SF SAC Data Collection Form for Single Audits

OMB No. 0348-0057
U.S. DEPT. OF COMM.– Econ. and Stat. Admin.– U.S. CENSUS BUREAU

SF-SAC

FORM
(12-15-2009)

ACTING AS COLLECTING AGENT FOR
OFFICE OF MANAGEMENT AND BUDGET

Data Collection Form for Reporting on

AUDITS OF STATES, LOCAL GOVERNMENTS, AND NON-PROFIT ORGANIZATIONS
for Fiscal Year Ending Dates in 2010, 2011, or 2012
Complete this form, as required by OMB Circular A-133, "Audits of States, Local Governments, and Non-Profit Organizations."

PART I

GENERAL INFORMATION (To be completed by auditee, except for Items 6, 7, and 8)

1. Fiscal period ending date for this submission
Month

Day

/

2. Type of Circular A-133 audit

Year

/

2

1

Yes

2

No

5. AUDITEE INFORMATION
a. Auditee name

Annual
Biennial

3

Other –

Months

d. Data Universal Numbering System (DUNS) Number

c. If Part I, Item 4b = "Yes," complete Part I, Item 4c
on the continuation sheet on Page 4.

_

e. Are multiple DUNS covered in this report?

1

Yes

2

No

f. If Part I, Item 4e = "Yes," complete Part I, Item 4f
on the continuation sheet on Page 4.

6. PRIMARY AUDITOR INFORMATION
(To be completed by auditor)
a. Primary auditor name

b. Primary auditor address (Number and street)

b. Auditee address (Number and street)
City

City

State

ZIP + 4 Code

c. Auditee contact
Name

_

State

ZIP + 4 Code

_

c. Primary auditor contact
Name

Title

Title

–

–

d. Primary auditor contact telephone

d. Auditee contact telephone

PR

) –

e. Auditee contact FAX

(

2

_

b. Are multiple EINs covered in this report?

(

1

EV
O I
N E
LY W

4. Auditee Identification Numbers
a. Primary Employer Identification Number (EIN)

_

3. Audit period covered

Single audit
Program-specific audit

1

)

f. Auditee contact E-mail

g. AUDITEE CERTIFICATION STATEMENT – This is
to certify that, to the best of my knowledge and belief, the
auditee has: (1) engaged an auditor to perform an audit
in accordance with the provisions of OMB Circular A-133
for the period described in Part I, Items 1 and 3; (2) the
auditor has completed such audit and presented a signed
audit report which states that the audit was conducted in
accordance with the provisions of the Circular; and, (3)
the information included in Parts I, II, and III of this
data collection form is accurate and complete. I declare
that the foregoing is true and correct.

Auditee
NOT certification
FOR SUBMISSION

NOT FOR SUBMISSION
NOT FOR SUBMISSION
Name
certifying
official
NOTofFOR
SUBMISSION
NOT FOR SUBMISSION
NOT FOR SUBMISSION
NOT
FOR SUBMISSION
Title
of certifying
official
NOT FOR SUBMISSION
NOT FOR SUBMISSION

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Date
NOT FOR SUBMISSION
NOT FOR SUBMISSION
NOT FOR SUBMISSION
NOT FOR SUBMISSION
NOT FOR SUBMISSION
NOT FOR SUBMISSION
NOT FOR SUBMISSION
NOT FOR SUBMISSION
NOT FOR SUBMISSION

(

)

–

e. Primary auditor contact FAX

(

)

f. Primary auditor contact E-mail

g. AUDITOR STATEMENT – The data elements and information
included in this form are limited to those prescribed by OMB
Circular A-133. The information included in Parts II and III of the
form, except for Part III, Items 7, 8, and 9a-9g, was transferred
from the auditor’s report(s) for the period described in Part I, Items
1 and 3, and is not a substitute for such reports. The auditor
has not performed any auditing procedures since the date of the
auditor’s report(s). A copy of the reporting package required by
OMB Circular A-133, which includes the complete auditor’s
report(s), is available in its entirety from the auditee at the address
provided in Part I of this form. As required by OMB Circular A-133,
the information in Parts II and III of this form was entered in this
form by the auditor based on information included in the reporting
package. The auditor has not performed any additional auditing
procedures in connection with the completion of this form.

