Applicant Organization Information

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* 1. Name of Organization/Municipality

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* 2. Unique Entity Identifier (EUI)

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* 3. Commercial and Government Entity (CAGE)

Person completing this form

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* 4. Name - Person Completing this Form

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* 5. Email

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* 6. Title

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* 7. Phone

Signatory - Person the subaward agreement should be sent to for signature

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* 8. Name - Signatory

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* 9. Email

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* 10. Title

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* 11. Phone

Financial representative from organization

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* 12. Name - Financial Representative

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* 13. Email

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* 14. Title

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* 15. Phone

Program representative from organization

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* 16. Name - Program Representative

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* 17. Email

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* 18. Title

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* 19. Phone

Data services representative from organization

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* 20. Name - Data Representative

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* 21. Email

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* 22. Title

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* 23. Phone

Financial Audit Data

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* 24. Date of last financial statement audit (date on audit report):

Leave blank if no audits have been completed to date for Questions 1-3 and skip to question 27 (Accounting and financial management systems)

Date

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* 25. Fiscal period audited: Start

Date

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* 26. Fiscal period audited: End

Date

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* 27. Auditor's opinion:

If other than unqualified, please state the reason under “Additional remarks” later in this form

Provide the most recent:
Audited Financial Statement

Accounting and Financial Management Systems
Answer the following questions about the accounting and financial management systems you currently have in place at your organization. The purpose of collecting this information is to assess if your financial system and controls meet federal requirements set forth in 2 CFR 200.300. If an organization does not have proper controls or systems in place, GreenLatinos will support the organization to come into compliance.

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* 28. Name of accounting software - If QuickBooks, please note if you are using the online or desktop version

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* 29. Does your accounting and financial management system(s) follow generally accepted accounting (GAAP) principles?

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* 30. Please indicate if your organization uses cash basis or accrual basis accounting.

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* 31. Does your accounting system identify the receipt and expenditure of funds separately for each grant?

Provide one of the following reports from your accounting system:
1) Profit and loss report by funder
2) Profit and loss report by program
3) Balance sheet, from the most recently finished fiscal year

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* 32. Does the accounting system provide the recording of expenditures for each grant by budget categories shown in the approved budget (i.e., supplies, travel, personnel, etc.)?

Provide a copy of your chart of accounts.

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* 33. Does your organization have a fraud prevention policy that enables the organization to detect,

investigate, and report any fraudulent activity immediately?

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* 34. Are records (i.e., timesheets) maintained for each employee that specifically identify time charged to a particular grant as well as non-grant funded activities?

Provide a sample of an APPROVED timesheet or a report from your timesheet system. We are seeking timesheets for a pay period, not one single day. Provide as much detail as possible – employee name, hours worked, project worked on, indication of supervisor approval.

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* 35. What timekeeping systems does your organization use?

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* 36. Does the accounting/financial system include budgetary controls to preclude incurring obligations or costs in excess of total funds available for a grant and/or to ensure appropriate spending of awards?

Budgetary controls include internal policies, procedures, and systems used to mitigate elements of financial risk for managing federal funding. Example: requiring two signatures for expenses over a certain dollar amount.

Note: this can be monitored outside the accounting system. For example, using excel to track spend down by grant.

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* 37. Rate the level at which your organization is familiar with the regulations and guidelines in 2 CFR 200 for determining allowance of costs in connection with federal grants?

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* 38. Are duties and responsibilities segregated in your organization (to the extent practicable) so that no one individual has complete authority over a financial transaction?

Provide any written internal control policies.

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* 39. Does your organization have an established current indirect cost rate with the federal government?

Provide a copy of your Negotiated Indirect Cost Rate Agreement (NICRA) issued by your corresponding Federal agency.

Procurement Standards

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* 40. Does your organization maintain 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 for both informal and procurement methods?

Informal Procurement methods include:
-Micro-procurements of $10k or less
-Small Procurements that exceed $10,000 but do not exceed $250,000

Formal Procurement methods include:
-Procurements that exceed $250,000 or a lower threshold that your
organization has established.

Provide us with any written procurement policies.

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* 41. Does your procurement system ensure selections are made on a competitive basis, that includes documented cost analysis where applicable?

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* 42. Does your organization have a property management system that maintains the necessary information regarding any equipment purchased with federal funding as required in the Equipment section of Subpart D of 2 CFR 200?

Equipment is defined as tangible property (including technology systems such as computers) having a useful life of more than one year AND a per unit cost that exceeds $5,000.

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* 43. Does your organization provide controls to insure safeguards against loss, damage or theft of any equipment and supplies?

Supplies are any tangible property other than equipment with a per unit cost of less than $5,000.

Organizational Policies

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* 44. Does your organization have a standard travel policy in place (i.e., policy that dictates your travel approval process, mileage or other reimbursements allowances, etc.)?

Provide us with a copy of this policy.

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* 45. Does your organization have a drug and alcohol policy in place?

Provide us with a copy of this policy.

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* 46. Does your organization have a whistleblower policy?

Provide us with a copy of this policy.

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* 47. Does your organization have a Texting While Driving policy?

Provide us with a copy of this policy.

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* 48. I certify that our organization maintains a non-discrimination policy, based on which we would report and act on any instances of potential discriminatory action on the basis of race, color, religion (creed), gender/sex, gender expression/gender identity, age, national origin, disability, marital status, sexual orientation, military status, ancestry, personal appearance, citizen status, pregnancy, child birth or related medical conditions, family responsibilities, matriculation, genetic information, and political or union affiliation, and etc.

Additional remarks or further explanations, Optional

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* 49. Please indicate the question(s) number you are providing a further explanation for. i.e. #3

Summarized list of requested supporting documents
Upload the following documents to SalesForce via LINK

Naming Documents:
Please add the name of your city to the beginning of documents uploaded separated by an underscore:
Document to upload: “FinancialStatement”
Format to upload: “[CityName]_FinancialStatement”

If any of the written policies being requested are part of a larger financial management handbook, please feel free to supply the entire handbook. We ask that you notate which page each policy is on in the financial management handbook (this can be done by using the comment functionality in the handbook document that you supply).
Note: the #'s are in reference to the Financial Readiness Assessment PDF

#3 Audited financial statements
#7 Profit and loss report by funder
#7 Profit and loss report by program
#7 Balance sheet
#8 Chart of accounts
#10 Timesheet
#14 Internal control policies
#15 Negotiated Indirect Cost Rate Agreement
#16 Procurement policy
#20 Travel policy
#21 Drug and alcohol policy
#22 Whistleblower policy
#23 Texting while driving policy
-Certificate of Insurance

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