1122-0030 Applicant Financial Capability Questionnaire

OMB Clearance #1122-0030
Expiration Date: 09/30/2019

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 financi al 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
1.

NAME OF APPLICANT ORGANIZATION:

2.

NAME AND TITLE OF AUTHORIZED REPRESENTATIVE:

3.

YEAR ORGANIZATION WAS FOUNDED/INCORPORATED:

4.

EMPLOYER IDENTIFICATION NUMBER (EIN):

5.

DUNS NUMBER:

8.

HAS YOUR ORGANIZATION RECEIVED FEDERAL ASSISTANCE
FUNDS IN THE LAST 2 YEARS?

6. PRIMARY ADDRESS OF THE ORGANIZATION:

7. DOES THE ORGANIZATION HAVE A CURRENT ORGANIZATIONAL CHART?



 YES  NO (IF YES, PLEASE PROVIDE A COPY)

9.

TOTAL OPERATING BUDGET IN THE PREVIOUS FISCAL YEAR:
$

 YES  NO
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

 YES

6. DOES THE ORGANIZATION HAVE A CURRENT AND APPROVED INDIRECT COST RATE?

 NO

 NOT SURE

7. DOES THE ACCOUNTING/FINANCIAL SYSTEM INCLUDE CONTROLS TO PREVENT INCURRING OBLIGATIO NS 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
1. DID THE ORGANIZATION HAVE A FINANCIAL STATEMENT AUDIT IN ITS MOST RECENT FISCAL YEAR?

 YES

2. IF THE ORGANIZATION HAD AN AUDIT IN ITS MOST RECENT FISCAL YEAR, IS THE REPORT AVAILABLE PUBLICLY?
IF YES, PLEASE PROVIDE LOCATION. EX. FEDERAL AUDIT CLEARINGHOUSE OR WEBSITE.

 NO

 YES

 NO

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

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unless it displays a currently valid OMB control number. We try to create forms that are accurate, can be easily understood, and which impose the least possible
burden on you to provide us with information. The estimated average time to complete and file this form is 4 hours per form. If you have comments regarding the
accuracy of this estimate, or suggestions for making this form simpler, you can write to the Office on Violence Against Women, U.S. Department of Justice, 145 N
Street, NE, 10th Floor, Washington, DC 20530.