4. freedom house financial questionnaire
DESCRIPTION
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ACCOUNTING QUESTIONNAIRE
FINANCIAL QUESTIONNAIRE
FOR
PROSPECTIVE FREEDOM HOUSE SUBGRANTEES
Accepting a subgrant from Freedom House creates a legal duty for the subgrantee to use the funds according to the Subgrant Agreement and US Federal regulations.
This Questionnaire will help Freedom House (FH) assess the financial systems of a prospective Freedom House subgrantee. Currently, your proposal is being considered by Freedom House.
Answer each question completely, using extra pages if necessary. Return your completed questionnaire with requested attachments to Freedom House as soon as possible. Your questionnaire must be received by Freedom House before Freedom House can issue any potential subgrant.
If you do not understand some of the terms used in this Questionnaire, please reference the Glossary of Terms on the last page of this questionnaire.
Complete the Questionnaire and checklist on page 13, sign and return it (along with any attachments) to Freedom House. You may either: mail, fax, or email the Questionnaire. Please note that Freedom House will not be able to accept any incomplete or unsigned questionnaires.Mail:
Ms. Elizabeth Donkervoort
Freedom House
1301 Connecticut Avenue, NW
Washington, DC 20036
Fax:
Ms. Elizabeth DonkervoortFreedom House
+1 202-293-2840E-mail:
[email protected] Reviewed by: Date:
CONTACT INFORMATIONPlease complete this section so that we can communicate with each other.
Legal Name of Organization (that will sign the Subgrant Agreement and accept responsibility for FH funds, if awarded):____________________________________________________________________________________
Name of Contact: _____________________________________________________________________
Name of Individual(s) Legally Authorized to Sign on Behalf of the Organization: ____________________________________________________________________________________________________
Mailing Address Street Address (necessary for express delivery)
StreetStreet
CityCity
CountryCountry
Postal CodePostal Code
Telephone (include all country and city codes):
Country Code: ________City Code: ________Phone Number: ____________________Email: Fax:____________________________
Skype:
1. Do you have access to the internet? Yes:ADVANCE \u2 No: ADVANCE \d2ADVANCE \u22. Do you have access to email?
Yes:ADVANCE \d2ADVANCE \u2 No: ADVANCE \u23. Can your email open WORD files sent as an attachment? Yes:ADVANCE \d2ADVANCE \u2 No: ADVANCE \d2ADVANCE \u2 Additional Comments (on how we can more easily stay in touch with you):
_______________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________SECTION A: General Information Please complete this section to provide general information about your organization.
1. What type of organization are you (non-profit, for profit (commercial), university, etc.)?
_______________________________________________________________________________2. Is your organization incorporated or legally registered?
Yes: No: (explain)
_______________________________________________________________________________
_______________________________________________________________________________ 2a. When and where was your organization incorporated or registered?
______________________________________________________________________________________________________________________________________________________________ 2b. Please provide a copy of your organization's incorporation or registration certificate.
Enclosed: ADVANCE \d2ADVANCE \u2 Not Enclosed: ADVANCE \d2ADVANCE \u2 (explain):
______________________________________________________________________________________________________________________________________________________________3. Is your organization required to pay taxes on revenue or income or is it exempt from paying taxes? Required to pay taxes on revenue or income: ADVANCE \d2ADVANCE \u2 Not required to pay taxes on revenue or income: ADVANCE \d2ADVANCE \u2_______________________________________________________________________________4. If based in the US, is your organization tax exempt under 501(c)(3) of the IRS code? Please provide a copy of your IRS determination letter.501(c)(3): ADVANCE \d2ADVANCE \u2 501(c)(3) letter not enclosed (explain): ADVANCE \u2 Not 501(c)(3): ADVANCE \d2ADVANCE \u2
_______________________________________________________________________________ _______________________________________________________________________________5. Please provide copies of any materials which describe your organization, its mission and history.
