03148-0057 SF-SAC Pilot Template

FORM SF-SAC
OMB No.

06/02/2016

U.S. Dept. of Comm. - Econ and Stat Admin. - U.S. Census Bureau

0348-0057: Approval Expires XX/XX/XXXX

ACTING AS COLLECTING AGENT FOR OFFICE OF MANAGEMENT AND BUDGET

Data Collection Form for Reporting on

Audits of States, Local Governments, Indian Tribes, Institutions of Higher Education and Nonprofit Organizations
For Fiscal Periods Beginning on or after December 26, 2014

PART I: GENERAL INFORMATION
1. Fiscal Period End Date
__ __ / __ __ /__ __ __ __
MM /

DD /

YYYY

REPORT ID:

VERSION:

2. Type of Uniform Guidance Audit
Single Audit
Program-specific audit

3. Audit Period Covered
Annual
Biennial
Other- If Other, Number of months:

4. Auditee Identification Numbers
a. Auditee Employer Identification Number (EIN)

d. Auditee Data Universal Numbering System (DUNS) Number

__ __ - __ __ __ __ __ __ __

b. Are multiple EINS covered in this report?
Yes

If Yes, complete Part I, Item 4c:

__ __ - __ __ __ - __ __ __ __

e. Are multiple DUNS covered in this report?
Yes

Auditee EIN Continuation Sheet
No

If Yes, complete Part I, Item 4f:
Auditee DUNS Continuation Sheet.

No

5. Auditee Information
a. Auditee name

6. Primary Auditor Information
a. Audit Firm/Organization Name

b. Auditee address (Number and street)

b. Audit Firm/Organization EIN
__ __ - __ __ __ __ __ __ __

c. Audit Firm/Organization address (Number and street)
Auditee City

Audit Firm/Organization City

Auditee State

Audit Firm/Organization State

Auditee ZIP Code

Audit Firm/Organization ZIP Code

c. Auditee Contact Name

d. Primary Auditor Contact Name

Auditee Contact Title

Primary Auditor Contact Title

d. Auditee Contact Telephone

e. Primary Auditor Contact Telephone

e. Auditee Contact E-mail

f. Primary Auditor Contact E-mail
7. Was a secondary auditor used?
Yes- If Yes, Complete Part I, Item 8 on the
Secondary Auditor Contact Information Sheet
No

FORM SF-SAC

REPORT ID:

VERSION:

Part II: FEDERAL AWARDS

Part III: INFORMATION
FROM THE SCHEDULE OF
FINDINGS AND
QUESTIONED COSTS

1. FEDERAL AWARDS EXPENDED DURING FISCAL YEAR

1. MAJOR PROGRAM
INFORMATION AND AUDIT
FINDINGS

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

CFDA Number

(n)

Used to collect other data used to identify the award which is not a CFDA number (e.g., program year, contract number). This item is optional if Item 1(b) has a valid CFDA Extension.

(c)

4

The system will provide total Federal Awards expended for each Federal program by summing the individual CFDA lines which have the same CFDA number.

5

The system will provide total Federal awards expended for each cluster of programs by summing the individual CFDA lines which have the same Cluster Name. If the program is not part of a cluster, select "N/A", otherwise select the cluster name.

6

Used to collect the loan or loan guarantee (loan) balances outstanding at the end of the audit period for loan programs as identified in Part II, Item 1(i) (2 CFR 200.510(b)(5))

7

If no identifying number was assigned, enter "N/A".

8

If major program is marked "Yes," enter only one letter (U = Unmodified opinion, Q = Qualified opinion, A = Adverse opinion, D = Disclaimer of opinion) corresponding to the type of audit report in the adjacent box. If major program is marked "No," leave the type of audit report box blank.

(Y/N)

Number of Audit Findings

Three digit CFDA extensions listed in the Catalog of Federal Domestic Assistance (CFDA). If the extension is unknown, see instructions.

(b)

If column (a) is "Y", type of audit report on Major
Program 8

See Appendix I of instructions for valid Federal Awarding Agency two-digit prefixes.

2
3

(a)

Major Program

(Y/N)

If column (n) is "Y", Provide
Amount Passed Through

(Y/N)

.00

1

(o)

MAJOR PROGRAM

Federal Award Passed Through to Subrecipients

$

(m)

If column (k) is "N", list identifying number assigned by
the Pass-through Entity, if assigned 7

TOTAL FEDERAL AWARDS EXPENDED

(l)
Federal Award Source
If column (k) is "N", list Name of Pass-through Entity

(Y/N)

(k)

Direct Award

Federal Program
Cluster Total 5
Total 4

If column (i) is "Y", the End of the Audit Period
Outstanding Loan Balance 6

($)

Loan/Loan Guarantee

Amount Expended

Cluster Name

1

Additional Award Identification3

CFDA Three Digit Extension 2

Federal Awarding Agency Prefix

Row Number (Auto-Generated)

Name of Federal Award

(i)
(j)
Loan/Loan
Guarantee

Form SF-SAC
Part II: FEDERAL AWARDS - Continued
2. Notes to the Schedule of Expenditures of Federal Awards (SEFA)
Note 1: Describe the significant accounting policies used in preparing the SEFA (2 CFR 200.510(b)(6)).

Note 2: Did the auditee elect to use the 10% de minimis cost rate (2 CFR 200.414(f))?
Yes, The auditee elected to use the 10% de minimis cost rate as covered in 2 CFR 200.414 Indirect (F&A) cost.
No, The auditee did not elect to use the 10% de minimis cost rate as covered in 2 CFR 200.414 Indirect (F&A)
cost.
Other. Please explain.

Additional Notes
Note 3:
Enter additional notes as needed.

Rep

Form SF-SAC

REPORT ID:

VERSION:

Part III: INFORMATION FROM THE SCHEDULE OF FINDINGS AND QUESTIONED COSTS - Continued
2. FINANCIAL STATEMENTS
a. Financial Statement Information
i. What were the results of the auditor's determination of whether the financial statements of the auditee
were prepared in accordance with generally accepted accounting principles (GAAP):
Select any combination:
Qualified opinion
Unmodified opinion
Adverse opinion
Disclaimer of opinion
If the financial statements of the auditee were prepared in accordance with GAAP, proceed to question b.

Financial statements were not prepared in accordance with GAAP but were prepared
in accordance with a special purpose framework.
ii. What was the special purpose framework? (Select only one)
Cash basis
Tax basis
Regulatory basis
Contractual basis
Other basis
iii. Was the special purpose framework used a basis of accounting
Yes
No
required by state law or tribal law?
iv. What was the auditor's opinion on the special purpose framework? (Select any combination)
Unmodified opinion
Qualified opinion
Adverse opinion
Disclaimer of opinion
b. Is a "going concern" emphasis-of-matter paragraph included in
the auditor's report?

Yes

No

c. Is a significant deficiency in internal control disclosed?

Yes

No

d. Is a material weakness in internal control disclosed?

Yes

No

e. Is a material noncompliance disclosed?

Yes

No

3. FEDERAL PROGRAMS
a. Does the auditor's report include a statement that the auditee's
financial statements include departments, agencies, or other
organizational units expending $750,000 or more in Federal awards
that have separate Uniform Guidance audits which are not included
in this audit? (AICPA Audit Guide)
Yes
b. What is the dollar threshold used to distinguish Type A and Type
B programs? (Uniform Guidance § 200.518(b)(1))
c. Did the auditee qualify as a low-risk auditee?
(Uniform Guidance § 200.520)

No

$ _______________________
Yes

No

d. Indicate which Federal Agency(ies) have prior audit findings shown in the Summary Schedule of Prior Audit
Findings related to direct funding. Mark (X) all that apply or None .
If an agency has been selected (see the full list of agencies in Appendix I of the instructions), it will appear in a
list in this section. For example, if 39. General Services Administration, 99. Miscellaneous, 68. National Gallery
of Art, and 07. Office of National Drug Control Policy are selected, the list will appear in this section as "39, 99,
68, 07".

REPORT ID:

Findings2

Significant Deficiency

Material Weakness

Other Matters

Modified Opinion

Additional Award Identification
(Optional)

CFDA Three Digit Extension

Federal Awarding Agency Prefix

Row Number from Part II, Item 1

(l)

(m)

(n)

If column (m) is "Y", provide Prior
Year Audit Finding Reference
Numbers

Compliance

(k)

Repeat Audit Finding from Prior Year

(j)

Audit Findings2

Type(s) of
Compliance
Requirement(s) 1

(YYYY-### )

(i)

Internal
Control Audit

Name of Federal program

Audit Finding Reference
Number

(h)

Questioned Costs

(g)

VERSION:

Other Audit Findings2

FORM SF-SAC
Part III: INFORMATION FROM THE SCHEDULE OF FINDINGS AND QUESTIONED COSTS - Continued
4. FEDERAL AWARD AUDIT FINDINGS
Schedule of Findings and Questioned Costs
(a)
(b)
(c)
(e)
(f)
(d)

(Y/N ) (Y/N ) (Y/N ) (Y/N ) (Y/N ) (Y/N ) (Y/N )

These columns are populated automatically from Part II, Item 1,
columns a, b, c, and d on rows with findings.
For each award with findings, one row is created for each finding
reported on Part III, Item 1c.
This page cannot be used if no findings are reported on Part III, Item
1c.

1

Enter the letter(s) of all type(s) of compliance requirement(s) that apply to audit findings (i.e., noncompliance, significant deficiency (including material weaknesses,), questioned costs, fraud,
and other items reported under 2 CFR 200.516(a)) reported for each Federal program.

2

A. Activities allowed or unallowed

F. Equipment and real property management

K. Reserved

B. Allowable costs/cost principles

G. Matching, level of effort, earmarking

L. Reporting

C. Cash management

H. Period of performance (or availability) of Federal funds

M. Subrecipient monitoring

D. Reserved

I. Procurement and suspension and debarment

N. Special tests and provisions

E. Eligibility

J. Program income

P. Other

There are 9 valid combinations of "Compliance Audit Findings," "Internal Control Audit Findings," and "Other Audit Findings" for each Federal program with audit findings. (See chart in instructions - Item 4k)

FORM SF-SAC

REPORT ID:

VERSION:

Part IV: CERTIFICATIONS
1. Auditee Certification Statement
This is to certify that, to the best of my knowledge and belief the
following is true and correct. The auditee has:
ensured that the Form SF-SAC and reporting package does not
include protected personally identifiable information (Protected PII) (2
CFR 200.79 and 2 CFR 200.82), or if it does, the Federal Audit
Clearinghouse is authorized to publicly post all information contained in
this Form SF-SAC and the audit report;

2. Auditor Statement
The data elements and information included in this form are limited to
those prescribed by the Uniform Guidance. The information in Part II of
this form is the responsibility of the auditee and is based on information
included in the reporting package required by the Uniform Guidance. The
information included in Part III of this form, except for Part III Item 2(a)(iii),
Item 3(d), and Items 4(a) – (d) (when there are audit findings), was
transferred by the auditor from the auditor's report(s) for the period
described in Part I, Items 1 and 3, and is not a substitute for such reports.
ensured that the Form SF-SAC and reporting package does not
include business identifiable information (BII) as defined below*, or if it The auditor has not performed any auditing procedures since the date of
does, the Federal Audit Clearinghouse is authorized to publicly post all the auditor's report(s) or any additional auditing procedures in connection
with the completion of this form. A copy of the reporting package required
information contained in this Form SF-SAC and the audit report;
by the Uniform Guidance, which includes the complete auditor’s report(s),
is required to be made available by the FAC on the FAC web site. It is also
complied with the requirements of 2 CFR Part 200 Subpart F
available in its entirety from the auditee at the address identified in Part I
specific to the auditee;
prepared the data in this form in accordance with 2 CFR Part 200 of this form and on the FAC web site.
and the accompanying instructions to this form;
included all information required to be reported in this form in its
entirety and such information is accurate and complete;
engaged an auditor to perform an audit in accordance with 2 CFR
Part 200.500 for the period described in Part I, Items 1 and 3;
ensured the auditor has completed such audit and issued the
signed audit report required by 200.515 which states that the audit has
conducted in accordance with the audit requirements of the Uniform
Guidance; and
authorized the FAC to make the Form SF-SAC and reporting
package publicly available on a Web site
*BII consists of information defined in the Freedom of Information Act (FOIA) as “trade secrets and commercial or financial information obtained from a person [that is] privileged or confidential.” (5 U.S.C.552(b)(4)).
This information is exempt from automatic release under the (b)(4) FOIA exemption. “Commercial” is not confined to records that reveal “basic commercial operations” but includes any records or information in which
the submitter has a commercial interest, and can include information submitted by a nonprofit entity.

Auditee Certification

(Date of Electronic Signature )
Name of certifying official
Title of certifying official

Auditor Signature

(Date of Electronic Signature )

FORM SF-SAC

REPORT ID:

VERSION:

Part IV: CERTIFICATIONS
1. Auditee Certification Statement
This is to certify that, to the best of my knowledge and belief the
following is true and correct. The auditee has:
qualified as an Indian Tribe or Tribal Organization (as defined in
the Indian Self-Determination, Education and Assistance Act (ISDEAA),
25 U.S.C 450b(l)) and opts not to authorize the Federal Audit
Clearinghouse to make the reporting package publicly available (tribes
selecting this option must submit the reporting package to passthrough entities as described in 2 CFR 200.512(b)(2));

2. Auditor Statement
The data elements and information included in this form are limited to
those prescribed by the Uniform Guidance. The information in Part II of
this form is the responsibility of the auditee and is based on information
included in the reporting package required by the Uniform Guidance. The
information included in Part III of this form, except for Part III Item 2(a)(iii),
Item 3(d), and Items 4(a) – (d) (when there are audit findings), was
transferred by the auditor from the auditor's report(s) for the period
described in Part I, Items 1 and 3, and is not a substitute for such reports.
The auditor has not performed any auditing procedures since the date of
the auditor's report(s) or any additional auditing procedures in connection
ensured that the Form SF-SAC and reporting package does not
include protected personally identifiable information (Protected PII) (2 with the completion of this form. A copy of the reporting package required
by the Uniform Guidance, which includes the complete auditor’s report(s),
CFR 200.79 and 2 CFR 200.82), or if it does, the Federal Audit
Clearinghouse is authorized to publicly post all information contained in is required to be made available by the FAC on the FAC web site. It is also
available in its entirety from the auditee at the address identified in Part I
the Form SF-SAC;
of this form and on the FAC web site.
ensured that the Form SF-SAC and reporting package does not
include business identifiable information (BII) as defined below*, or if it
does, the Federal Audit Clearinghouse is authorized to publicly post all
information contained in the Form SF-SAC;
complied with the requirements of 2 CFR Part 200 Suppart F
specific to the auditee;
prepared the data in this form in accordance with 2 CFR Part 200
and the accompanying instructions to this form;
included all information required to be reported in this form in its
entirety and such information is accurate and complete;
engaged an auditor to perform an audit in accordance with 2 CFR
Part 200.500 for the period described in Part I, Items 1 and 3;
ensured the auditor has completed such audit and issued the
signed audit report required by 200.515 which states that the audit has
conducted in accordance with the audit requirements of the Uniform
Guidance; and
authorized the FAC to make the Form SF-SAC publicly available
on a Web site
*BII consists of information defined in the Freedom of Information Act (FOIA) as “trade secrets and commercial or financial information obtained from a person [that is] privileged or confidential.” (5 U.S.C.552(b)(4)).
This information is exempt from automatic release under the (b)(4) FOIA exemption. “Commercial” is not confined to records that reveal “basic commercial operations” but includes any records or information in which
the submitter has a commercial interest, and can include information submitted by a nonprofit entity.

Auditee Certification

(Date of Electronic Signature )
Name of certifying official
Title of certifying official

Auditor Signature

(Date of Electronic Signature )

FORM SF-SAC
REPORT ID:
PART I, Item 4c. AUDITEE EIN CONTINUATION SHEET
(FROM PART I, ITEM 4b)

VERSION:

List the multiple Employer Identification Numbers (EINs) covered in this report.

-

REPORT ID:
VERSION:
FORM SF-SAC
PART I, Item 4f. AUDITEE DUNS CONTINUATION SHEET
(FROM PART I, ITEM 4e)
List the multiple DUNS covered in this report.

-

-

FORM SF-SAC
Part I, Item 8, SECONDARY AUDITORS' CONTACT INFORMATION

Auditor Firm name
(a)

Auditor EIN
(b)

Auditor address (Number
and street)
(c)

REPORT ID:

City
(d)

State ZIP
(e) (f)

Contact Name
(g)

Title
(h)

Auditor
contact
telephone
(i)

Auditor
contact FAX
(j)

VERSION:

Auditor contact E-mail
(k)