Form 1122-XXXX Financial Capability Form

Approved: OMB No. XXXX-XXXX

U.S. DEPARTMENT OF JUSTICE OFFICE ON VIOLENCE AGAINST WOMEN (OVW) APPLICANT FINANCIAL CAPABILITY QUESTIONNAIRE
			SECTION A: PURPOSE
Federal agencies are required to review and evaluate the potential risks posed by applicants prior to awarding Federal funds (2 C.F.R. § 200.205). OVW considers a variety of factors and information in completing this risk assessment. OVW’s evaluation may include the following: financial capability and/or stability of the applicant organization; quality of the organization’s management and financial systems; history of past performance; and results of audits and/or reports. Completion of this form is intended to assist OVW in evaluating the financial capability of the applicant organization. This form is to be completed by non-profit organizations applying for OVW programs that have not had a current/active award with OVW or the Office of Justice Programs (OJP) within the last three years.
		SECTION B: ORGANIZATION INFORMATION
NAME OF APPLICANT ORGANIZATION:
NAME AND TITLE OF AUTHORIZED REPRESENTATIVE:
3. YEAR ORGANIZATION WAS FOUNDED/INCORPORATED:				6. PRIMARY ADDRESS OF THE ORGANIZATION:
4. EMPLOYER IDENTIFICATION NUMBER (EIN):
5. DUNS NUMBER:				7. DOES THE ORGANIZATION HAVE A CURRENT ORGANIZATIONAL CHART?  YES  NO (IF YES, PLEASE PROVIDE A COPY)
8. HAS YOUR ORGANIZATION RECEIVED FEDERAL ASSISTANCE FUNDS IN THE LAST 2 YEARS?  YES  NO				9. TOTAL OPERATING BUDGET IN THE PREVIOUS FISCAL YEAR: $
	SECTION C: ACCOUNTING SYSTEM
1. Has any Government Agency rendered an official written opinion concerning the adequacy of the accounting system for the collection, identification and allocation of costs under Federal contracts/grants?  YES  NO
a. If yes, provide name, and address of Agency performing review:					b. Attach a copy of the latest review and any subsequent correspondence, clearance documents, etc.
2. WHICH OF THE FOLLOWING BEST DESCRIBES THE ORGANIZATION’S ACCOUNTING SYSTEM?  MANUAL  AUTOMATED  COMBINATION
3. IS THE ORGANIZATION’S FINANCIAL MANAGEMENT PERFORMED IN-HOUSE (BY EMPLOYED STAFF) OR OUTSOURCED WITH CONTRACTED INDIVIDUALS?  IN-HOUSE  OUTSOURCED/CONTRACTED  COMBINATION
4. DOES THE ORGANIZATION HAVE SUFFICIENT INTERNAL CONTROLS IN PLACE TO ESTABLISH PROPER SEGREGATION OF DUTIES?  YES  NO  NOT SURE
5. DOES THE ORGANIZATION MAINTAIN TIMESHEETS (OR TIME AND ACTIVITY REPORTS) FOR EMPLOYEES THAT TRACK ACTUAL EFFORT BY PROJECT OR COST OBJECTIVE?  YES  NO  NOT SURE

6. DOES THE ORGANIZATION HAVE A CURRENT AND APPROVED INDIRECT COST RATE?  YES  NO  NOT SURE

7. DOES THE ACCOUNTING/FINANCIAL SYSTEM INCLUDE CONTROLS TO PREVENT INCURRING OBLIGATIONS IN EXCESS OF:

a. TOTAL FUNDS AVAILABLE FOR A GRANT?  YES  NO  NOT SURE

b. TOTAL FUNDS AVAILABLE FOR A BUDGET COST CATEGORY (e.g. Personnel, Fringe Benefits, etc)  YES  NO  NOT SURE

8. ARE THE INDIVIDUALS RESPONSIBLE FOR ADMINISTERING GRANT FUNDS FAMILIAR WITH THE CURRENT REGULATIONS AND GUIDELINES ON ADMINISTRATION, COST PRINCIPLES AND AUDIT REQUIREMENTS FOR FEDERAL GRANTS (INCLUDING 2 C.F.R. 200)?

 YES  NO  NOT SURE

		SECTION D: HISTORY OF PERFORMANCE
1. HAS THE ORGANIZATION EVER HAD A FEDERAL AWARD SUSPENDED OR TERMINATED FOR NON-COMPLIANCE?  YES  NO  NOT SURE
	SECTION E: FINANCIAL STATEMENTS
DID THE ORGANIZATION HAVE A FINANCIAL STATEMENT AUDIT IN ITS MOST RECENT FISCAL YEAR?  YES  NO
2. IF THE ORGANIZATION HAD AN AUDIT IN ITS MOST RECENT FISCAL YEAR, IS THE REPORT AVAILABLE PUBLICLY?  YES  NO IF YES, PLEASE PROVIDE LOCATION. EX. FEDERAL AUDIT CLEARINGHOUSE OR WEBSITE. IF NO, PLEASE PROVIDE A COPY.
			SECTION F: ADDITIONAL INFORMATION
1. Use this space for any additional information (indicate section and item numbers if a continuation)
			SECTION G: APPLICANT CERTIFICATION
“I certify that the above information is complete and correct to the best of my knowledge.” (The individual certifying this form should be familiar with the organization’s management and financial systems.)
1. NAME OF THE CERTIFYING OFFICIAL				b. SIGNATURE AND DATE
a. TITLE

PUBLIC REPORTING BURDEN FOR THIS COLLECTION OF INFORMATION IS ESTIMATED TO AVERAGE 4 HOURS (OR 240 MINUTES) PER RESPONSE, INCLUDING THE TIME FOR REVIEWING INSTRUCTIONS, SEARCHING EXISTING DATA SOURCES, GATHERING AND MAINTAINING THE DATA NEEDED, AND COMPLETING AND REVIEWING THE COLLECTION OF INFORMATION. SEND COMMENTS REGARDING THIS BURDEN ESTIMATE OR ANY OTHER ASPECTS OF THIS COLLECTION OF INFORMATION, INCLUDING SUGGESTIONS FOR REDUCING THIS BURDEN, TO ATTORNEY ADVISOR, OFFICE ON VIOLENCE AGAINST WOMEN, 145 N STREET NE, WASHINGTON, DC 20530; AND TO OFFICE OF MANAGEMENT AND BUDGET, OFFICE OF INFORMATION AND REGULATORY AFFAIRS, ATTENTION: DEPARTMENT OF JUSTICE DESK OFFICER, WASHINGTON, DC 20530 OR SENT TO OIRA_SUBMISSIONS@OMB.EOP.GOV.