Form FS-1500-22 Financial Capability Questionaire

USDA Forest Service OMB 0596-0217

FS-1500-22

FINANCIAL CAPABILITY QUESTIONNAIRE

Fiscal Year:      

Adequate accounting systems should meet the following criteria as outlined in the most current version of the Office of Management and Budget’s (OMB) Circular of Uniform Administrative Requirements, Cost Principles, and Audit Requirements.

(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

1. Name of Organization and Address:

     

     

     

     

2. Authorized Representative’s Name and Title:      

3. Phone:     -     -      ext.      

4. Fax:     -     -     

5. Email:      

6. Year Established:

    

7. Employer Identification Number (EIN):

   -      

8. DUNS Number:

    -    -     

9. Type of Organization:      

10. Approximate Number of Employees:      

Full Time (Paid):      

Full Time (Volunteer):      

Part Time (Paid):      

Part Time (Volunteer):      

Federal AuDIT DATA

11. 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 annually expend over $750,000 in federal funds

Incurred Cost Accounting System Timekeeping

12. Date of Last Federal Audit/Review (m/d/yyyy):      

Audit Agency/Firm:

     

If findings are reported, explain:      

FINANCIAL STATEMENT AUDIT DATA

13. Date of Last Financial Statement Audit:      

Fiscal Period Audited:     

Audit Firm:      

Auditor’s Opinion on Financial Statement:

Unqualified Opinion

Qualified, Disclaimer or Adverse Opinions

If other than unqualified, state reason:      

If you have not had an audit completed in the last two years, please submit a copy of your most recent tax forms (990 for non-profits). If you do not have a current tax form, please explain:      

ACCOUNTING SYSTEM

14. 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

15. If yes, provide name and address of Agency performing review:

     

Attach a copy of the latest review and any subsequent correspondence, clearance documents, etc.

16. Which of the following best describes your accounting system:

Manual Automated Combination

17. Does the accounting system identify the receipt and expenditure of program funds separately for each grant?

Yes No Not Sure

18. Does the accounting system provide for the recording of expenditures for each grant/contract by budget cost categories shown in the approved budget?

Yes No Not Sure

19. Does the accounting system provide for the recording of cost sharing or match for each grant? Can you ensure that documentation is available to support recorded match or cost share?

Yes No Not Sure

20. Are time distribution records maintained for each employee that specifically identify effort charged to a particular grant or cost objective?

Yes No Not Sure

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

Yes No Not Sure

22. Does the accounting/financial system include budgetary controls to preclude incurring obligations or costs in excess of total funds available for a budget cost category (e.g. Personnel, Travel, etc.)?

Yes No Not Sure

23. Is your organization 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 grants?

Yes No Not Sure

FUNDS Management

24. Is a separate bank account maintained for Federal grant funds?

Yes No

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

Yes No

PROPERTY STANDARDS, PROCUREMENT STANDARDS,

AND TRAVEL policies

PROPERTY STANDARDS

26. Does your property management system(s) provide for maintaining: (1) a description of the equipment; (2) an identification number; (3) source of the property, including the award number; (4) where title vests; (5) acquisition date; (6) federal share of property cost; (7) location and condition of the property; (8) acquisition cost; & (9) ultimate disposition information?

Yes No Not Sure

27. Does your property management system(s) provide for a physical inventory and reconciliation of property at least every two years?

Yes No Not Sure

28. Does your property management system(s) provide controls to insure safeguards against loss, damage or theft of the property?

Yes No Not Sure

PROCUREMENT STANDARDS

29. Does your organization maintain written procurement procedures which (1) avoid unnecessary purchases; (2) provide an analysis of lease and purchase alternatives; and (3) provide a process for soliciting goods and services?

Yes No Not Sure

30. Does your procurement system provide for the conduct to ensure selection on a competitive basis and documentation of cost or price analysis for each procurement action?

Yes No Not Sure

31. Does your procurement system include provisions for checking the “Excluded Parties List” system for suspended or debarred sub-grantees and contractors, prior to award? www.sam.gov

Yes No Not Sure

TRAVEL POLICY

32. Does your organization maintain a standard travel policy or, if no policy exists, does your organization adhere to rates and amounts established under 5 U.S.C. 5701–11, (‘‘Travel and Subsistence Expenses; Mileage Allowances’’), and policies under the Federal Acquisition Regulations at 48 CFR 31.205– 46(a)?

Yes No Not Sure

SUBRECIPIENT MANAGEMENT

33. (For Pass-through entities only). Does your organization have controls in place to monitor activities of subrecipients, as necessary, to ensure that Federal awards are used for authorized purposes in compliance with laws, regulations, and the provisions of the award and that performance goals are achieved (A-133.400 d(3)).

Yes No Not Sure

INDIRECT COSTS
34. My organization has an established indirect cost rate	Yes No Not Sure

35. If my organization chooses to charge indirect costs to the Federal award or use indirect costs as a match, you understand that you must prepare an indirect cost rate proposal and submit it to your cognizant Federal agency for approval. Alternatively, you may use a de minimus rate of 10% of modified total direct costs (MTDC).

Yes No Not Sure

STANDARDS FOR FINANCIAL MANAGEMENT SYSTEMS

and APPLICANT CERTIFICATION

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

Signature:

Name:      

Title:      

Burden Statement

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 0596-0217 Response to this collection of information is Mandatory (Title VIII of IIJA). The time required to complete this information collection is estimated to average 1 hours per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s Target Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, DC 20250-9410, or call toll free at (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 522) govern the confidentiality to be provided for information received by the Forest Service.

Page 5 of 5 Revised 11-25-2013