Accounting System & Financial capability Questionnaire

OMB No. 0581-0240

Grant Program Accounting System & Financial Capability Questionnaire

Purpose

Recipients of Federal funds must maintain adequate accounting systems that meet the criteria outlined in 2 CFR §200’s Standards for Financial and Program Management. The responses to this questionnaire are used to assist in the Agricultural Marketing Service’s (AMS) evaluation of your accounting system to ensure the adequate, appropriate, and transparent use of Federal funds. Failure to comply with the criteria outlined in the regulations above may preclude your organization from receiving an award. This form applies to AMS’ competitive grant programs.

Organization Information

Organization Name: Enter the Legal Name of the Organization

Employer Identification Number: Enter Organization’s EIN

Authorized Organization Representative (AOR): Enter the Name of Individual Authorized to Sign this Document

Year the Organization was established: Enter Calendar Year

Number of Employees: Enter Number of Employees

Grant Staff Information

Provide the name of the project staff and number of years that they have been employed by the applicant organization.

Staff Member	Name	Number of Years
AOR
Project Director
Financial Point of Contact

Financial Managment System and Internal Controls

Requirement		Yes	No
Is there a dedicated accountant or finance manager responsible for monitoring organizational funds?		☐	☐
Does your organization have written accounting policies and procedures that meet the requirements associated with 2 CFR §200.302? If yes, provide a copy of or a hyperlink to your organization’s written accounting policies and procedures (e.g., payment procedures and budgeting process).		☐	☐
Hyperlink (if available):
Does your organization have a written account of its internal controls as required by 2 CFR §200.303? If yes, provide a copy of or a hyperlink to your organization’s written internal controls for Federal awards (e.g., segregation of duties).		☐	☐
Hyperlink (if available):

Audit Financial and Reports

Requirement		Yes	No
Does your organization issue annual financial reports and/or plans?		☐	☐
Has your organization been audited within the last 5 fiscal years? If yes, provide a copy of or a hyperlink to the audit report.		☐	☐
Hyperlink (if available):

Additional Information

Additional financial information including expanding on responses in previous sections

Applicant Certification

I certify that the above information is complete and correct to the best of my knowledge.

AOR Signature and Date
Phone:
Email:

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-0240. The time required to complete this information collection is estimated to average 1 hour 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.

USDA’s Nondiscrimination Statement (effective 2015)

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

2. fax: (202) 690-7442; or

3. email: [email protected].

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