Questionnaire_Audit Review template (Per Q&A Addendum Vendor Request).pdf

MARYLAND DEPARTMENT OF AGING

FISCAL ASSESSMENT REPORT -AAA

July 1, _____ - June 30, _____/September 30, ______

MDoA: Annual Financial Assessment FY __- FY__ FY __

Area Agency on Aging (Name)

Print

SECTION I: GENERAL FINANCIAL MANAGEMENT

Accurate, current, and complete disclosure of the financial results of each project or program shall be made in accordance with the financial reporting requirements of the grant or sub grant.

Records identifying adequately the source and application of funds for grant or sub grantee – supported activities shall be maintained.

Effective controls and accountability shall be maintained for all grant or sub grant cash, real and personal property, and other assets.

The actual expenditures and income reported are in conformance for each grant budget and or sub grant for the period and are supported with the appropriate financial records.

The recipient shall establish procedures to minimize time elapsing between the advance of Federal grant or sub-grant funds and their disbursement.

Procedures shall be established for determining the reasonableness, allow ability, and allocation of costs amongst all grant funding.

Accounting records shall be supported by adequate source documentation.

Financial reviews are to be performed at least once every three years, which analyze the fiscal integrity of the grantee with timely and appropriate resolution of findings and recommendations.

Was a certified audit conducted for each of the Fiscal Year(s) of ___, ___, ___ for your agency or nonprofit?

( ) Yes ( ) No Please provide a copy of the audit report and have available for our inspection Single Audit document conducted for your agency.

Were there any audit findings that relate to your agency? If so, which years? __________________ ( ) Yes ( ) No

If yes, did you respond to these findings, and was a copy of the response sent to the Maryland Department of Aging? Please attach a copy of the findings and responses.

Did the auditors suggest any changes to your Financial Management system? ( ) Yes ( ) No If yes, please list all recommendations made by auditors:

Have the changes suggested been implemented? If so, when? ( ) Yes ( ) No Date __________ Please Explain:

When the last financial assessment was conducted in FY __ by the State did you reconcile the issues outstanding? If not, please disclose the end result below. Your financial assessment should be done annually.

Were deficiencies or recommendations noted in the previous financial assessment report corrected?

( ) Yes ( ) No Follow Up:

Did you acknowledge receiving a copy of the assessment report, or a letter? ( ) Yes ( ) No

Are client services provided directly by the AAA? ( ) Yes ( ) No If yes, list services provided directly by AAA:_____________________________________________________

Are client services provided through sub-grant/contracts? ( ) Yes ( ) No If yes, list the services provided through sub-grantee/contracts. For each service, indicate sub-grantee name or contract utilized.

Services Sub-grant/Contract

For each type of service, how many delivery sites are there?

(Include sites managed directly or by sub-grant/contract to another organization).

Is there a current policy and procedures manual including a complete description of the financial management functions of your operations? ( ) Yes ( ) No

Is there an up-to-date organization chart? (Please provide a copy) ( ) Yes ( ) No If you do not have one for each year, please prepare a current up to date organizational chart. Include a copy with this report.

We require a copy of your end of year ledgers for all FY__, FY__, FY__.

Please have this prepared for the review and for the Financial Reviewers file.

The ledger of accounting of costs by grant will need to agree to the summary statement of costs/expenditures that you reported to the State Department of Aging for each of the programs and or grants. A copy of your revenue statement for the same period as it relates to these specific grants will be required. All end of year accruals will need to have final supporting documentation of expense where applicable. Please have all accrual information available at the time of your onsite review.

SECTION II: PROGRAM PLANNING AND BUDGETING

How often are your AAA financial plans developed?

Are measurable organizational objectives set? ( ) Yes ( ) No If so, note below:

How are funding priorities established?

What steps are taken if projected revenues are not sufficient to cover projected expenditures?

