Entity Annual Report (Form E-1)
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STATE BOARD OF ACCOUNTS
302 West Washington Street, Room E418
ENTITY ANNUAL REPORT
Indianapolis, Indiana 46204-2765
State Form 54402 (8-10) / Form E-1
Telephone: (317) 232-2513
Prescribed by State Board of Accounts
Fax: (317) 232-4711
Web Site:
Note:
The Entity Annual Report (Form E-1) is used to determine the audit requirements placed on
your entity by IC 5-11-1-9. File report within sixty (60) days of the close of your entity's
OFFICE USE ONLY
fiscal year end. Instructions for completing Form E-1 are available at .
Fiscal Year End of Entity
SBA Number: _________________
Audit Determination (check one):
______ ______ ______
Complete
Waived
Month
Day
Year
Legal Name
Federal ID Number
Doing Business As (DBA)
Business Telephone Number
(
)
Street Address (number and street)
City
County
State
ZIP Code
E-mail Address of Entity
Name of Operating Officer
Title
TYPE OF ORGANIZATION (check one)
LEGAL STATUS (check one)
Corporation
Partnership
Individual
Association
For Profit
Not-For-Profit
FINANCIAL INFORMATION
1. Government funds received during year (Detailed on Page 2)
$__________________
2. Government funds disbursed during year
$__________________
3. Entity's total disbursements (or expenditures) for the year
$__________________
4. Percent of government funds disbursed to entity's total
disbursements (or expenditures) (Line 2 divided by Line 3)
_________________ %
This information is reported on the (check one)
cash basis
accrual basis.
Is this the initial Form E-1 filing for the entity? (check one)
Yes
No
CERTIFICATION
This is to certify that the data contained in this report is accurate to the best of my knowledge and belief.
Signature:___________________________________
Title: ________________________________________
Printed Name: _______________________________
Date Signed (month, day, year): ___________________
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