CVIP risk assessment.pdf

Exhibit E: Sub-Recipient Risk Assessment Questionnaire In compliance with the U.S. Department of Justice (DOJ) Office of Justice Programs, Bureau of Justice Assistance (“federal grantor”), all sub-recipients must complete this pre-award risk questionnaire before entering into a sub-award agreement with the City of Toledo. This questionnaire—combined with the Cityʼs program staff assessment—will assist the City in determining any conditions/assistance to be included in your sub-award agreement for work under this grant per 2 CFR 200.332. There are no predetermined answers that would automatically disqualify your organization from consideration for an award.

Organization Name:

Type of Organization Requesting Funding:

Organization Unique Entity Identifier

Organization Fiscal Year (Start & End Month):

Date of Form Completion:

Completed By Name & Title: Email Address: Phone #:

Performance History

1. 1. Has your organization received a federal award directly from an awarding agency in the past 5 years? If yes, please list the federal grantor agency name, time period, award amount, audit findings (and corrective actions/completion date(s)), and grant number.

2. In the preceding fiscal year, did your organization receive 80% or more of its annual gross revenue from federal funds? ☐ Yes ☐ No

3. In the preceding fiscal year, did your organization receive $25 million or more of its annual gross revenue from federal funds? ☐ Yes ☐ No

Management Systems & Personnel

1. 1. In the past 5 years, has your organization managed grant funds, loans or other types of financial assistance from any of the following entities?

Federal ☐ Yes ☐ No State ☐ Yes ☐ No Lucas County ☐ Yes ☐ No Private ☐ Yes ☐ No

2. 2. Does your organization have any new or substantially changed management systems (technological or other) in the past 12 months? If yes, please specify what has changed.

☐ Yes ☐ No

New/Changed Systems:

3. 3. Has your organization had changes to the following key staff or positions in the past 12 months? If yes, explain in the comments section.

Governing Body ☐ Yes ☐ No Executive Management ☐ Yes ☐ No Financial Officer ☐ Yes ☐ No Risk Manager ☐ Yes ☐ No Other:

Laura Shaffer Cross-Out

Laura Shaffer Sticky Note Accepted set by Laura Shaffer

Laura Shaffer Sticky Note Accepted set by Laura Shaffer

4. Does your organization have capacity to manage and implement federal regulations, including 2 CFR 200 and specific federal funder regulations? If your organization does have experience using 2 CFR 200, please describe your experience below.

☐ ☐ Yes ☐ No ☐ No and Request Technical Assistance (Listed Below)

Experience with 2 CFR 200 (Describe):

5. Does your organization have current staff with experience in this type of program? ☐ Yes ☐ No

If yes, how many? If no, is there a staffing plan to hire?

6. Is the “total compensation” for your organization’s five highest-paid officers publicly listed or otherwise listed in SAM.gov1. If no, please enter the information for Name and Total Compensation below.

☐ Yes ☐ No

Name. If the number of officers is less than 5, please enter N/A for the respective row 1.

2.

3.

4.

5.

Total Compensation. The total compensation, as defined in 2 CFR part 170.330, earned by the five high-paid officers; if the number of officers is less than 5, please enter 0 for the respective row 1.

2.

3.

4.

5.

7. Is your organization’s system of internal controls reasonable in accordance with the applicable cost principles (including the segregation of duties, handling of cash, contracting procedures, and personnel and travel policies)?

☐ Yes ☐ No ☐ Unsure

“As required by the 2 CFR Part 170, Appendix A award term regarding reporting subaward and executive compensation, recipients must also report the names and total compensation of their five most highly compensated executives and their subrecipients’ executives for the preceding completed fiscal year if

(1) the recipient received 80 percent or more of its annual gross revenues from Federal procurement contracts (and subcontracts) and Federal financial assistance subject to the Transparency Act, as provided by 2 CFR 170.320 (and subawards), and received $25,000,000 or more in annual gross revenues from Federal procurement contracts (and subcontracts) and Federal financial assistance subject to the Transparency Act (and subawards), and (2) if the information is not otherwise public.”

Audit Reports and Findings

1. Has your organization had an audit or monitoring visit in the last 24 months? ☐ Yes ☐ No

If yes, what type of audit or visit? (Please send reports with this form)

2. Are there any unresolved audit or monitoring findings? ☐ Yes ☐ No

If yes, what type and number of finding(s)?

Financial Stability

1. Which of the following best describes your organization’s accounting system?

☐ Manual ☐ Automated ☐ Combo

2. Does your organization have an accounting system in place to segregate expenditures by funding source? ☐ Yes ☐ No

If yes, what type of system?

3. Does your organization maintain central files for grants, loans, or other types of financial assistance? ☐ Yes ☐ No

Comments: Please use this section to provide additional information on the foregoing questions. Be sure to clearly list section and number on which you are providing comment.

Sub-Recipient Risk Assessment Attachments Applicants must submit all attachments as listed below. Any documents requiring signatures must be signed in blue ink.

Attachment #1: 501(C)(3) Non-Profit Organization, Government Entity or Quasi-Government Entity (Not for Profit) Certification Form

• Organization must be a 501(c)(3) and provide a copy of certification documentation; or,

• Organization must provide a copy of Government Entity or Quasi-Government Entity (Not for Profit) certification documentation.

• NOTE: Provide explanation if name on the certificate does not match organization name.

Attachment #2: State of Ohio Tax-Exempt Certification

• Organization must have tax-exempt status and provide a copy of tax-exempt status from the IRS.

• NOTE: Provide explanation if name on the certification does not match organization name.

Attachment #3: Conflict of Interest Certification – Instructions

• Use the Conflict of Interest Certification document provided in this application. See Conflict of Interest Certification Form

Attachment #5: 990 Form – Instructions

• Provide a copy of the organizationʼs 2024 990 Form.

• If you have requested an extension, submit a copy of the request for the extension and provide a copy of your 2023 990 Form.

Attachment #6: Most recent Audited Financial Statement (If available)

• Provide a copy of your most recent Audited Financial Statement.

Attachment #7: 2024 Income and Expense Statement

• Provide a copy of your most recent income and expense statement.

Attachment #8: Proof of Insurance – Instructions

• Provide a copy of all insurance certificates stating the expiration date of each policy.

• Organization must have General Liability and Directors/Officers Liability Insurance.

(Declaration Page needed only).

• NOTE: insurance binders will not be accepted.

Attachment #9: Copy of Most Recent Bylaws – Instructions

• Submit a copy of your organizationʼs most current bylaws; this includes all updates and revisions.

Attachment #11: Board of Directorsʼ Information

• List each member of the organizationʼs current Board of Directors, including:

o Indicate the memberʼs first and last name and titled position on the Board (if applicable) as well as the date the member joined the Board.

THE CITY OF TOLEDO RESERVES THE RIGHT TO VERIFY THE INFORMATION IN

THIS APPLICATION

Attachment #4: Certification and Signature: Instructions

• Complete the form provided in this application.

See Certification and Signature Form

Attachment #10: Certifications Regarding Lobbying; Debarment, Suspension, and Other Responsibility Matters; Drug-Free Workplace Requirements; Coordination with Affected Agencies

• Complete the form provided in this application. See Attached.

Laura Shaffer Cross-Out

Laura Shaffer Cross-Out

Conflict of Interest Certification Form I hereby certify that no part of net earnings and/or interest of this organization shall inure to the benefit of, or be distributable to, its members, founder, directors, officers, contributors, or other private persons.

I further certify that this organization is not controlled, nor receives directions from individuals or entities seeking profit from the organization.

Name and Address of Organization:

Signature of Certifying Official

Print Name and Title

County of Lucas) State of Ohio) ss.

Before me, a Notary Public for the State of Ohio, personally appeared ___________________________, who after being duly sworn, affirmed that the above statement is the truth, to the best of his/her knowledge.

I set my hand this _________ day of ____________________, 20___.

Notary Public, State of Ohio

Certification and Signature Form I certify that to the best of my knowledge and belief, information contained in this application is true and accurate. I also certify that my applicant organization has met the following conditions:

* Is a 501(c)(3) nonprofit agency chartered by the State of ________ for at least two (2) years and has had tax exempt status for at least one (1) year;

* Maintains a detailed financial management system that operates according to Generally Accepted Accounting Principles (“GAAP");

* Has a fund-accounting system, based on a Chart of Accounts with revenue and expense coding;

* Practices nondiscrimination in the provision of assistance and employment;

* Is current with all property and payroll liability taxes;

* The location and provision of services will be within the City of Toledo;

* The applicant agrees to participate in an interview and/or host a site visit if deemed appropriate or warranted;

The applicant acknowledges and understands that the applicant assumes ultimate responsibility for preparing an accurate and complete application that meets all said rules and regulations.

Deliberate misrepresentations of any information provided in the application will result in immediate withdrawal of application consideration and/or termination of any contract(s) entered into with the City of

Toledo, Department of Finance and the Applicant which were based, in part or in whole, upon the misinformation provided by the applicant and will result in repayment of any funds forwarded to the Applicant under that contract(s).

I understand this application does not in any way guarantee the applicant will receive grant funding. The governing body agrees to fully comply with the required assurances, if funds are awarded.

Furthermore, it is understood that any funds provided to the agency shall be recaptured by the City of

Toledo, Department of Finance for failure to complete the activity.

Signature of Executive Director:

Signature of Board President:

Name:

Title: Executive Director

Date:

Name:

Title: Board President

Date:

The Department of Finance reserves the right to verify the information in this application.

Laura Shaffer Cross-Out

certifications (1)