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FMCSA Administrative Capability Questionnaire (Self Certification Form) For State and Local Governments and Non-Profit Organizations
OVERVIEW
States, local governments, and non-profit organizations that receive Federal Motor Carrier Safety Administration (FMCSA) financial assistance funds are subject to the administrative and financial standards set forth in the relevant Code of Federal Regulation (CFR) sections and Office of Management and Budget (OMB) Circulars. The CFR sections and OMB Circulars that apply specifically to State, local government, and non-profit organization recipients of Federal grant funds are:
· 2 CFR 215, “Uniform Administrative Requirements for Grants and Cooperative Agreement with Institutions of Higher Education, Hospitals, and Other Non-Profit Organizations (OMB A-110)”
· 2 CFR 220, “Cost Principles for Educational Institutions (OMB A-21)”
· 2 CFR 225, “Cost Principles for State, Local, and Indian Tribal Governments (OMB A-87)”
· 2 CFR 230, “Cost Principles for Non-Profit Organizations (OMB A-122)”
· 49 CFR Part 18, “Transportation – Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments (OMB Circular A-102 codified at 49 CFR Part 18)”
· OMB Circular A-133, “Audits of States, Local Government, and Non-Profit Organizations”
PURPOSE
The purpose of this questionnaire is to provide States, local governments, and non-profit organizations seeking FMCSA grant funds with a tool to assess their ability to successfully manage Federal grant funds against administrative and financial standards. If an organization’s policies and procedures do not fully comply with the requirements in the questionnaire, then the organization may need revised or new policies in order to comply with Federal financial management standards.
SUBMISSION INSTRUCTIONS
Complete and sign the questionnaire and include it as part of the organization’s application for FMCSA grant funds. If your organization experiences challenges pertaining to submitting your Self Certification Form, it is recommended that your organization provide a hard copy to the Division Office who will deliver the Form to the Program Manager via email.
PART I – Contact Information
| 1. |
| Legal name of your organization associated with the Dun and Bradstreet Data Universal Numbering System (DUNS) Number |
| 3. |
| Address associated with your DUNS Number |
| 4. |
| Employer Identification Number (EIN) |
| 5. |
| Congressional District |
| 6. |
| Organization Phone Number |
| 7. |
| If applicable, please list any affiliated organizations that may influence actions related to the grant |
| 8. |
| Name of the primary application point of contact (POC) for the grant(s) |
PART II – General Information and Assurances
| 1. |
| Is your organization in compliance with applicable Anti-Lobbying Policies included in Lobbying Form GG and, if applicable, the SF-LLL Disclosure of Lobbying Activities? |
| 2. |
| Have any key personnel listed in the application for your organization been debarred or suspended from participation in Federal assistance programs? |
| 3. |
| Does your organization have any findings related to violations of the Civil Rights Act, Age Discrimination Act, Americans with Disabilities Act, and other civil rights laws? |
| 4. |
| Does your organization maintain a Drug-Free Workplace per the FMCSA Financial Assistance Agreement General Provisions and Assurances? |
PART III – Audit History
| 1. |
| Is your accounting system accrual based or cash based? |
| 2. |
| Is your accounting system manual, automated, or a combination? |
| 3. |
| Has an audit been performed on the organization’s financial statement? |
| 4. |
| What was the audit opinion? |
| 5. |
| If your organization has expended more than $500,000 in Federal grant funds within the last year, has OMB A-133 Audit been performed? |
| 6. |
| If yes, were there any major findings? |
| 7. |
| In no, please explain why an audit was not performed. |
| 8. |
| If your organization was subject to any other audits in the last two years (e.g., Office of Inspector General (OIG), Programmatic, State) please describe whether or not there were audit findings. |
PART IV – Administrative Capability
| Instructions: Check the appropriate box to the right for each item. If your organization meets the requirement, check the box in the “Yes” column. If your organization does not meet the requirement described, check the box in the “No/Explain” column. If applicable, provide explanations in the “No/Explain” column or in an attachment. |
| Yes |
| No/Explain |
Financial Management
| 1. |
| Does your organization provide procedures for determining the reasonableness, allocability and allowability of costs in accordance with the applicable cost principles? |
| 2. |
| Does your organization provide for effective control and accountability for all grant cash, real and personal property, and other assets? (49 CFR 18.20(b)(3))? |
| 3. |
| Does your organization provide accurate, current, and complete disclosure of the financial results of the financially assisted activities required by the financial reporting requirements of the grant? (49 CFR 18.20(b)(1))? |
| 4. |
| Does your organization permit preparation of reports required by the applicable statutes and regulations? (49 CFR 18.20(a)(1))? |
| 5. |
| Does your organization permit the documentation of funds to a level of expenditure adequate to establish that funds have not been expended in violation of applicable statutes (49 CFR 18.20(a)(2))? |
| 6. |
| Does your organization contain information pertaining to grant awards and authorizations, obligations, unobligated balances, assets, liabilities, expenditures, and income sufficient to identify the source and application of funds provided for financially-assisted activities? (49 CFR 18.20(b)(2))? |
| 7. |
| Does your organization have an approved indirect cost rate with the Federal Government that covers the entire proposed period of performance for the grant application? |
Procurement Standards
| 1. |
| When procuring property, including equipment and services under grants, does your organization’s contract administration system thoroughly document and inventory all equipment purchased with grant funds? (49 CFR 18.32(d)(1)) |
| 2. |
| Does your organization provide controls to ensure safeguards against loss, damage, or theft of the property? (49 CFR 18.32(d)(3))? |
| 3. |
| Does your organization provide adequate maintenance of the property? (49 CFR 18.32(d)(4))? |
| 4. |
| Does your organization follow 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 that maximizes competition to obtain good value? (49 CFR 18.32(d)(5))? |
| 5. |
| Does your organization define equipment as property that is non-expendable, tangible personal property having a useful life of more than one year and is an acquisition cost valued at $5,000 or the lesser of the capitalization level established by the State or local government? (2 CFR 225 Appendix B, 15.a.(2) and 2 CFR 230, Section 15.a.(2))? |
Personnel
| 1. |
| Does your organization maintain written standards of conduct governing the performance of employees engaged in the award and administration of contracts (e.g., conflict of interest forms)? (49 CFR 18.36(b)(3))? |
| 2. |
| Does your organization maintain a personnel system which provides for the submission of personnel activity reports on the activities of each employee whose compensation is charged to an assistance agreement? |
(2 CFR 225 Appendix B, 8.h.(5) and 2 CFR 230 Appendix B, Section 8.m.)
| 3. |
| Are your organization’s fringe benefits applied reasonably and consistently to all grants and identified by individual employee or allotted by a fringe benefit rate? |
Sub-Award System
| 1. |
| Does your organization’s sub-award administration system meet Federal requirements? (OMB Circular A-133, Subpart D§__.400(d); 49 CFR Part 18) |
| 2. |
| Does your organization maintain written procedures outlining sub-grantee responsibilities and include: |
1) clauses required by Federal statute and EO’s and their implementing regulations, and; 2) a provision for compliance with 49 CFR Part 18.42 in the sub-grantee agreement?
PART V - CERTIFICATION AND SUBMISSION
CERTIFICATION OF APPLICANT’S AUTHORIZED REPRESENTATIVE (REQUIRED):
I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete. I acknowledge that any knowingly false or misleading statement may be punishable by fine or imprisonment or both under applicable law.
Name_____________________________________________________
Title______________________________________________________
Signature__________________________________________________
Date______________________________________________________
Department of Transportation