Attachment 5- Applicant Organization Survey.pdf

Applicant Organizational Information

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Instructions: The Applicant Organizational Information template 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:

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:

Email Address:

Telephone

Number:

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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:

FINANCIAL AND ACCOUNTING MANAGEMENT

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

2. Does your organization have an automated accounting system? Yes No

2.1: If Yes, respond to the questions below:

2.1a Does the accounting system account for costs by individual projects? Yes No

If No, please explain:

2.1b Can the accounting system generate reports that show costs incurred for individual awards?

Yes No

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If No, please explain:

2.1c Does the accounting system allow for reporting of Cash and In-kind contributions (from non-federal sources) i.e., cost share?

Yes No

If No, please explain:

3. Which of the following best describes your organization’s accounting system? (check the appropriate response)

Manual: Automated:

Combination: Other:

4. How frequently do you post to the general ledger?

(check the appropriate response)

Daily: Weekly:

Monthly: Other:

5. Does your accounting system accurately and completely track receipt and disbursement of funds by each grant and/or funding source?

Yes No

If No, please explain:

6. Does your accounting system provide for recording of actual expenditures for each grant/contract by budget cost categories reflected in the approved budget?

Yes No

If No, please explain:

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

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

Name: Title:

Name: Title:

REPRESENTATION REGARDING TAX LIABILITY OR CRIMINAL CONVICTION

1. Has your organization been convicted of a felony criminal violation under a Federal law within the preceding 24 months?

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2. Does your organization have any unpaid Federal tax liability that has been assessed for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability?

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. Does your organization have written policies and procedures for the business management areas below?

(check the appropriate response)

Personnel Policies and Procedures: Yes No Not Sure

Procurement Policies and Procedures: Yes No Not Sure

Cash Management Policies and Procedures: Yes No Not Sure

Sub-Grant Monitoring and Management: Yes No Not Sure

Property Policies and Procedures: Yes No Not Sure

Travel Policies and Procedures: Yes No Not Sure

Anti-Nepotism Policy Yes No Not Sure

If No (to any above), please explain:

3. Are time and activity records maintained by funding source and project for each employee to account for total level of effort (100%) devoted to each project?

Yes No

If No, please explain:

4. Does your organization have a written budgetary process and controls to prevent incurring obligations in excess of the grant amount for individual cost categories?

Yes No

If No, please explain:

5. Are appropriate duties separated to ensure one individual (i.e., project or financial) is not controlling all aspects of a transaction/process?

Yes No

If No, please explain:

6. 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)

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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:

Not Sure

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

Yes No

If Yes, please explain:

7. 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

7.1 Please provide the information requested below on all awards or funding received in the last five years, 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.

Name of Authorized Representative:

Title: Date: