For-Profit Organization

Financial Management Questionnaire

To assist the Georgia Department of Education (GaDOE) in determining whether a for-profit organization is financially capable of administering a grant or performing services under a contact, the information on the following form must be completed.

This form should be filled out annually by for-profit organizations seeking grants or contracts from GaDOE.

I. General Information
Name of Organization:
Data Universal Numbering System (DUNS) Number:
Federal Employment Identification (FEI) Number:
Address (Number and Street/ PO Box):
City/Town:	State:	Zip Code:
Phone #:	- -	Ext:
Fax #:	- -	Email Address:
Name of Officers:	Title:	Phone #:	Email Address:
- -
- -
- -
- -
- -
- -
- -
- -
2. Is your organization aware of any conflicts of interest?
If yes, please note any conflicts of interest.
Name of Employee:	Name of Other Party:	Relationship:	Other Comments:
II. Type of Fund
1. Please indicate if your organization is applying for a grant or contract.
2. Please indicate how your grant or contract will be funded.
III. Financial Information Disclosure:
1. Fiscal Year:	Ending Date:
2. What percent of funds is used for administrative purposes?	%
3. Does your organization have past due debt owed to the state or federal government?
Debt Owed To:	Amount:	Why the Debt is Past Due:
4. Has your organization declared bankruptcy in the last 3 years?
If yes, explain.
5. Does your organization have any ongoing or pending litigation which may have a financial impact?
If yes, state the approximate amount.	$
Describe.
6. Are there any going concern issues?
If yes, explain.
7. Do state and federal funds comprise more than 75% of your organizations total revenue?
8. Has your organization previously received a federal or state grant or contract?
If yes, please list the following for each.
Amount:	Funding Source (federal/state) & Type (grant/contract):	Agency Providing Funds:	Latest Year Receiving Funds:
$
$
$
Amount (cont.):	Funding Source (federal/state) & Type (grant/contract) (cont.):	Agency Providing Funds (cont.):	Latest Year Receiving Funds (cont.):
$
$
$
10. Has your organization been audited (financial or programmatic)?
If yes, please attach the most recent audit completed.
If no, explain.
11. If your organization was audited, were there any findings?
If yes, list the findings.
12. Was corrective action taken to address the findings?
If yes, please attach documentation to show that corrective action was taken.
If no, explain.
IV. Internal Controls
1. Is your organization’s staff sufficient to provide for adequate separation of duties in regards to deposits, payments, reconciliations, supervisory reviews, and preparation of financial statements?
If no, explain.
2. Is your organization’s accounting system able to account for state and federal grants and contracts separately?
If no, explain.
3. Is your organization’s accounting system able to account for costs according to the categories that would be contained in your approved state or federal program budget?
If no, explain.
4. Is your organization’s time distribution system able to account for each employee’s time by project, being distributed to the proper state or federal program?
If no, explain.
5. If your organization receives federal funds, is your organization in compliance with OMB Circular A-87, “Cost Principles for State, Federal, and Indian Tribal Governments?”
6. Does your organization have written procurement policies?
If no, explain.
To the best of my knowledge and belief, I certify that all data in this document is true and correct.
Name of Representative (Please Print):	Title:
Signature:	Date: