Attachment 5 - grants-organizational-information-sheet.pdf

ORGANIZATIONAL INFORMATION SHEET

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Instructions: The Applicant Organizational Information Sheet should be filled out in its entirety. Please note that the response “Not Applicable,” or “N/A,” is generally not acceptable. Instead, a sufficient explanation should be provided to explain why an item is not applicable.

GENERAL INFORMATION

1. Organization Name:

2. Assessment Completed By: Title:

3. Type of Organization

(check all that apply)

Non-U.S.

Based:

Non-Profit:

Non-

Governmental:

U.S. Based:

For-Profit:

(Commercial)

Educational

Institution:

Governmental Other:

If Other, please explain:

4. Is your organization incorporated, registered, or licensed as a legal entity: Yes No

If Yes:

Place of Incorporation or Registration (State/County):

Incorporation or Registration Date (MM/DD/YYYY):

If No:

List parent company or organization name and address OR explain status below:

5. Program Director (The person who will oversee the day to day activities of the award):

Program Director Name:

Program Director Title:

Email Address:

Telephone Number:

Address:

6. Financial or Business Official (The person who is responsible for the financial components of the award):

Budget Officer Name:

Budget Officer Title:

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Email Address:

Telephone Number:

Address:

ORGANIZATION STRUCTURE

1. Is your organization governed by Board of Directors? Yes No

If Yes:

Has your Board authorized your organization to enter into this grant/cooperative agreement?

Yes No

If Yes: Provide documentation indicating Board approval.

2. How many employees are employed by your organization?

3. Is your organization registered with Dun and Bradstreet (DUNS) and the System for Award Management (SAM)?

Yes No

If No, please explain:

4. List all individuals authorized to sign award and amendment documents on behalf of your organization:

Name: Title:

Name: Title:

Name: Title:

Name: Title:

FINANCIAL AND ACCOUNTING MANAGEMENT

1. What is the ending date of your organization’s fiscal year (MM/DD/YYYY)?

2. Does your organization have a NICRA (Negotiated Indirect Cost Rate Agreement)? Yes No

3. List all individuals authorized to sign payment requests and financial reporting on behalf of your organization:

Name: Title:

Name: Title:

Name: Title:

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Name: Title:

BUSINESS MANAGEMENT SYSTEMS

1. Does the organization have a working knowledge of the following U.S. Government, Office of Management and Budget (OMB) Requirements? (check the appropriate response)

2 CFR 200 Uniform Administrative Requirements, Costs Principles, and Audit Requirements for Federal Awards:

Yes No Not Sure

2. Has your organization ever undergone an audit? Yes No

If Yes: Give the date of your last audit:

What type of audit was it? (check the appropriate response)

Program-specific Audit – an audit of a Federal award program

Single Audit – an audit that includes both the organization’s financial statements and the Federal Awards to be conducted

If it was another type of audit, please explain:

Has your organization received any adverse findings in any audit in the past three years?

Yes No

If Yes, please explain:

3. Has your organization received grant funds before? Yes No

If Yes:

Did your organization expend $750,000 or more in U.S.

Government funds in the previous year?

Yes No

3.1 Please provide the information requested below on all awards or funding received in the previous year, specifically note if funds are U.S. Government (USG) funds.

Name of Donor Amount Period Place of Implementation

*By signing this application, I certify that the statements herein are true, complete, and accurate to the best of my knowledge.

Signature of Authorized Representative:

Title: Date: