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Approved: OMB No. 1121-0329 OJP award recipient must (U.S. Department of Justice, Office of Justice Prograns)

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U.S. DEPARTMENT OF JUSTICE
OFFICE OF JUSTICE PROGRAMS
Approved: OMB No. 1121-0329
Expires 12/31/2023
Background
Recipients’ financial management systems and internal controls must meet certain requ uding those
set out in the “Part 200 Uniform Requirements” (2.C.F.R. Part 2800).
Including at a minimum, the financial management system of each
OJP award recipient must provide
for the following:
(1)
Identification, in its accounts, of all Federal awards received and expended and the Federal programs under
which they were received. Federal program and Federal award identification must include, as applicable, the
CFDA title and number, Federal award identification number and year, and the name of the Federal agency.
(2) Accurate, current, and complete disclosure of the financial res
ults of each Federal award or program.
(3) Records that identify adequately the source and application of funds for Federally-funded activities. These
records must contain information pertaining to Federal awards, authorizations, obligations, unobligated
balances, assets, expenditures, income, and interest, and be supported by source documentation.
(4) Effective control over, and accountability for, all funds, prop
erty, and other assets. The recipient must
adequately safeguard all assets and assure that they are used s
olely for authorized purposes.
(5) Comparison of expenditures with budget amounts for each Federal award.
(6) Written procedures to document the receipt and disbursement of
Federal funds including procedures to
minimize the time elapsing between the transfer of funds from the United States Treasury and the disbursement
by the OJP recipient.
(7) Written procedures for determining the allowability of costs in accordance with both the terms and conditions of
the Federal award and the cost principles to apply to the Federal award.
(8) Other important requirements related to retention requirements for records, use of open and machine readable
formats in records, and certain Federal rights of access to awa
rd-related records and recipient personnel.
irements, incl
1. Name of Organization and Address:
Organization Name:
Street1:
Street2:
City:
State:
Zip Code:
2. Authorized Representative’s Name and Title:
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Title:
3. Phone:
4.F ax:
5. E mail:
6. Year Established:
7. Employer Identification Number (EIN):
8. Unique Entity Identifier (UEI) Number:
9. a) Is the applicant entity a nonprofit organization (including a nonprofit institution of higher education) as
described in 26 U.S.C. 501(c)(3) and exempt from taxation under 26 U.S.C. 501(a)?
Yes No
If "No" skip to Question 10.
If "Yes", complete Questions 9. b) and 9. c).
Page 1 of 4
U.S. DEPARTMENT OF JUSTICE
OFFICE OF JUSTICE PROGRAMS
Approved: OMB No. 1121-0329
Expires 12/31/2023
AUDIT INFORMATION
the amount of funds available under a Federal award (the total amount of the
award, as well as the amount available in each budget cost category)?
19. Is the applicant entity familiar with the "cost principles" that apply to recent
and future Federal awards, including the general and specific principles set out
in 2 C.F.R. Part 200?
Yes No Not Sure
9. b) Does the applicant nonprofit organization maintain offshore accounts for
the purpose of avoiding paying the tax described in 26 U.S.C. 5
11(a)?
9. c) With respect to the most recent year in which the applicant nonprofit
organization was required to file a tax return, does the applicant nonprofit
organization believe (or assert) that it satisfies the requirements of 26 C.F.R.
53.4958-6 (which relate to the reasonableness of compensation of certain
individuals)?
If "Yes", refer to “Additional Attachments” under “What An Application Should
Include” in the OJP solicitation (or application guidance) unde
r which the
applicant is submitting its application. If the solicitation/guidance describes the
“Disclosure of Process related to Executive Compensation,” the
applicant
nonprofit organization must provide -- as an attachment to its application -- a
disclosure that satisfies the minimum requirements as described by OJP.
For purposes of this questionnaire, an “audit” is conducted by an independent, external auditor using generally
accepted auditing standards (GAAS) or Generally Governmental Au
diting Standards (GAGAS), and results in an
audit report with an opinion.
10. Has the applicant entity undergone any of the following types of audit(s)(Please check all that apply):
“Single Audit” under OMB A-133 or Subpart F of 2 C.F.R.
Part 200
Financial Statement
Audit
Defense Contract Agency Audit (DCAA)
Other Audit & Agency (list type of audit):
None (if none, skip to question 13)
11.
Most Recent Audit Report
Issued:
Within the last
Within the last Over 2 years ago N/A
12 months 2 years
Name of Audit Agency/Firm:
AUDITOR'S OPINION
Unqualified Opinion
Qualified Opinion
Disclaimer, Going Concern
N/A: No audits as
or Adverse Opinions
described above
Enter the number of findings (if none, enter "0":
Enter the dollar amount of questioned costs (if none, enter "$0"):
Were material weaknesses noted in the report or opinion?
Yes
No
13. Which of the following best describes the applicant entity's accounting system:
ACCOUNTING SYSTEM
Manual Automated Combination of manual and automated
14. Does the applicant entity's accounting system have the capability to
Yes No Not Sure
identify the receipt and expenditure of award funds separately for each
Federal award?
15. Does the applicant entity's accounting system have the capability to
Yes No Not Sure
record expenditures for each Federal award by the budget cost categories
shown in the approved budget?
