Form Sf-Sac - Audits Of States, Local Governments, And Non-Profit Organizations
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14OMB No. 0348-0057
U.S. DEPT. OF COMM.–
U.S. CENSUS BUREAU
SF-SAC
Econ. and Stat. Admin.–
FORM
ACTING AS COLLECTING AGENT FOR
(5-2004)
OFFICE OF MANAGEMENT AND BUDGET
Data Collection Form for Reporting on
AUDITS OF STATES, LOCAL GOVERNMENTS, AND NON-PROFIT ORGANIZATIONS
for Fiscal Year Ending Dates in 2004, 2005, or 2006
Federal Audit Clearinghouse
Complete this form, as required by OMB Circular A-133, "Audits
RETURN
1201 E. 10th Street
of States, Local Governments, and Non-Profit Organizations."
TO
Jeffersonville, IN 47132
PART I
GENERAL INFORMATION (To be completed by auditee, except for Items 4 and 7)
1.
Fiscal period ending date for this submission
2.
Type of Circular A-133 audit
Month
Day
Year
Fiscal Period End Dates Must
Single audit
Program-specific audit
1
2
/
/
Be In 2004, 2005, or 2006
3.
Audit period covered
4. FEDERAL
Date received by
Federal clearinghouse
GOVERNMENT
USE ONLY
Annual
Biennial
Other –
Months
1
2
3
5. Auditee Identification Numbers
a.
Primary Employer Identification Number (EIN)
b.
Are multiple EINs covered in this report?
Yes
No
1
2
_
If Part I, Item 5b = "Yes," complete Part I, Item 5c
c.
on the continuation sheet on Page 4.
d. Data Universal Numbering System (DUNS) Number
e.
Are multiple DUNS covered in this report?
Yes
No
1
2
_ _
_
f.
If Part I, Item 5e = "Yes," complete Part I, Item 5f
on the continuation sheet on Page 4.
6.
AUDITEE INFORMATION
7. AUDITOR INFORMATION (To be completed by auditor)
a .
Auditee name
a .
Auditor name
b .
Auditee address
b .
Auditor address
(Number and street)
(Number and street)
City
City
State
State
ZIP + 4 Code
_
ZIP + 4 Code
_
c .
Auditee contact
c .
Auditor contact
Name
Name
Title
Title
d .
Auditee contact telephone
d .
Auditor contact telephone
(
)
–
(
)
–
e .
Auditee contact FAX
e .
Auditor contact FAX
(
)
–
(
)
–
f .
Auditee contact E-mail
f .
Auditor contact E-mail
g.
AUDITEE CERTIFICATION STATEMENT – This is to
g.
AUDITOR STATEMENT – The data elements and
certify that, to the best of my knowledge and belief, the auditee
information included in this form are limited to those prescribed
has: (1) engaged an auditor to perform an audit in accordance
by OMB Circular A-133. The information included in Parts II and
with the provisions of OMB Circular A-133 for the period
III of the form, except for Part III, Items 7, 8, and 9a-9f, was
described in Part I, Items 1 and 3; (2) the auditor has completed
transferred from the auditor’s report(s) for the period described
such audit and presented a signed audit report which states that
in Part I, Items 1 and 3, and is not a substitute for such
the audit was conducted in accordance with the provisions of the
reports. The auditor has not performed any auditing procedures
Circular; and, (3) the information included in Parts I, II, and III
since the date of the auditor’s report(s). A copy of the reporting
of this data collection form is accurate and complete. I declare
package required by OMB Circular A-133, which includes the
that the foregoing is true and correct.
complete auditor’s report(s), is available in its entirety from the
auditee at the address provided in Part I of this form. As
Date
Signature of certifying official
required by OMB Circular A-133, the information in Parts II
Month
Day
Year
and III of this form was entered in this form by the auditor
/
/
based on information included in the reporting package. The
Printed Name of certifying official
auditor has not performed any additional auditing procedures in
connection with the completion of this form.
Date
Signature of auditor
Printed Title of certifying official
Month
Day
Year
/
/
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