7a. Add Secondary auditor information? (Optional)
1
Yes 2
No
b. If "Yes," complete Part I, Item 8 on the continuation
sheet on page 5.

NOT FOR
SUBMISSION
Auditor
certification

NOT FOR SUBMISSION
Date
NOT FOR SUBMISSION NOT FOR SUBMISSION
NOT FOR SUBMISSION NOT FOR SUBMISSION

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PART II

FINANCIAL STATEMENTS (To be completed by auditor)

1. Type of audit report
Mark either:

1

Unqualified opinion

any combination of:

2

Qualified opinion

OR
3

Adverse opinion

4

Disclaimer of opinion

1

Yes

2

No

3. Is a significant deficiency disclosed?

1

Yes

2

No – SKIP to Item 5

4. Is any significant deficiency reported as a material weakness?

1

Yes

2

No

5. Is a material noncompliance disclosed?

1

Yes

2

No

1

Yes

PART III

EV
O I
N E
LY W

2. Is a "going concern" explanatory paragraph included in the audit report?

FEDERAL PROGRAMS (To be completed by auditor)

1. Does the auditor’s report include a statement that the auditee’s financial
statements include departments, agencies, or other organizational units
expending $500,000 or more in Federal awards that have separate A-133
audits which are not included in this audit? (AICPA Audit Guide, Chapter 12)
2. What is the dollar threshold to distinguish Type A and Type B programs?
(OMB Circular A-133 §___ .520(b))

2

No

$

1

Yes

2

No

4. Is a significant deficiency disclosed for any major program? (§ ___ .510(a)(1))

1

Yes

2

No –SKIP to Item 6

5. Is any significant deficiency reported for any major program as a material
weakness? (§ ___ .510(a)(1))

1

Yes

2

No

6. Are any known questioned costs reported? (§ ___ .510(a)(3) or (4))

1

Yes

2

No

7. Were Prior Audit Findings related to direct funding shown in the Summary Schedule of
Prior Audit Findings? (§___.315(b))

1

Yes

2

No

PR

3. Did the auditee qualify as a low-risk auditee? (§___ .530)

8. Indicate which Federal agency(ies) have current year audit findings related to direct funding or prior audit findings shown
in the Summary Schedule of Prior Audit Findings related to direct funding. (Mark (X) all that apply or None)
98
10
23
11
94
12
84
81
66

U.S. Agency for Inter­
national Development
Agriculture
Appalachian Regional
Commission
Commerce
Corporation for National
and Community Service
Defense
Education
Energy
Environmental
Protection Agency

39
93

97

14
03
15
16
17
09

General Services Administration
Health and Human Services
Homeland Security
Housing and Urban
Development
Institute of Museum and
Library Services
Interior
Justice
Labor
Legal Services Corporation

89

05

06

47
07
59

National Aeronautics and
Space Administration
National Archives and
Records Administration
National Endowment for
the Arts
National Endowment for
the Humanities
National Science
Foundation
Office of National Drug
Control Policy
Small Business
Administration

96
19
20
21

64
00

Social Security
Administration
U.S. Department
of State
Transportation
Treasury

Veterans Affairs
None
Other – Specify:

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FEDERAL PROGRAMS – Continued

.

.

.

.

.

.

.

.

.

.

(b)

Extension 2

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

$

Amount
expended

.00

Direct
award

Major program

$

$

$

$

$

$

$

$

$

$

(f)

.00

.00

.00

.00

.00

.00

.00

.00

.00

.00

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

(g)

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

Y
N

If yes, type
Major
of audit
program
report 4
(h)
(i)
(a)

Type(s) of
compliance
requirement(s)5

type of audit report in the adjacent box. If major program is marked "No," leave the type of audit report box blank.

6 N/A

Activities allowed or unallowed
Allowable costs/cost principles
Cash management
Davis – Bacon Act

for NONE

A.
B.
C.
D.
E.
F.
G.
H.

Eligibility
Equipment and real property management
Matching, level of effort, earmarking
Period of availability of Federal funds

costs, fraud, and other items reported under §___ .510(a)) reported for each Federal program.

I. Procurement and suspension
and debarment
J. Program income
K. Real property acquisition and
relocation assistance

L.
M.
N.
O.
P.

Reporting
Subrecipient monitoring
Special tests and provisions
None
Other

5 Enter the letter(s) of all type(s) of compliance requirement(s) that apply to audit findings (i.e., noncompliance, significant deficiency (including material weaknesses), questioned

(b)

Audit finding
reference
number(s)6

10. AUDIT FINDINGS

_

1 See Appendix 1 of instructions for valid Federal Agency two-digit prefixes.
2 Or other identifying number when the Catalog of Federal Domestic Assistance (CFDA) number is not available. (See Instructions)
3 American Recovery and Reinvestment Act of 2009 (ARRA).
4 If major program is marked "Yes," enter only o n e letter (U = Unqualified opinion, Q = Qualified opinion, A = Adverse opinion, D = Disclaimer of opinion) corresponding to the

(e)

Name of Federal
program

PR
EV
ON IE
W
LY

Y
N

Y
N

(d)

(c)

1

A
R
R
A3

Research
and
develop­
ment

TOTAL FEDERAL AWARDS EXPENDED

Federal
Agency
Prefix1
(a)

CFDA Number

9. FEDERAL AWARDS EXPENDED DURING FISCAL YEAR

PART III

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List the multiple DUNS covered in the report.

PR
EV
ON IE
W
LY
_

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_

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f.

Item 5 Continuation Sheet

c. List the multiple Employer Identification Numbers (EINs) covered in this report.

PART I

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GENERAL INFORMATION – Continued

ZIP + 4 Code

)

Title

Title

(

)

(

)

f. Secondary Auditor contact E-mail

f. Secondary Auditor contact E-mail

) –

e. Secondary Auditor contact FAX

) –

e. Secondary Auditor contact FAX

(

d. Secondary Auditor contact telephone

–

d. Secondary Auditor contact telephone

(

Name

–

ZIP + 4 Code

c. Secondary Auditor contact

Name

c. Secondary Auditor contact

State

State

_

_

_

b. Secondary Auditor address (Number and street)

City

ZIP + 4 Code

)

5. a. Secondary Auditor name

City

b. Secondary Auditor address (Number and street)

4. a. Secondary Auditor name

(

(

f. Secondary Auditor contact E-mail

f. Secondary Auditor contact E-mail

) –

e. Secondary Auditor contact FAX

) –

e. Secondary Auditor contact FAX

(

d. Secondary Auditor contact telephone

–

d. Secondary Auditor contact telephone

(

Title

Title

c. Secondary Auditor contact

Name

–

3. a. Secondary Auditor name

_

ZIP + 4 Code

(

)

_

ZIP + 4 Code

(

)

f. Secondary Auditor contact E-mail

e. Secondary Auditor contact FAX

) –

–

d. Secondary Auditor contact telephone

(

Title

Name

c. Secondary Auditor contact

State

City

_

b. Secondary Auditor address (Number and street)

6. a. Secondary Auditor name

f. Secondary Auditor contact E-mail

e. Secondary Auditor contact FAX

) –

–

d. Secondary Auditor contact telephone

(

Title

Name

c. Secondary Auditor contact

State

City

b. Secondary Auditor address (Number and street)

PR
EV
ON IE
W
LY

Name

c. Secondary Auditor contact

State

_

State

b. Secondary Auditor address (Number and street)

City

ZIP + 4 Code

2. a. Secondary Auditor name

City

b. Secondary Auditor address (Number and street)

1. a. Secondary Auditor name

8. Part I, Item 8, Secondary Auditor’s Contact Information. (List the Secondary Auditor’s Contact information)

PART I

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