THE STATE OF WYOMING



SUBRECIPIENT INFORMATION FORMAny organization planning to enter into a collaborative sub-recipient relationship with Wyoming Department of Workforce Services (DWS) must complete this form at the proposal stage. The form must be signed by an authorized representative. This is not a subcontract – completing this form does not authorize spending on this grant. Please answer the following questions to determine if a formal sub-recipient partnership can be established between your organization and DWS. This form will be considered valid for one year from the date of signature by your organization’s authorized official. Please answer the following questions BEFORE completing the rest of the form.YesNoIs your organization presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in any Federal Department or Agency?YesNoIs your organization delinquent on repayment of any Federal debt including direct and guaranteed loans and other debt as defined in OMB Uniform Guidance?If you answered ‘Yes’ to either of the above questions it will not be possible to establish a sub-agreement with your organization and you need not complete the remaining sections of this form. Please notify the DWS program manager as soon as possible.ENTITY INFORMATIONEntity Name: Fiscal Year Ending:(MM/DD/YYYY) ____/____/____Street Address:EIN #: FORMTEXT ?????DUNS #: FORMTEXT ?????SAM #:City:State:Zip:Contact Name:Title:Phone:Fax:Email:Uniform Guidance Single Audit (Subpart F) (please check the box to the right of the ‘Yes’ or ‘No’ as it applies)Does sub-recipient receive $750,000 or more in federal funds?YesNoIf Sub-recipient receives $750,000 or more in federal funds, was the Uniform Guidance Single Audit? If no, please answer the questions below and provide an explanation in the comment section below if needed.YesNoMy organization is a non-profit that expended less than $750,000 in U.S. Federal funds during our previous fiscal year.YesNoMy organization is a foreign entity.YesNoMy organization is a for-profit entity.YesNoMy organization is a U.S. Government entity.YesNoIf a Single Audit was conducted, were there any findings or exceptions noted? If yes, please attach pages outlining audit findings and explain resolution action in comment section below.YesNoGENERAL INFORMATIONDoes your entity have written personnel policies to address the following topics per 2 CFR 200? YES NOHiring FORMCHECKBOX FORMCHECKBOX Compensation FORMCHECKBOX FORMCHECKBOX Leave FORMCHECKBOX FORMCHECKBOX Performance Management FORMCHECKBOX FORMCHECKBOX Separation FORMCHECKBOX FORMCHECKBOX Conflict of Interest FORMCHECKBOX FORMCHECKBOX How frequently are those policies updated? FORMTEXT ?????Is your entity aware of the requirements of 2 CFR 200? FORMCHECKBOX YES FORMCHECKBOX NODoes your entity have an independent CPA or Accountant? FORMCHECKBOX YES FORMCHECKBOX NOPer 2 CFR 200.113, have you or your entity had any violations of Federal criminal law involving the following violations potentially affecting the Federal award? YES NOFraud FORMCHECKBOX FORMCHECKBOX Bribery FORMCHECKBOX FORMCHECKBOX Gratuity FORMCHECKBOX FORMCHECKBOX If “Yes”, please disclose the information below:Type of Entity: FORMCHECKBOX City FORMCHECKBOX County FORMCHECKBOX Non-Profit FORMCHECKBOX For-Profit FORMCHECKBOX Other FORMTEXT ?????GENERAL ACCOUNTING INFORMATIONDoes your entity have written accounting policies to address the following topics per 2 CFR 200? YES NOAccounting System FORMCHECKBOX FORMCHECKBOX Billing FORMCHECKBOX FORMCHECKBOX Cost Allowability FORMCHECKBOX FORMCHECKBOX Recording Time Worked/ Timesheet FORMCHECKBOX FORMCHECKBOX Leave Time FORMCHECKBOX FORMCHECKBOX Recording Direct and Indirect Costs FORMCHECKBOX FORMCHECKBOX How frequently are those policies updated? FORMTEXT ?????Does the subrecipient receive an annual single audit performed by a CPA? FORMCHECKBOX YES FORMCHECKBOX NOIf Yes:Name of CPA: FORMTEXT ?????Period Covered: FORMTEXT ?????Has the audit been completed for the most recent fiscal year? FORMCHECKBOX YES FORMCHECKBOX NOIf “No”, when is it expected to be completed (MM/DD/YYYY)? FORMTEXT ?????Note: A complete copy of subrecipient’s most recent audit report, or the URL link to a complete coy, must be furnished to DWS before a subaward can be issued.ACCOUNTING SYSTEMWhat type of accounting software does the Entity use? FORMCHECKBOX Quick Books FORMCHECKBOX Quicken FORMCHECKBOX Internally-developed system FORMCHECKBOX Commercial system Name of vendor: FORMTEXT ????? FORMCHECKBOX Manual accounting system [example: Excel, ledger paper, etc.]How many years has your entity used the accounting software? FORMTEXT ?????Is access to accounting records limited to authorized personnel? FORMCHECKBOX YES FORMCHECKBOX NOIs the accounting software password protected? FORMCHECKBOX YES FORMCHECKBOX NOWho determines/approves the levels of access to the software? FORMTEXT ?????Are authorized personnel provided training on the software? FORMCHECKBOX YES FORMCHECKBOX NOHow often? FORMTEXT ?????By whom? FORMTEXT ?????What types of expenditures does your Entity typically incur on projects: YES NOPayroll FORMCHECKBOX FORMCHECKBOX Equipment FORMCHECKBOX FORMCHECKBOX Computer FORMCHECKBOX FORMCHECKBOX Indirect Costs FORMCHECKBOX FORMCHECKBOX Travel/ Per Diem FORMCHECKBOX FORMCHECKBOX Phone Calls FORMCHECKBOX FORMCHECKBOX Copies FORMCHECKBOX FORMCHECKBOX Are the project expenditures marked in #4 tracked by unique project numbers? FORMCHECKBOX YES FORMCHECKBOX NOIs the accounting system able to prepare reports of total costs per project? FORMCHECKBOX YES FORMCHECKBOX NODoes your entity utilize in-kind contributions or other matching requirements? FORMCHECKBOX YES FORMCHECKBOX NOIf Yes: How are they tracked? FORMTEXT ?????Are timesheets and project expenditures approved by the appropriate person? FORMCHECKBOX YES FORMCHECKBOX NO If Yes: By whom? FORMTEXT ?????How frequently? FORMTEXT ?????Are project budgets created, maintained and reviewed? FORMCHECKBOX YES FORMCHECKBOX NO If Yes: By whom? FORMTEXT ?????How frequently? FORMTEXT ?????What is the procedure when a project exceeds the budget? FORMTEXT ????? How frequently are billings prepared and presented to DWS? FORMTEXT ?????Does your Entity review project cost reports prior to billing DWS? FORMCHECKBOX YES FORMCHECKBOX NO If Yes: By whom? FORMTEXT ?????Are billings approved by the appropriate person prior to being sent to DWS? FORMCHECKBOX YES FORMCHECKBOX NO If Yes: By whom? FORMTEXT ?????PROCUREMENTDoes your entity have written Procurement Policies to address the following topics per 2 CFR 200? YES NOGeneral Procurement Standards including:Standards of Conduct FORMCHECKBOX FORMCHECKBOX Conflicts of Interest FORMCHECKBOX FORMCHECKBOX Unnecessary or duplicate items FORMCHECKBOX FORMCHECKBOX Awarding contracts to responsible contractors FORMCHECKBOX FORMCHECKBOX Maintain sufficient records FORMCHECKBOX FORMCHECKBOX Settlement of contractual and administrative issues FORMCHECKBOX FORMCHECKBOX Competition FORMCHECKBOX FORMCHECKBOX Methods of Procurement FORMCHECKBOX FORMCHECKBOX Contracting with minority businesses, women’s business enterprises, and labor surplus area firms FORMCHECKBOX FORMCHECKBOX Contract cost and price analysis FORMCHECKBOX FORMCHECKBOX Procurement record retention FORMCHECKBOX FORMCHECKBOX How frequently are those policies updated? FORMTEXT ?????CERTIFICATIONSConflict of Interest:Subrecipient organization hereby certifies that it has an active and enforced conflict of interest policy that is consistent with the provision of ______. Subrecipient also certifies that, to the best of its knowledge: (10 all financial disclosures have been made related to the activities that may be funded by or through a resulting agreement, and required by its conflict of interest policy; and (2) all identified conflict of interest have or will have been satisfactorily managed, reduced, or eliminated in accordance with subrecipient’s conflict of interest policy prior to the expenditures of any funds under any resulting agreement. Suspension and Debarment:I hereby certify that no employee of the subrecipient organization is debarred, suspended or otherwise excluded from or ineligible from participating in federal assistance programs or activities.Fiscal Responsibility (check each box that applies):The organization certifies that its financial system is in accordance with generally accepted accounting principles and: FORMCHECKBOX Has the capability to identify, in its accounts, all Federal awards received and expended and the Federal programs under which they were received. FORMCHECKBOX Maintains internal controls to assure that it is managing Federal awards received and expended and the Federal programs under which they were received. FORMCHECKBOX Complies with appelicable laws and regulations. FORMCHECKBOX Can prepare appropriate financial statements, including the schedule of expenditures of federal awards. FORMCHECKBOX There are no outstanding audit findings which would impact this project. If there are findings, submit a copy of the most recent report that describes the findings and steps to be taken to correct the findings. By signing this form, I certify that the above information, certifications, and representations have been read, are understood, are accurate, and true to the best of my knowledge, and that I am authorized to act on behalf of the subrecipient named herein. The appropriate programmatic and administrative personnel involved are aware of agency policies in regard to subawards/contracts and are prepared to establish the necessary procedures to ensure compliance with such regulations and policies. ENTITY’S SIGNATUREI am this entity’s representative who is authorized to sign financial documents. I certify that we are in compliance with Federal laws and regulations. The statements made herein are true and correct to the best of my knowledge.Representative Signature:__________________________________ Date:_______________________Representative Printed Name:_______________________________ Title:_______________________ ................
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