRQLQFOXGLQJVXJJHVWLRQVIRUUHGXFLQJWKLVEXUGHQWR86'HSDUWPHQWRI$JULFXOWXUH
)RRGDQG1XWULWLRQAdministration2IILFHRI3ROLF\6XSSRUW%UDGGRFN3ODFHWK)ORRU$OH[DQGULD9$
 $77135$ 0686 'RQRWUHWXUQWKHFRPSOHWHGIRUPWRWKLVDGGUHVV

1RQ(PSOR\HH Information
)XOO/HJDO1$0( /DVW)LUVW0LGGOH6XIIL[

0$/(
)(0$/(

/,1&3$665(48,5('
<(6

+20($''5(66

$3$570(1781,7180%(5

67$7(

&,7<

=,3&2'(

%86,1(66$''5(66

68,7(180%(5

&,7<

67$7(

35,0$5<3+21( $UHDFRGHQXPEHU $/7(51$7(3+21( $UHDFRGHQXPEHU

%,57+'$7( 00''<<<<

$)),/,$7,217<3(

12

=,3&2'(

%86,1(66(0$,/$''5(66

62&,$/6(&85,7<180%(5

&28175<2)&,7,=(16+,3

3/$&(2)%,57+ &LW\VWDWHFRXQWU\LIQRW86$

Contract $JUHHPHQWAssignment and COR 6SRQVRUInformation
&203$1<1$0(

&2175$&7*5$1725$*5((0(17180%(5

&2563216251$0(

&256321625:25.3+21(180%(5

&256321625&(//3+21( $UHDFRGHQXPEHU

3/$11('(;,7'$7(

3RVLWLRQ5LVN'HVLJQDWLRQ 6HHQRWHVEHORZ 
6SRQVRU6LJQDWXUH

3RVLWLRQ5LVN'HVLJQDWLRQ1RWHV

$VUHTXLUHGE\VHFWLRQ E RIWLWOH&RGHRI)HGHUDO5HJXODWLRQV &)5 WKLVV\VWHPLVIRUXQLIRUPDQGFRQVLVWHQWSRVLWLRQGHVLJQDWLRQRIDQ\SRVLWLRQVLQFOXGLQJFRQWUDFWRU
HPSOR\HHSRVLWLRQVZKHQWKHLQYHVWLJDWLRQZLOOEHFRQGXFWHGXQGHUWKH)HGHUDO,QYHVWLJDWLYH6WDQGDUGVSUHVFULEHGE\WKH2IILFHRI3HUVRQQHO0DQDJHPHQWDQGWKH2IILFHRIWKH
'LUHFWRURI1DWLRQDO,QWHOOLJHQFHLQ'HFHPEHU3XUVXDQWWRDQDVVLJQPHQWRIIXQFWLRQVXQGHUVHFWLRQ H RI(2WKH'HFHPEHU)HGHUDO,QYHVWLJDWLYH6WDQGDUGV
DSSO\WRLQYHVWLJDWLRQVIRUFRQWUDFWRUHPSOR\HHILWQHVV
7KH&RQWUDFWLQJ2IILFHU¶V5HSUHVHQWDWLYH &25 ZLOOXVHWKH230$XWRPDWHG3RVLWLRQ'HVLJQDWLRQ7RROWRGHWHUPLQHWKHDSSURSULDWHSRVLWLRQGHVLJQDWLRQUHTXLUHPHQWIRUDOO
FRQWUDFWRUHPSOR\HHSRVLWLRQV,I\RXKDYHDQ\TXHVWLRQVLQXVLQJWKH230$XWRPDWHG3RVLWLRQ'HVLJQDWLRQ7RRORULQGHVLJQDWLQJWKHSRVLWLRQFRQVXOWZLWKWKH)1A+5'3HUVRQQHO
6HFXULW\6SHFLDOLVW7KHWRROFDQEHIRXQGKHUHKWWSVZZZRSPJRYVXLWDELOLW\VXLWDELOLW\H[HFXWLYHDJHQWSRVLWLRQGHVLJQDWLRQWRRO
7KHSRVLWLRQGHVLJQDWLRQV\VWHPFRQVLVWVRIDIRXUVWHSSURFHVVWKDWZLOOJXLGHWKHGHVLJQDWRUWKURXJKDQH[DPLQDWLRQRIWKHSRVLWLRQ¶VGXWLHVDQGUHVSRQVLELOLWLHV7KHFRPSOHWLRQRI
WKLVSURFHVVZLOOUHVXOWLQDILQDOGHVLJQDWLRQIRUWKHSRVLWLRQZKLFKLQWXUQZLOOGHWHUPLQHWKHLQYHVWLJDWLYHUHTXLUHPHQWVIRUWKHFRQWUDFWRUHPSOR\HHSRVLWLRQ

