Appendix E

FY16 21st CCLC

Non-Profit Organization

Financial Management Questionnaire

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:
- -
- -
- -
- -
- -
- -
- -
- -
1. Does your organization have a governing board?
If yes, please list the board members.
Name of Members:	Title:
Name of Members (cont.):	Title (cont.):
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:
3. Please attach a copy of your organization’s articles or charter.
4. Please attach a copy of your organization’s 501(c)(3) Internal Revenue Service forms.
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.):
$
$
$
9. Has your organization filed a federal 990 tax return for the last fiscal/calendar year?
If yes, please attach the return.
If no, explain why the return has not been filed and attach your latest return.
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.
13. Did your organization expend $500,000 or more in federal funds in your last fiscal year?
If yes, please attach your most recent A-133 audit report.
14. Did your organization expend $100,000 or more in state funds in your last fiscal year (if yes, you should have checked ‘yes’ for #10 and have attached an audit report)?
15. Did your organization expend at least $25,000 but not more than $100,000 in state funds in your last fiscal year?
If yes, please attach audited or unaudited entity-wide financial statements.
16. If you answered yes to #13, #14, or #15, did your organization submit the required information to the Georgia Department of Audits and the state agency from which funds were received?
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-122, “Cost Principles for Non-Profits?”
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: