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59 <br />appearing below to report the "Total Compensation" for the five (5) most highly compensated <br />"Executives", in rank order, in your organization. For purposes of this request, the following terms <br />apply as defined in 2 CFR Ch. 1 Part 170 Appendix A: <br />"Executive" is defined as "officers, managing partners, or other employees in management positions". <br />"Total Compensation" is defined as the cash and noncash dollar value earned by the executive during the <br />most recently completed fiscal year and includes the following: <br />i. Salary and bonus. <br />ii. Awards of stock, stock options, and stock appreciation rights. Use the dollar amount <br />recognized for financial statement reporting purposes with respect to the fiscal year in <br />accordance with the Statement of Financial Accounting Standards No. 123 (Revised 2004) <br />(FAS 123R), Shared Based Payments. <br />iii. Earnings for services under non -equity incentive plans. This does not include group life, <br />health, hospitalization or medical reimbursement plans that do not discriminate in favor of <br />executives, and are available generally to all salaried employees. <br />iv. Change in pension value. This is the change in present value of defined benefit and actuarial <br />pension plans. <br />V. Above -market earnings on deferred compensation which is not tax -qualified. <br />vi. Other compensation, if the aggregate value of all such other compensation (e.g. severance, <br />termination payments, value of life insurance paid on behalf of the employee, perquisites or <br />property) for the executive exceeds $10,000. <br />TOTAL COMPENSATION CHART FOR MOST RECENTLY COMPLETED FISCAL YEAR <br />(Date of Fiscal Year Completion <br />Rank <br />(Highest to <br />Lowest) <br />Name <br />(Last, First, MI <br />Title <br />Total Compensation <br />for Most Recently <br />Completed Fiscal Year <br />1 <br />2 <br />3 <br />4 <br />5 <br />THE UNDERSIGNED CERTIFIES THAT ON THE DATE WRITTEN BELOW, THE INFORMATION <br />PROVIDED HEREIN IS ACCURATE. <br />[.y[el►Grr�li�l <br />NAME AND TITLE: <br />DATE: <br />