Is a cash flow projection made? ( ) Yes ( ) No

*Are your operating budgets compared with actual revenues and expenditures? ( ) Yes ( ) No Does your AAA participate in Single Audit? ( ) Yes ( ) No

Please explain:

*If you answered yes, how often are these comparisons made?

What steps are taken if significant variances occur between budgeted and actual revenues?

SECTION III: FEDERAL FINANCING REQUIREMENTS IN OOA GRANTS

Are receipts and expenditures for each grant accounted for separately? ( ) Yes ( ) No

How much cash is currently on hand?

What were the organization’s sources for matching funds? (FY__, FY__, FY__)

Was the organization able to meet matching requirements for FY __, FY__, FY__ ( ) Yes ( ) No

If not, why not and what steps were taken to be in compliance?

Are any of the matching funds used to support more than one Federal grant? ( ) Yes ( ) No Please list below:

Are Department of Aging funds used as a match for Federal programs other than Title III? ( ) Yes ( ) No

What types of in-kind contributions were received in the past year?

Were donations other than clients’ contributions received in the past year? ( ) Yes ( ) No

FY__, FY__, FY__

Is the use of donated money restricted? ( ) Yes ( ) No

If yes, was an account set up or posted in the general ledger? ( ) Yes ( ) No Describe:

What types of program income are earned?

Please include contributions:

SECTION IV: PROGRAM INCOME (All Programs of your AAA)

How is program income utilized?

Are participants asked to contribute? ( ) Yes ( ) No

What is your average donation for Eating Together across all sites? FY__$__, FY__$__ , FY__ $__

Is anyone denied participation in programs if contributions are not made? ( ) Yes ( ) No Please explain:

Was any property sold in the past year? ( ) Yes ( ) No

If yes, how are the proceeds from the sale to be used and how are they accounted for?

Was interest income earned in the past year? ( ) Yes ( ) No If interest income was generated in the past year, was it recorded in the accounting records? ( ) Yes ( ) No

SECTION V: PROCUREMENT OF SERVICES AND CONTRACT/SUBGRANT MANAGEMENT

What affirmative action steps exist to assure minority and small businesses are sought in procuring services?

Under what conditions are sub-grants used?

Are contracts and sub-grants monitored to compare actual performance with specific contract requirements?

How often do service providers submit performance reports?

Who is responsible for monitoring sub-grants and contracts for your AAA?

Have you reviewed your sub grantees final submission reports for FY __, FY__, FY__ and reconciled to their general ledger? ( ) Yes ( ) No. If you answered no, please immediately coordinate this effort. Please have a copy for our review.

SECTION VI: COST ALLOWABILITY AND ALLOCATION

What procedures are employed to ensure that unallowable costs are not charged to grant?

Is your local agency adhering to the following for both FY__, FY__, FY__?

a) 10% administrative cost - limit for Title 111 ( ) Yes ( ) No

b) 25% administrative match of Title 111- C1 & C2 ( ) Yes ( ) No

c) 10% local match of Title 111- B ( ) Yes ( ) No

d) 30% did you transfer 111-B to 111-C (in excess) ( ) Yes ( ) No

e) 40% did you transfer 111-C1 to 111- C2 (in excess) ( ) Yes ( ) No

f) 25% local match 111-E Allocation ( ) Yes ( ) No

Explain: Local Match - Cash or In kind

What is the agency’s Title IIIB allocation $ _______________

Less Ombudsman Allocation $ _______________

What is the agency’s IIIB allocation for priority service? $ _______________

Is at least:

a) 5% of the IIIB allocation being expended for legal services? ( ) Yes ( ) No

b) 10% of IIIB allocation being expended for in-home ( ) Yes ( ) No

c) 15% of IIIB allocation being expended for access services? ( ) Yes ( ) No

Title IIIB totals for Budgeted Actual %

FY__

a) Legal Services ____________ ____________ ____________

b) Access Service ____________ ____________ ____________

c) In-Home Services ____________ ____________ ____________

Total ____________ ____________ ____________

Total of IIIB expended on ____________ ____________ ____________ Priority services = %

Title IIIB totals for Budgeted Actual %

FY__

a) Legal Services ____________ ____________ ____________

b) Access Service ____________ ____________ ____________

c) In-Home Services ____________ ____________ ____________

Total ____________ ____________ ____________

Total of IIIB expended on ____________ ____________ ____________ Priority services = %

State grants require that you report and separate expense and revenue by cost centers for each grant. Is this your current practice? Do you allocate employee time, travel and all other expenses by grant program objectives and services? ( ) Yes ( ) No Please explain if you answered no

SECTION VII: CASH RECEIPTS

What staff is involved in the collection of participant contributions?

How are cash receipts from contributions documented by the provider and or the AAA?

Who handles cash receipts received in the office?

Does the person who opens the mail prepare a cash receipts listing? ( ) Yes ( ) No

How often are cash receipts recorded?

Are entries in the cash receipts journal classified by fund source? ( ) Yes ( ) No

How often are cash receipts deposited?

Are Eating Together contributions counted on the site of collection and recorded by two individuals?

Are any expenditures taken from daily un-deposited receipts? ( ) Yes ( ) No

Where do you keep cash receipts prior to deposit? Please list: If this is not a standard practice across all sites please explain. What is your policy of collection for site to collect and deposit?

Number of days_________ Please explain the process:

How are checks endorsed to credit the agency or program?

SECTION VIII: PETTY CASH FUND

Does the organization have a petty cash fund? ( ) Yes ( ) No How many locations or programs have a petty cash fund? Please list:

How much is in each petty cash fund?

Who has access to petty cash funds?

Where is the petty cash fund kept?

What types of expenditures were made from the petty cash fund?

Is there a maximum amount allowed for a single petty cash disbursement? ( ) Yes ( ) No

What is that amount if applicable? $_____________

What documentation is required for a petty cash disbursement?

Do petty cash vouchers provide adequate financial support? ( ) Yes ( ) No

How is the petty cash fund replenished and who can sign for replenishment?

List title of position:

SECTION IX: PROPERTY MANAGEMENT

How are properties valued in the accounting records?

How is the funding source of each property item identified?

Does the organization keep property records, including that of fixed assets? ( ) Yes ( ) No

Is there adequate documentation on each property item held by your organization? ( ) Yes ( ) No

How often are physical inventories taken of property and other fixed assets held by the organization?

Do you maintain a fixed asset inventory? ( ) Yes ( ) No

SECTION X: EXPENDITURE / DISBURSEMENTS

How are disbursements made?

What documentation supports disbursements and receipt of goods of services rendered?

How is supporting documentation checked before authorization for payment? (Please describe)

Are checks ever made out to “cash” or “bearer”?

Are blank checks signed in advance?

How are voided checks handled?

What steps are taken to ensure that duplicate payments of invoices are avoided?

Where do you store checks that are not immediately mailed? How about check waiting for pick up?

SECTION XI: PERSONNEL AND FRINGE BENEFITS

Is the person who signs checks different from the person who maintains personnel records (including the payroll journal)? ( ) Yes ( ) No

How many individuals are currently employed by your department or your organization?

Are payroll checks given directly to employees? ( ) Yes ( ) No Do you offer direct deposit to your employees? ( ) Yes ( ) No

Are individual employees’ earnings records maintained? If so, how? ( ) Yes ( ) No

Does the organization have a W-4 on file for each employee? ( ) Yes ( ) No Do you maintain payroll distribution summary for multiple program responsibilities? ( ) Yes ( ) No Do you maintain support time sheets to report multiple program responsivities? ( ) Yes ( ) No Fringe Benefits:

What is your current average fringe benefit for full-time employees? __________% What is your current average fringe benefit for part-time employees? __________% Do you charge fringe based on actual fringe benefits per employee or some other mechanism?

Please explain:

SECTION XII: PURCHASING

How do staff requisition goods or services?

Who reviews and approves requests?

What is the basis for approving requests?

Are purchase orders prepared? ( ) Yes ( ) No

How is the person requesting goods or services informed that a purchase order has been issued?

Are contracts signed by the director and reviewed by legal counsel? ( ) Yes ( ) No Does the director need to seek additional approval to authorize a contract? ( ) Yes ( ) No If so, at what dollar value is required for additional approval. $ Who is the approver?

Please list approver by title of position:

What procedures are followed to determine that goods received match the type of quantity of goods ordered?

How are invoices reviewed before payment?

SECTION XIII: SENIOR CARE

Note: All questions, unless otherwise stated, refer to the year being assessed.

How much Senior Care funds was unspent at the end of the fiscal year (6/30/ ) , (6/30/ ), (6/30/ )

$_________________FY__ $ ________________FY__ $___________________FY__

Was there any particular reason for there being unexpended ( ) Yes ( ) No funds?

Did you return these unspent funds to the Maryland Department ( ) Yes ( ) No of Aging?

Do you anticipate any unspent funds at the end of the year for ( ) Yes ( ) No 6/30/__ & 6/30/__ & 6/30/__

Is your Senior Care program included in any audit performed ( ) Yes ( ) No on your agency, e.g. single audit.

If yes, please include a copy of the single audit for each year to be sent to the Maryland Department of Aging with this report.

Is Senior Care supported by any other Department of Aging ( ) Yes ( ) No programs or funding sources?

If yes, list programs that support your Senior Care program and provide dollar amounts.

Program Dollar Amount

Do you use private vendors to provide in-home services? ( ) Yes ( ) No If yes, list vendors used for each year.

Do you pay your private vendors out of Senior Care and or other grants for Adult Medical Day Care services at the established fiscal year Medicaid rate? ( ) Yes - ( ) No. If you answered no, please explain?

Senior Care gap-filling funds in relation to the Department of Social Services In-Home Aide Service program (IHAS) is performed.

Are you aware of the above statement, and to your knowledge, ( ) Yes ( ) No a check on IHAS is being completed?

You must have supporting documentation for the administrative cost line item for Senior Care. Please remit that information along with this document. Did you charge more than 9% of your actual expenses?

( ) Yes -How much in excess of 9%. $________FY__ $_________FY__ $________FY__ ( ) No Are all care gap-filling services allowable expenses? Please explain how you validate.

Does your Senior Care program maintain a loan closet? ( ) Yes ( ) No

If so, state the value and how much of this equipment was purchased from Senior Care during the last two fiscal years.

Value: FY __ $ _______ FY__ $_________ FY__$_________ List some of the items included in loan closet that were purchased:

Did you use any of your Senior Care gap-filling funds for Case ( ) Yes ( ) No Management or Assessment Services during the last two fiscal years?

If so was this approved by Senior Care- State Department of Aging ( ) Yes ( ) No Staff?

If yes, state total gap filling dollars used for each. (Case Management) FY __- $_______

FY__ $_______

FY__ $_______

(Assessment) FY__$________

FY__$________

FY__$________

How many clients are you currently serving in the current fiscal year? _________________________

Is there a current waiting list for Senior Care? ( ) Yes ( ) No If yes, how many people are on your waiting list?

What type of services are potential clients waiting on?

If no, why are you not maintaining a waiting list?

SECTION XIV: MAP INFORMATION & ASSISTANCE

What is the amount of State funds awarded to MAP - I & A program this current fiscal year?

What was you FY __ Budget _____ FY __ Expenditures ___________

Did you revert funds back for these programs FY __-$_________ FY__-$__________FY-$________

Has your program experienced an increase or decrease in the amount of state funding received? If there has been an increase, specifically how were the additional monies spent? If decrease, how did it impact the program?