Enclosed: ADVANCE \d2ADVANCE \u2
Not Enclosed: ADVANCE \u2 (explain)
______________________________________________________________________________________________________________________________________________________________6. Is your organization affiliated with any other organization?Yes: ADVANCE \u2
No: ADVANCE \d2ADVANCE \u2
If yes, please provide details:
ADVANCE \d2
ADVANCE \u2_______________________________________________________________________________ _______________________________________________________________________________
7. Please list the names of the members of the Board of Directors or Board of Trustees and their position titles (Chairman, Secretary, Treasurer, regular member, etc.) and provide an organizational chart, if available:
Position Title
Name__________________________________
______________________________________
__________________________________
______________________________________
__________________________________
______________________________________
__________________________________
______________________________________
__________________________________
______________________________________
__________________________________
______________________________________
8. Please list the names of principals and key personnel that will have responsibility for carrying out the programmatic activities described in your project proposal.
Position Title
Name__________________________________
______________________________________
__________________________________
______________________________________
__________________________________
______________________________________
9. Please list all staff members who have responsibility for accounting including budgeting and banking. If one or more of these positions does not exist in your organization, please leave it blank.
President: ___________________________________ paid position: _____ volunteer position: _____
Secretary-General: ___________________________ paid position: _____ volunteer position: _____
Executive Director: ___________________________ paid position: _____ volunteer position: _____
Chief Financial Officer: ________________________paid position: _____ volunteer position: _____
Accountant: __________________________________paid position: _____ volunteer position: _____
Bookkeeper: _________________________________paid position: _____ volunteer position: _____
Accounting Firm: _____________________________paid position: _____ volunteer position: _____
Other (list position): ___________________________paid position: _____ volunteer position: _____
Other (list position): ___________________________paid position: _____ volunteer position: _____
Other (list position): ___________________________paid position: _____ volunteer position: _____10. List the number of employees in your organization:
Full-Time Employees: ______ Part-Time Employees: _______ Consultants: ______ Volunteers: ____11. Enter the beginning and ending dates of your organization's fiscal (financial) year:
From: (Month, Day) _________________ To: (Month, Day) _______________
12. Will your organization have support from other funding sources, specifically for the project described in your proposal to FH, during the period of the FH subgrant, if it is awarded?
Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \d2ADVANCE \u2
12a. If yes, please complete section I of the enclosed Current Funding and Past Performance Data Sheet. 13. Will your organization have support from other funding sources, for activities OTHER than the project described in your proposal to FH, during the period of the FH subgrant, if it is awarded?
Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \d2ADVANCE \u2
13a. If yes, please complete section II of the enclosed Current Funding and Past Performance Data Sheet. 14. Has your organization previously received donor funds for past projects? Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \d2ADVANCE \u2
14a. If yes, please complete section III of the enclosed Current Funding and Past Performance Data Sheet. 15. Current Funding and Past Performance Data Sheet is enclosed: Yes: ADVANCE \d2ADVANCE \u2 No: ADVANCE \d2ADVANCE \u2 (explain)
______________________________________________________________________________________________________________________________________________________________16. Did 80% of funds your organization received in the previous fiscal year consist of US Government funds?Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \d2ADVANCE \u217. Did your organization receive more than $25,000,000 in US Government funds in the previous fiscal year?
Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \d2ADVANCE \u218. If you answered yes for both questions 16 and 17, please provide a list of your organizations five most highly-compensated employees.
1._______________________
2._______________________
3._______________________
4._______________________
5._______________________
ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2____________________________________________________________________________________
SECTION B: Internal ControlsInternal controls are your procedures which make sure that: 1) expenses are approved by an authorized person as required by laws, regulations, and your organizations policies, 2) money and equipment are kept safely, and 3) accounting records are complete, accurate and kept on a regular basis. Please complete the following questions concerning your organization's internal controls.