+LJK5LVN7LHUDQG1DWLRQDO6HFXULW\'HVLJQDWHG3RVLWLRQ7LHUDQG7LHU
&RQWUDFWRUV$IILOLDWHV,WLVDQWLFLSDWHGWKDWQRFRQWUDFWRUVZLOOUHTXLUHDKLJKULVNRUQDWLRQDOVHFXULW\LQYHVWLJDWLRQ,IWKHUHPD\EHDQHHGSOHDVHFRQWDFWWKH)1A+5'3HUVRQQHO
6HFXULW\6SHFLDOLVWIRUJXLGDQFH
0RGHUDWH5LVN7LHU
&RQWUDFWRUV$IILOLDWHV7KH7LHULVWKHOHYHORILQYHVWLJDWLRQQHHGHGIRUFRQWUDFWSHUVRQQHOSHUIRUPLQJIRUDSHULRGRIGD\VRUJUHDWHUZLWKUHVSRQVLELOLWLHVVXFKDVGDWDEDVH
DGPLQLVWUDWLRQVRIWZDUHGHYHORSPHQWWHFKQLFDOPDLQWHQDQFH/$1DGPLQLVWUDWLRQRUGXWLHVWKDWLQYROYHVXEVWDQWLDODFFHVVWRVHQVLWLYHLQIRUPDWLRQ7KH7LHUZLOOUHTXLUHUH
LQYHVWLJDWLRQHYHU\ILYH\HDUV
/RZ5LVN7LHU
&RQWUDFWRUV$IILOLDWHV&RQWUDFWRUVSHUIRUPLQJIRUDSHULRGRIGD\VRUJUHDWHUQRWFDWHJRUL]HGLQDQ\RIWKHSUHYLRXVFDWHJRULHVDUHFRQVLGHUHGWRUHTXLUH7LHUEDFNJURXQG
LQYHVWLJDWLRQV7KH7LHULQYHVWLJDWLRQLVWKHPLQLPXPUHTXLUHGLQYHVWLJDWLRQIRUWKHLVVXDQFHRIWKH86'$/LQF3DVV7KH7LHUUHPDLQVLQIRUFHLQGHILQLWHO\EXWUHTXLUHVDQXSGDWHG
ILQJHUSULQWFKHFN 6$& HYHU\ILYH\HDUV
),1*(535,17&+(&. 6$&
&RQWUDFWRUV$IILOLDWHV&RQWUDFWRUVSHUIRUPLQJIRUDSHULRGRIOHVVWKDQGD\VUHTXLUHDILQJHUSULQWFKHFN7KH6$&LVWKHPLQLPXPUHTXLUHGLQYHVWLJDWLRQIRUDQLQWHULPILWQHVV
GHWHUPLQDWLRQDQGIRULVVXDQFHRIWKH/LQF3DVVZKLOHWKHDSSURSULDWH7LHUHGLQYHVWLJDWLRQLVLQSURFHVV

FORM FNA-775 (06/22) Previous Editions Obsolete
Electronic Form Version Designed in AEM 6.4Version

SBU

Non-Employee Data Sheet