How many access sites do you have and has this number increased or decreased since the previous fiscal years?

Explain.

What other funding sources provide support to the MAP / I & A program?

Funding Source FY __ FY__ FY__

State MAP I & A $__________ $_____________ $_____________ Federal FFP Reimbursement $__________ $_____________ $_____________ Level 1 screen (FFP) match _ $__________ $_____________ $____________ NFPE – FFP match $__________ $_____________ $_____________ MFP Transition funding $__________ $_____________ $______________

Currently, how many MAP I & A staff positions are there and what percentage of time is allotted to the program?

Are the positions being funded with state monies/ federal funding? If so, please indicate the amount for each position as it applies.

Provide the units of service numbers projected for clients served?

How many unduplicated persons have you projected to serve in the upcoming fiscal year?

How does this number compare to the actual number from last fiscal year?

What is the percentage of individuals served from the target areas?

How does this figure differ from the previous fiscal year?

SECTION XV: SENIOR GUARDIANSHIP

In FY __ how many unduplicated clients did you serve who were court appointed? ___________ In FY __ how many unduplicated clients did you serve who were court appointed? __________ In FY __ how many unduplicated clients did you serve who were court appointed? __________

How much did you receive State funds for Guardianship in FY__ $______, FY__$____ FY__$______ How did you use state funds (please describe below). Did you have carryover FY __to FY__ $______, FY__ to FY__ $_____, FY__ to FY__ $_______

SECTION XVI: STATE NUTRITION

Are State Nutrition funds expended for meal cost only? ( ) Yes ( ) No Are State Nutrition Funds expended for staffing or Nutrition Education ( ) Yes ( ) No Elaborate on staff or education if you answered yes:

How much is your State Nutrition award for the FY (6/30/__)? $________ How much is your State Nutrition award for the FY (6/30/__)? $________ How much is your State Nutrition award for the FY (6/30/__)? $________

Increase/decrease in dollars over fiscal year __:

FY __ $____________

Increase/decrease in dollars over fiscal year __

FY__ $ _____________

Increase/decrease in dollars over fiscal year __

FY__ $ _____________

How many Nutrition sites do you currently serve?

Have you opened new sites during the FY__,FY__FY__ ( ) Yes ( ) No

If yes, how many; and list new sites by date.

Have you closed any sites during FY __,FY__ or FY__ ( ) Yes ( ) No List sites closed by date and reason why?

Give total C1 meals served with Federal and State funds (FY__): _____ (FY__): ______(FY__): _______

Give total C2 meals served with Federal and State funds. (FY_): ______(FY__): (FY__):_______ How many meals do you plan to serve during the current year? C1&C2 _________________ (FY20)

How many meals were served with State Nutrition funds only _______________________

What is your FY__ meal cost: C1 $__________________ Lunch $__________________ C2 $__________________ Lunch $__________________ Kosher $__________________ Other $__________________

What was your FY__ meal cost:C1 $__________________ Lunch $__________________ :C2 $__________________ Lunch $__________________ Kosher $__________________ Other $__________________

What was your FY__ meal cost:C1 $__________________ Lunch $__________________ :C2 $__________________ Lunch $__________________ Kosher $__________________ Other $__________________

Are donations to the Nutrition Program being accounted ( ) Yes ( ) No for separately from other donations and or program income? ( ) Yes ( ) No Are congregate donations going back into congregate and home delivered going back into home delivered?

( ) Yes ( ) No Is the increase or decrease in meals in accordance with increased funding? Other? ( ) Yes ( ) No Explain:

What is the breakdown percentage between C1 and C2 for Nutrition program funds?

Did you purchase shelf stable meals with your State Nutrition funds? ( ) Yes ( ) No

(FY__, FY__, FY__)

If yes, how much was expended on shelf stable meals?

