Form OJP 7120/1 OJP 7120/1 Accounting System and Financial Capability Questionnaire

Approved: OMB No. 1121-0021

Expires 07/2012

U.S. DEPARTMENT OF JUSTICE OFFICE OF JUSTICE PROGRAMS ACCOUNTING SYSTEM AND FINANCIAL CAPABILITY QUESTIONNAIRE
	SECTION A: PURPOSE

SECTION B: GENERAL

1. If your firm publishes a general information pamphlet setting forth the history, purpose and organizational structure of your business, please provide this office with a copy; otherwise, complete the following items:

a. When was the organization founded/incorporated (month, day, year)	b. Principle officers	Titles
c. Employer Identification Number:
d. Number of Employees Full Time: Part Time:
2. Is the firm affiliated with any other firm: ☐ Yes ☐ No If “yes”, provide details:		3. Total Sales/Revenues in most recent accounting period. (12 months) $

	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.
	Note: If review occurred within the past three years, omit questions 2-9 of this Section and Section D.
2. Which of the following best describes the accounting system: ☐ Manual ☐ Automated ☐ Combination

3. Does the accounting system identify the receipt and expenditure of program funds separately for each contract/grant?	☐ Yes	☐ No	☐ Not Sure
4. Does the accounting system provide for the recording of expenditures for each grant/contract by the component project and budget cost categories shown in the approved budget?	☐ Yes	☐ No	☐ Not Sure
5. Are time distribution records maintained for an employee when his/her effort can be specifically identified to a particular cost objective?	☐ Yes	☐ No	☐ Not Sure
6. If the organization proposes an overhead rate, does the accounting system provide for the segregation of direct and indirect expenses?	☐ Yes	☐ No	☐ Not Sure
7. Does the accounting/financial system include budgetary controls to preclude incurring obligations in excess of: a. Total funds available for a grant? b. Total funds available for a budget cost category (e.g. Personnel, Travel, etc)?	☐ Yes ☐ Yes	☐ No ☐ No	☐ Not Sure ☐ Not Sure
8. Is the firm generally familiar with the existing regulation and guidelines containing the cost principles and procedures for the determination and allowance of costs in connection with Federal contracts/grants?	☐ Yes	☐ No	☐ Not Sure

	SECTION D: FUNDS CONTROL
1. If Federal grant/contract funds are commingled with organization funds, can the Federal grant funds and related costs and expenses be readily identified?		☐ Yes	☐ No	☐ Not Sure

	SECTION E: FINANCIAL STATEMENTS
1. Did an independent certified public accountant (CPA) ever examine the financial statements?		☐ Yes	☐ No
2. If an independent CPA review was performed please provide this office with a copy of their latest report and any management letters issued.		☐ Enclosed	☐ N / A
3. If an independent CPA was engaged to perform a review and no report was issued, please provide details and an explanation below:

	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.

1. Signature	b. Firm Name, Address, and Telephone Number
a. Title

	SECTION H: CPA CERTIFICATION
The purpose of the CPA certification is to assure the Federal agency that the recipient can establish fiscal controls and accounting procedures which assure that Federal and State/local funds available for the conduct of the grant programs and projects are disbursed and accounted for properly. If the audit report requested in Section E 2 above is not enclosed, then completion of this section is required.

1. Signature	b. Firm Name, Address, and Telephone Number
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. OMB APPROVAL, ALONG WITH THE NUMBER, MUST BE DISPLAYED ON THIS INFORMATION COLLECTION. SEND COMMENTS REGARDING THIS BURDEN ESTIMATE OR ANY OTHER ASPECTS OF THIS COLLECTION OF INFORMATION, INCLUDING SUGGESTIONS FOR REDUCING THIS BURDEN, TO OFFICE OF JUSTICE PROGRAMS, OFFICE OF THE CHIEF FINANCIAL OFFICER, 810 - 7^TH STREET, NW, WASHINGTON, DC 20531; AND TO THE PUBLIC USE REPORTS PROJECT, 1121-7120, OFFICE OF INFORMATION AND REGULATORY AFFAIRS, OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

OJP FORM 7120/1 (2/02) (continued on reverse)