0348-0057 SF-SAC Data Collection For Single Audit

FORM SF-SAC

10/31/2013

U.S. Dept. of Comm. - Econ and Stat Admin. - U.S. Census Bureau

OMB No.

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 2013, 2014, or 2015

PART I: GENERAL INFORMATION
1. Fiscal Period End Date
__ __ / __ __ /__ __ __ __
MM /

DD /

YYYY

REPORT ID:

2. Type of Circular A-133 audit
Single Audit
Program-specific audit

3. Audit Period Covered
Annual
Biennial
Other- If Other, Number of months:

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

d. Auditee Data Universal Numbering System (DUNS) Number

__ __ - __ __ __ __ __ __ __

b. Are multiple EINS covered in this report?
Yes

If Yes, complete Part I, Item 4c:

__ __ - __ __ __ - __ __ __ __

e. Are multiple DUNS covered in this report?
Yes

Auditee EIN Continuation Sheet
No

If Yes, complete Part I, Item 4f:
Auditee DUNS Continuation Sheet.

No

5. Auditee Information
a. Auditee name

6. Primary Auditor Information
a. Audit Firm/Organization Name

b. Auditee address (Number and street)

b. Audit Firm/Organization EIN
__ __ - __ __ __ __ __ __ __

c. Audit Firm/Organization address
Auditee City

Audit Firm/Organization City

Auditee State

Audit Firm/Organization State

Auditee ZIP Code

Audit Firm/Organization ZIP Code

c. Auditee Contact Name

d. Primary Auditor Contact Name

Auditee Contact Title

Primary Auditor Contact Title

d. Auditee Contact Telephone

e. Primary Auditor Contact Telephone

e. Auditee Contact Fax

f. Primary Auditor Contact FAX

f. Auditee Contact E-mail

g. Primary Auditor Contact E-mail
7. Was a secondary auditor used?
Yes- If Yes, Complete Part I, Item 8 on the
Secondary Auditor Contact Information Sheet
No

VERSION:

Form SF-SAC

REPORT ID:

PART II: FINANCIAL STATEMENTS (To be completed by auditor)
1.Type of audit report
Mark either:
Unmodified Opinion OR ANY COMBINATION OF:

VERSION:

Qualified opinion
Adverse opinion
Disclaimer of opinion

2. Is a "going concern" emphasis-of-matter paragraph included in the audit
report?

Yes

No

3. Is a significant deficiency disclosed?

Yes

No

4. Is a material weakness disclosed?

Yes

No

5. Is a material noncompliance disclosed?

Yes

No

PART III: 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)

Yes

2. What is the dollar threshold to distinguish Type A and Type B programs?
(OMB Circular A-133 § _.520(b))

No

$ _______________________

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

Yes

No

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

Yes

No

5. 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
39
93
97
14
03
15
16

U.S. Agency for International Development
Agriculture
Appalachian Regional Commission
Commerce
Corporation for National and Community Service
Defense
Education
Energy
Environmental Protection Agency
General Services Administration
Health and Human Services
Homeland Security
Housing and Urban Development
Institute of Museum and Library Science
Interior
Justice

17
09
43
89
05
06
47
07
59
96
19
20
21
64
00

Labor
Legal Services Corporation
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
Social Security Administration
U.S. Department of State
Transportation
Treasury
Veterans Affairs
None
OTHER - SPECIFY:

FORM SF-SAC
PART III: FEDERAL PROGRAMS - Continued
6. FEDERAL AWARDS EXPENDED DURING FISCAL YEAR
(a)
(b)

REPORT ID:

Name of Federal program

Amount expended
($)

(e)

(f)

(g)

(h)

CFDA Number

ARRA 3

Direct award

Major program

(Y/N)

(Y/N)

(Y/N)

(Y/N)

(Y/N)

.00

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 - Item 6)

3

American Recovery and Reinvestment Act of 2009 (ARRA).

4

Loan/Loan Guarantee

2

1

$

(j)
MAJOR
PROGRAM

Research & Development

CFDA Extension

Federal Agency Prefix

Row Number

TOTAL FEDERAL AWARDS EXPENDED

(i)

If major program is marked "yes," enter only one letter (U = Unmodified opinion, Q = Qualified opinion, A = Adverse opinion, D = Disclaimer of opinion) corresponding to the type of audit report in the
adjacent box. If major program is marked "No," leave the type of audit report box blank.

(k)

Number of Audit Findings

(d)

If yes, type of audit report on
Major Program 4

(c)

VERSION:

REPORT ID:

(e)

(f)

(i)

Compliance

Internal
Control

Findings2

Findings2

Material Weakness

Significant Deficiency

Other Matters

(k)

Modified Opinion

CFDA Extension

Federal Agency Prefix

Page 3 Row Number

(j)

(Y/N )

(Y/N ) (Y/N ) (Y/N ) (Y/N )

Type(s) of
Compliance
Requirement(s) 1

(YYYY-### )

(h)

(Y/N )

Name of Federal program
Audit Finding
Reference Number

(g)

Questioned Costs

(d)

VERSION:

Other Findings2

FORM SF-SAC
Part III: FEDERAL PROGRAMS - Continued
7. FEDERAL AWARD FINDINGS
(a)
(b)
(c)

These columns are populated automatically from Part III,
Item 6, columns a, b, and c on rows with findings.
For each award with findings, one row is created for each
finding reported on Part III, Item 6k.
This page is not required if no findings are reported on Part
III, Item 6k.

1

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

2

A. Activities Allowed or Unallowed

F. Equipment and real property management

K. Real property acquisition and relocation assistance

B. Allowable costs/cost principles

G. Matching, level of effort, earmarking

L. Reporting

C. Cash management

H. Period of availability of Federal funds

M. Subrecipient monitoring

D. Davis-Bacon Act

I. Procurement and suspension and debarment

N. Special tests and provisions

E. Eligibility

J. Program income

P. Other

There are 9 valid combinations of "Compliance Findings," "Internal Control Findings," and "Other Findings" for each Federal program with findings. (See instructions - Item 7)

FORM SF-SAC
CERTIFICATIONS

REPORT ID:

VERSION:

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.

Auditor Statement
The data elements and information included in this form are limited to
those prescribed by OMB Circular A-133. Except for Part III, Items 4, 5, 6a6h, and, when audit findings are reported, 7a-7c, the information included
in Parts II and III of this form 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.

Auditee Certification

Auditor Certification

(Date of Electronic Signature )
Name of certifying official
Title of certifying official

(Date of Electronic Signature )

FORM SF-SAC
REPORT ID:
PART I, Item 4c. AUDITEE EIN CONTINUATION SHEET
(FROM PART I, ITEM 4b)

VERSION:

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

FORM SF-SAC
REPORT ID:
VERSION:
PART I, Item 4f. AUDITEE DUNS CONTINUATION SHEET
(FROM PART I, ITEM 4e)
List the multiple DUNS covered in this report.

-

-

FORM SF-SAC
Part I, Item 8, SECONDARY AUDITORS' CONTACT INFORMATION

Auditor Firm name
(a)

Auditor EIN
(b)

Auditor address (Number
and street)
(c)

REPORT ID:

City
(d)

State ZIP
(e) (f)

Contact Name
(g)

Title
(h)

Auditor
contact
telephone
(i)

Auditor
contact FAX
(j)

VERSION:

Auditor contact E-mail
(k)