Form 17003 Form 17003 Grant Recipient's Accounting System and Financial Capabi

OMB Control No. 3095-0072
Expiration date: XX/XX/201X

NATIONAL HISTORICAL PUBLICATIONS AND RECORDS COMMISSION – *5$N7R(C,3IE17
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ACCOUNTING SYSTEM AND FINANCIAL CAPABILITY QUESTIONNAIRE
If you are a recipient of a Federal grant, you must have adequate financial controls. Adequate accounting systems should
meet the following criteria:
(1) Accounting records should provide information needed to adequately identify the receipt of funds under each grant
awarded and the expenditure of funds for each grant.
(2) Entries in accounting records should refer to subsidiary records and/or documentation which support the entry and which
can be readily located.
(3) The accounting system should provide accurate and current financial reporting information.
(4) The accounting system should be integrated with an adequate system of internal controls to safeguard the funds and
assets covered, check the accuracy and reliability of accounting data, promote operational efficiency, and encourage
adherence to prescribed management policies.

APPLICANT ORGANIZATIONAL INFORMATION
Name of Organization and Address:

NHPRC Application No:

Authorized Representative’s Name and Title:
Phone:

Ext:

Fax:

Email:

Year Established
(yyyy):

Employer Identification Number (EIN)
(example XX-XXXXXXX):

DUNS Number
(example XXX-XX-XXXX):

Type of Organization:
Approximate Number of Employees:
Full Time (Paid):
Full Time (Volunteer):

Part Time (Paid):
Part Time (Volunteer):
FEDERAL AUDIT DATA

Have you been audited by a Federal agency?:
Yes
No
If yes, please indicate the type:
OMB A-133 Single Audit (required of institutions that received more than $750,000 in 2014 in Federal grants; or
$500,000 in years prior to 2014)
Incurred Cost

Accounting System

Provide url:
Date of Last Federal Audit/Review
(m/d/yyyy):

Timekeeping
Audit Agency/Firm:

If Findings Reports, Explain:

FINANCIAL STATEMENT AUDIT DATA
Date of Last Financial Statement Audit (m/d/yyyy):
Fiscal Period Audited:
Audit Firm:
Provide url:
Auditor’s Opinion on Financial Statement Modified:

Yes

No

If Modified Opinion, State Reason:

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

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OMB Control No. 3095-0072
Expiration date: XX/XX/201X

If you have not had an audit completed in the last two years, please submit a copy of your most recent 990 tax
form. If you do not have a 990 tax form, please explain:

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
Attach a copy of the latest
2. If yes, provide name and address of Agency performing review:
review and any subsequent
correspondence, clearance
documents, etc.
3. Which of the following best describes the accounting system:
Manual
Automated
Combination
4. Does the accounting system identify the receipt and expenditure of program
funds separately for each contract/grant?
5. 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?
6. Does the accounting system provide for the recording of cost sharing for
each project, and ensure that documentation is available to support recorded
cost sharing?

Yes

No

Not Sure

Yes

No

Not Sure

Yes

No

Not Sure

7. Does the accounting/financial system include budgetary controls to preclude
incurring obligations in excess of total funds available for a grant?

Yes

No

Not Sure

8. Does the accounting/financial system include budgetary controls to preclude
incurring obligations in excess of total funds available for a budget cost
category (e.g. Personnel, Travel, etc)?
9. 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?
TIME AND EFFORT REPORTING

Yes

No

Not Sure

Yes

No

Not Sure

Are time distribution records maintained for an employee when his/her effort can
Yes
No
Not Sure
be specifically identified to a particular cost objective?
If yes, attach sample time sheet and/or procedures for allocating salary and wage charges to Federal
awards
FUNDS MANAGEMENT
Is a separate bank account maintained for Federal grant funds?

Yes

No

If a separate bank account is not maintained, can the Federal grant funds and
related expenses be readily identified?

Yes

No

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

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NA FORM 17003 (04-15)

OMB Control No. 3095-0072
Expiration date: XX/XX/201X

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

APPLICANT CERTIFICATION
I certify that the above information is complete and correct to the best of my knowledge.
Signature:
Name:
Title:

Paperwork Reduction Act Public Burden Statement

The information requested on this form is being collected and used to ensure that recipients of grants from the National Archive’s
National Historical Publication and Records Commission have the necessary financial and management controls to manage Federal
funds. We estimate the public burden per response is four hours to read the instructions, gather necessary data, and complete the
information collection. The Paperwork Reduction Act requires us to notify you that a Federal agency may not conduct or sponsor and
you are not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB
control number for this information collection is 3095-0072. Send comments regarding the burden estimate or any other aspect of the
collection of information, including suggestions for reducing this burden, to National Archives and Records Administration (ISSD),
Room 4400, 8601 Adelphi Road, College Park, MD 20740-6001, and to the Office of Management and Budget, Paperwork Reduction
Project (3095-0072), Washington, DC 20503. DO NOT SEND COMPLETED FORMS TO THESE ADDRESSES. Mail these forms to:
NHPRC
Room 114
National Archives and Records Administration
700 Pennsylvania Avenue, NW
Washington, DC 20408-0001
These forms can also be scanned and emailed to: [email protected], or faxed to 202-357-5914.

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

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