16. Does the applicant entity's accounting system have the capability to
Yes No Not Sure
record cost sharing ("match") separately for each Federal award, and
maintain documentation to support recorded match or cost share?
Yes No
Yes No
12. On the most recent audit, what was the auditor’s opinion?
Page 2 of 4
U.S. DEPARTMENT OF JUSTICE
OFFICE OF JUSTICE PROGRAMS
Approved: OMB No. 1121-0329
Expires 12/31/2023
Page 3 of 4
17. Does the applicant entity's accounting system have the capability to
Yes Not Sure
accurately track employees actual time spent performing work for each federal
award, and to accurately allocate charges for employee salaries and wages
for
each federal award, and maintain records to support the actual
time spent
and
specific allocation of charges associated with each applicant e
mployee?
18. Does the applicant entity’s accounting system include budgetary
controls
Yes
No
Not Sure
to preclude the applicant entity from incurring obligations or costs that exceed
the amount of funds available under a federal award (the total amount of the
award, as well as the amount available in each budget cost cate
gory)?
19. Is applicant entity familiar with
the "cost principles" that apply to recent
No
Not Sure
and future federal
awards, including
the general and specific principles set out
in 2 C.F.R Part 200?
Yes No
PROPERTY STANDARDS AND PROCUREMENT STANDARDS
20. Does the applicant entity’s property management system(s) maintain the
No
Not Sure
following information on property purchased with federal
award funds (1) a
Yes
description of the property; (2) an identification
number; (3) the source of
funding for the property, including the
award number; (4) who holds title; (5)
acquisition date; (6) acquisition
cost; (7) federal share of the acquisition cost;
(8) location and
condition of the property; (9) ultimate disposition information?
21. Does the appl
icant entity maintain written policies and
procedures for
Not Sure
procurement transactions that -- (1) are designed to avoid unnecessary or
duplicative purchases;
(2) provide for analysis of lease versus
purchase
alternatives;
(3)
set out a process for soliciting goods and services, and (4)
include standards of conduct that address conflicts of interest
?
22.
a) Are the applicant entity’s procurement policies and procedures
Yes No Not Sure
designed to ensure that procurements are conducted in a manner that
provides full and open competition to the extent practicable, and to avoid
practices that restrict competition?
22. b) Do the applicant entity's procurement policies and procedure
s require
Yes
No
Not Sure
documentation of the history of a procurement, including the ra
tionale for the
method of procurement, selection of contract type, selection or rejection of
contractors, and basis for the contract price?
23. Does the applicant entity have written policies and procedures designed
Yes No
Not Sure
to prevent the applicant entity from entering into a procurement contract
under a federal award with any entity or individual that is suspended or
debarred from such contracts, including provisions for checking the “Excluded
Parties List” system (www.sam.gov) for suspended or debarred sub-grantees
and contractors, prior to award?
Yes No
TRAVEL POLICY
24. Does the applicant entity:
No
(a) maintain a standard travel policy?
Yes
(b) adhere to the Federal Travel Regulation (FTR)?
Yes
SUBRECIPIENT MANAGEMENT AND MONITORING
No
Yes No Not Sure
N/A - Applicant does not make
25. Does the applicant entity have written policies, procedures, and/or
guidance designed to ensure that any subawards made by the applicant
entity under a federal award -- (1) clearly document applicable federal
requirements, (2) are appropriately monitored by the applicant, and (3)
comply with the requirements in 2 CFR Part 200 (see 2 CFR 200.331)?
subawards under any OJP
awards
Page 4 of 4
U.S. DEPARTMENT OF JUSTICE
OFFICE OF JUSTICE PROGRAMS
Approved: OMB No. 1121-0329
Expires 12/31/2023
26. Is the applicant entity aware of the differences between subawards under
No Not Sure
federal awards and procurement contracts under federal awards, including
the different roles and responsibilities associated with each?
N/A - Applicant does not make
subawards under any OJP
awards
27. Does the applicant entity have written policies and procedures designed
Yes
Not Sure
to prevent the applicant entity from making a subaward under a federal
award
to any entity or individual is suspended or debarred from such
N/A - Applicant does not make
subawards?
subawards under any OJP
awards
Yes No
DESIGNATION AS 'HIGH-RISK' BY OTHER FEDERAL AGENCIES
28. Is the applicant entity designated “high risk” by a federal grant-making
Yes No Not Sure
agency outside of DOJ? (High risk includes any status under which a federal
awarding agency provides additional oversight due to the applicant's past
performance, or other programmatic or financial concerns with the applicant.)
If "Yes", provide the following:
(a) Name(s) of the federal awarding agency:
(b) Date(s) the agency notified the applicant entity of the "high risk" designation:
(c) Contact information for the "high risk" point of contact at the federal agency:
Name:
Phone:
Email:
(d) Reason for "high risk" status, as set out by the federal agency:
CERTIFICATION ON BEHALF OF THE APPLICANT ENTITY
(Must be made by the chief executive, executive director, chief financial officer, designated authorized
representative ("AOR"), or other official with the requisite knowledge and authority)
On behalf of the applicant entity, I certify to the U.S. Department of Justice that the information provided above is
complete and correct to the best of my knowledge. I have the requisite authority and information to make this
certification on behalf of the applicant entity.
Name: Date:
Title:
Executive Director
Chief Financial Officer Chairman
Other:
Phone:
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Completed 13 June 2022

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