1. List the name and the position title for the people responsible for the following: Responsible for:Name(s) and position title(s)
Cash
Bank Accounts
Equipment
Approving Expenses
Checking expenses to make sure they are allowable
Keeping all invoices and other expense documentation for this grant
Signing checks and/or authorizing bank transfers
Maintaining accounting records
Reconciling bank statements to the accounting records
Preparing financial reports
Preparing narrative reports
2. Are any members of the staff or board related? Yes: ADVANCE \d2ADVANCE \u2
No: ADVANCE \d2ADVANCE \u22a. If yes, identify and state relationship (spouse, child, parent, sibling, cousin, etc.)
NameName of relativeRelationship
3. Are timesheets kept for each paid employee? Yes: ADVANCE \d2ADVANCE \u2
No: ADVANCE \d2ADVANCE \u2
3a. If not, will timesheets be maintained for the subgrant in fulfillment of FH requirements:
Yes: ADVANCE \d2ADVANCE \u2
No: ADVANCE \d2ADVANCE \u2
4. Do you issue an employment letter or contract which includes the employees salary?
Yes: ADVANCE \d2ADVANCE \u2 No: ADVANCE \d2ADVANCE \u25. Do you have a written procurement policy?
Yes: ADVANCE \d2ADVANCE \u2 (if yes and English copy is available, please enclose) No: ADVANCE \d2ADVANCE \u26. Do you keep inventory records for equipment?
Yes: ADVANCE \d2ADVANCE \u2
No: ADVANCE \u2 (explain)
____________________________________________________________________________________7. How often do you compare inventory records to the actual equipment?
ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2____________________________________________________________________________________ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2____________________________________________________________________________________8. Is your organization familiar with US government regulations concerning costs which can be charged to US grants (OMB Circular A-122 "Cost Principles for Nonprofit Organizations" or OMB Circular A-21 "Cost Principles for Educational Institutions")?
Yes: No:
ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2____________________________________________________________________________________
SECTION C: Accounting SystemThe purpose of an accounting system is to: 1) accurately record all financial transactions, and 2) ensure that all financial transactions are supported by invoices, timesheets and other documentation. The type of accounting system often depends on the size of the organization. Some organizations may have computerized accounting systems, while others use a manual system to record each transaction in a ledger. In either case, FH subgrant funds must be properly authorized, used for the intended purpose and recorded in an organized and regular manner.
1. Briefly describe your organization's accounting system including: a) any manual ledgers used to record transactions (general ledger, cash disbursements ledger, etc.); b) any computerized accounting system used (please indicate the name of the accounting program); and c) how transactions are summarized in your financial reports.
(a)_________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
(b)_________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
(c)__________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
2. Does your organization have written accounting policies and procedures?
Yes: ADVANCE \d2ADVANCE \u2 (If English copies are available, please enclose) No: ADVANCE \u2 3. Complete the following information concerning the person who will maintain your accounting records: 3a. How many years of experience does this person have? _______
3b. How many years has this person been with your organization? _______
3c. Does this person know how to use Excel?Yes ADVANCE \d2ADVANCE \u2NoADVANCE \d2ADVANCE \u2 3d. Does this person know how to use a computerized accounting system? Yes ADVANCE \d2ADVANCE \u2NoADVANCE \d2ADVANCE \u2 3e. Does this person have a degree in accounting or finance? Yes ADVANCE \d2ADVANCE \u2NoADVANCE \d2ADVANCE \u2 3f. Can this person communicate in English? Yes ADVANCE \d2ADVANCE \u2NoADVANCE \d2ADVANCE \u2 (State preferred languages below)
____________________________________________________________________________________4. Are your financial reports prepared on a: Cash basis: ADVANCE \d2ADVANCE \u2 Accrual basis: ADVANCE \d2ADVANCE \u2
5. Can your accounting records keep separate the receipts and payments for an FH subgrant from the receipts and payments for your other activities? Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \d2ADVANCE \u26. Can your accounting records summarize costs for the FH subgrant according to different budget categories such as salaries, space and utilities, supplies and equipment?
Yes: ADVANCE \d2ADVANCE \u2 No: ADVANCE \d2ADVANCE \u27. How often are financial reports prepared?
Monthly: Quarterly: Annually: Not prepared: (explain)____________________________________________________________________________________
____________________________________________________________________________________
8. How would your organization make sure that 1) individual budget categories, and 2) total budget limits for an FH subgrant would not be exceeded? ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9. Do you keep invoices, vouchers and timesheets for all payments made from subgrant funds?
Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \u2 (explain)
________________________________________________________________________________________________________________________________________________________________________10. Are there any circumstances in which invoices, vouchers and timesheets cannot or would not be obtained for FH subgrant funds?ADVANCE \u2 Yes: ADVANCE \u2 (explain) No: ADVANCE \d2
____________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________11. Briefly describe your organization's system for filing and keeping supporting documentation
such as invoices and timesheets.____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________12. FH requests its subgrantees to submit supporting financial documents with financial reports. Are there any circumstances where original invoices, receipts and timesheets cannot be forwarded to FH? Please note that copies are required if originals cannot be sent. Yes: ADVANCE \u2 (explain) No: ADVANCE \d2
____________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________13. Would your organization be able to keep accounting records including invoices, vouchers and timesheets for at least three years after the final financial report is submitted to FH?
Yes: ADVANCE \d2 ADVANCE \u2 No: ADVANCE \d2ADVANCE \u2 (explain)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________14. Does your organization have a Negotiated Indirect Cost Rate Agreement approved by a US Government agency?
Yes: ADVANCE \d2ADVANCE \u2 (If yes, please enclose copy of rate agreement) No: ADVANCE \d2ADVANCE \u2
ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2____________________________________________________________________________________
SECTION D: Funds ControlFreedom House subgrantees who receive advances of subgrant funds must maintain a separate bank account in the name of the organization. Only FH subgrant funds can be kept in that bank account. The bank account may be in local currency or US dollars. FH normally pays subgrantees periodically by wire transfer of US dollars to the separate bank account. Access to the bank account must be limited to authorized people. Bank balances should be compared each month with your accounting records. If cash cannot be kept in a bank, it is very important to keep the cash in a strong safe and have strict controls over it.1. Can a separate bank account, registered in the name of your organization, be established for FH subgrant funds only? Yes: ADVANCE \d2ADVANCE \u2 No: ADVANCE \d2ADVANCE \u2 1a. If not, how do you plan to receive funds from a possible subgrant?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. Will funds in the bank account be in:
Local currency: ADVANCE \d2ADVANCE \u2 U.S. dollars: ADVANCE \d2ADVANCE \u23. Are all bank accounts and check signers authorized by your Board of Directors or Trustees?
Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \d24. Will any cash from FH subgrant funds be kept outside the bank (for petty cash, etc.)?
Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \d2 4a. If yes, please explain the amount of funds to be kept, the name and position title of the person responsible for the cash, and how cash will be maintained.
Amount:____________________________________________________________________________
Name:______________________________________________________________________________
Position Title:_________________________________________________________________________
How is cash kept secure?:_______________________________________________________________
____________________________________________________________________________________5. If your organization does not have a bank account, how is cash kept safely?
ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________6. If FH subgrant funds will be held in a non-US bank, please answer questions 6a through 6f. 6a. Are bank deposits insured by the government? Yes: No: 6b. Are there any government restrictions on the number of bank accounts an organization may have?
Yes: ADVANCE \d2No: ADVANCE \d2 If yes, please explain:
___________________________________________________________________________________
___________________________________________________________________________________
6c. Does your bank automatically convert US dollars to local currency immediately after receiving them?
Yes: ADVANCE \d2ADVANCE \u2No: 6d. How will payments for subgrant expenses be made from the separate bank account (check all that apply):
ADVANCE \d2 ADVANCE \u2 Checks drawn on the bank account.