FY __ $__________________ FY__ $________________FY__ $________________

Have you expanded services to five days of operation in the congregate sites? ( ) Yes ( ) No

If yes, explain:

Have you initiated new Nutrition Sites where there are unmet needs? ( ) Yes ( ) No

If yes, explain:

ADDITIONAL STATE NUTRITION DATA:

POLICY: State general funds for nutrition must be expended only for meals to seniors.

FY__:

CATEGORY OF

MEALS

$ ALLOCATED $ SPENT MEALS

PURCHASED

Congregate meals in existing locations

Congregate meals at new locations

Congregate meals to add more service days

Home delivered meals

TOTAL

FY__

CATEGORY OF

MEALS

$ ALLOCATED $ SPENT MEALS

PURCHASED

FY__

CATEGORY OF

MEALS

$ ALLOCATED $ SPENT MEALS

PURCHASED

Accounting Records shall be supported by adequate source documentation.

Please test for your effective controls and accountability of left over meals, contributions, meals served, site deliveries, and home delivery. Please provide assurance this is being accomplished with a below explanation of the producers being followed and which staff positions.

Describe: Left Over Meals:

Cash / Contribution Management Site Management Home Delivery

Provide all meal contracts for FEDERAL Fiscal Years-FY __, _FY_FY__. Please include home delivered and congregate meal contracts if and where applicable.

FY __

Contract Meal

Price Vendor

Meals Ordered by all Sites

Meals Received by all Sites and homes

Total all Invoices from Caterer

Payment to Caterer

NSIP Funds

FY __

Contract Meal Price

Meals Ordered by all Site

Meals Received by all Sites and home

Total all Invoices from Caterer

Payment

FY __

Contract Meal Price

Meals Ordered by all Site

Meals Received by all Sites and home

Total all Invoices from Caterer

Payment

SECTION XVII: STATE HEALTH INSURANCE ASSISTANCE PROGRAM

Background Information

The goals of the State Health Insurance Counseling Program are:

To develop a formal, coordinated system of health insurance counseling and advocacy.

To educate senior citizens in Medicare and supplemental insurance benefits and coverage.

To provide senior citizens with assistance with claims, understanding of benefits, and the purchase of adequate supplemental coverage.

To address problems senior citizens, encounter in securing, utilizing, and paying for health insurance.

When necessary, to assist senior citizens in appealing Medicare benefits or reimbursement decisions.

To save senior citizens unnecessary out-of-pocket health costs resulting from overlapping insurance coverage, insufficient reimbursement for covered services, and lack of knowledge on how to appeal Medicare coverage determinations.

What is your total FY __ and FY__ and FY__ SHIP budget? (Include match if applicable) What is your total Senior Medicare Patrol –SMP Budget for FY__, FY__, and FY__?

What is your Medicare Improvements for Patients and Providers Act- MIPPA Budget FY, __FY, __and FY __?

Do you keep separate cost centers for all three of these grants? ( ) Yes ( ) No: If you answer no please explain:

Is your match cash or in kind?

Volunteers do you spend SHIP funds on recruiting volunteers? If yes explain below:

Are all unexpended funds returned to the Department of Aging: ( ) Yes ( ) No

If Department of Aging did not fund this program, could you continue ( ) Yes ( ) No the program?

SECTION XVIII: SENIOR ASSISTED LIVING GROUP HOME SUBSIDY

How much is your Senior Assisted Living Group Home Housing award?

$__________________FY __ $__________________ FY__$__________________FY__

How much are you using for administration? FY__ $_________FY__ $__________FY__$________ You must have supporting documentation for the administrative cost line item for S A L G H S. Please remit that information along with this document. Did you charge more than 10% of your actual expenses? ( ) Yes - if so how much in excess of 10%. $________________ No ( )

How many persons are currently receiving subsidies?

How many people were enrolled at the beginning of fiscal year (7/1/__)?

How many persons were enrolled at end of fiscal year (6/30/__)?

Were any subsidies paid in advance for persons in the program: ( ) Yes ( ) No i.e., did you prepay July’s subsidies in June?

If yes, this is not allowable.

Step taken to repay Maryland Department of Aging:

Are provider/resident agreements up to date? ( ) Yes ( ) No

Is evidence of thirty days written notice in the file? ( ) Yes ( ) No

How many clients are currently enrolled?

**To Be Completed by State Department of Aging: __________________ **Files - how many files were selected?

State Department of Aging will complete (Names of persons whose application files were selected for test:

**Were the dates on the application current? - State Department of Aging will complete: ( ) Yes ( ) No

**Income

**Was there evidence of income verification? ( ) Yes ( ) No

If not, list items missing from which files:

Items Missing ** Items Found **

**Property Was there evidence of current value and addresses of the properties owned by applicant or recipient if applicable? ( ) Yes ( ) No

Was there evidence of cash assets owned by applicant or recipient of subsidy? ( ) Yes ( ) No

Was there evidence of monthly medical expenses claimed? ( ) Yes ( ) No

Was the application signed by each client and dated? ( ) Yes ( ) No

SENIOR CENTER OPERATING FUNDS (SCOF)

Did your AAA apply for and receive State funds for the following fiscal years?

FY __ Carryover to FY__ $__________FY__ Carryover to FY__$_____________ FY__ Budget $ ____________ FY __Expenditures $_________ Carryover $________ FY__ Budget $_____________ FY __ Expenditures $_________ Carryover $________ FY__ Budget $_____________ FY __ Expenditures $_________ Carryover $________ Did you SCOF program activities generate any revenue ( ) Yes ( ) No If yes did you report income and how did you utilize the funds?

Did you report a final itemized year end expenditure report as required: ( ) Yes ( ) No Are you aware of the retention period for these records of 3 years ( ) Yes ( ) No

SENIOR CITIZENS ACTIVITIES CENTERS CAPITAL IMPROVEMENT GRANT

Name of Project:

Location/Address of Project:

Capital Funding: Type of Project:

Amount % of Project (Check appropriate spaces)

Applicant: $_________ %______ Acquisition _______ Local Govt. $_________ %______ Construction _______ Federal (specify) $_________ %______ Renovation _______ MDoA $_________ %______ Equipment _______ Other State Agencies $_________ %______ Conversion _______ (Specify) Other Funding (Specify)

TOTAL $________________

Disbursements – Reported from Beginning of Project

ITEM TOTAL COSTS

Architectural Costs:

Design Costs:

Construction Costs:

Capital Equipment Costs:

Other Project Costs:

TOTAL PROJECT COSTS

Board of Public Works Grant Certificate Date (Month/Year): ____________________________

Project Completion Date (Month/Year): ______________________________

If the project is less than 100% complete, when will the project reach 50% complete?

(Month/Year) ______________________ (Month/Year) ______________________

Please provide a copy of your retention records policy for all Triple A funding and program management requirements.

MDoA: Annual Financial Assessment FY__, FY__FY___

This 25-page document was completed by:

Print Name Date

Fiscal Specialist who the Maryland Department of Aging financial review specialists may contact to set up on site visit and who can provide information regarding this document and provide all source documentation requested.

Name –Print Email Office phone #

Signed by AAA- Director ___________________________________________________

Your County or Counties: _______________________________

Date: ___________

By signing above:

This document was prepared for the purpose of providing information to the State Department of Aging for an onsite review as it relates to compliance and accounting record keeping. I attest the information provided to the best of my knowledge is correct.

This document is due back by 4/22/24.

Please send the completed document along with your Single Audit and or Audits for this period (copy) to:

State Department of Aging Attention: Internal Financial Reviewer / Auditor 301 West Preston Street Baltimore, MD. 21201 Or email to: ___________________________ For questions call: 410-767-_ _ _ _