ADVANCE \d2ADVANCE \u2 Bank transfers to seller.
ADVANCE \u2 Withdrawals of cash from bank account, followed by payments in cash.
ADVANCE \d2ADVANCE \u2 Other (please describe):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________6e. Are there any government or bank restrictions, taxes or other fees that will be placed on the bank account?
ADVANCE \d2
ADVANCE \u2 Yes: ADVANCE \d2ADVANCE \u2 (Explain) No: ADVANCE \u2____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6f. Are there any taxes, exchange requirements, or other charges that you will have to pay when converting US dollars to local currency?
ADVANCE \d2
ADVANCE \u2
Yes: ADVANCE \u2 (Explain) No: ADVANCE \d2ADVANCE \u2____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2____________________________________________________________________________________
SECTION E: AuditIf your organization is awarded a subgrant, Freedom House requires that you submit a copy of the most recent financial audit report, if one was conducted. An audit is a review of your accounting records by an independent accountant someone who does not work for you. An audit report contains your financial statements as well as an opinion by the accountant stating that your financial statements are correct. Please provide the following information on prior audits of your organization.
1. Does your organization have regular audits which you pay for?
Yes: (please provide the most recent copy) No audits performed:
1a. If yes, who performs the audit?
____________________________________________________________________________________
1b. How often are audits performed?
Quarterly: Yearly: Every 2 years: Other: (explain)
____________________________________________________________________________________
1c. What type of audit is performed?
Financial: A-133: Program: Other: ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u21d. If your organization receives an FH subgrant, would FH subgrant funds be included in such an audit?
Yes: ADVANCE \d2No: ADVANCE \d2 ADVANCE \d2
ADVANCE \u2 1e. If there is an audit, will the FH subgrant appear as a separate item?
Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \d2ADVANCE \u2ADVANCE \d2
ADVANCE \u2 1f. Will the report be prepared in, or translated into English?
Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \d2ADVANCE \u2ADVANCE \d2
ADVANCE \u22. If your organization does not have a recent audit, please provide a copy of the following financial information, if available:
a. A "Balance Sheet" for your prior fiscal year; and
b. A "Revenue and Expense Statement" for your prior fiscal year.
3. Are there any reasons (local conditions, laws, or institutional circumstances) that would prevent an independent accountant from performing an audit of your organization?
Yes: ADVANCE \d2ADVANCE \u2No: ADVANCE \d2ADVANCE \u2 If yes, please explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CHECKLIST AND SIGNATURE PAGEFreedom House requests that your organization submit a number of documents along with the completed Financial Questionnaire. Complete this page to ensure that all requested information has been included.
1. Place an X in the box next to the documents you will be sending to FH:
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2ADVANCE \u2 Incorporation Papers or Certificate of Registration (requested on page 3) is attached. (If available)
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2ADVANCE \u2 The IRS Determination Letter (requested on page 3) is attached. (If applicable)
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2
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ADVANCE \u2ADVANCE \u2 Information describing your organization (requested on page 3) is attached.
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2ADVANCE \u2 Organizational chart (requested on page 4) is attached. (If available)
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2ADVANCE \u2 Current Funding & Past Performance Data Sheet (requested on page 5) is attached. ADVANCE \u2
ADVANCE \d2
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2 Written procurement policy (requested on page 6) is attached. (if available)
Written accounting policies and procedures (requested on page 7) are attached. (if available)ADVANCE \u2 A Negotiated Indirect Cost Rate Agreement (requested on page 9) is attached. (If applicable,)ADVANCE \u2 A Copy of your organization's most recent audit (requested on page 11) is attached. (If available)ADVANCE \d2 ADVANCE \u2If your organization does not have a recent audit, a "Balance Sheet" and "Revenue and Expense Statement" for the prior financial year (requested on page 12). (If available)ADVANCE \d2 All questions have been fully answered.
ADVANCE \u2
ADVANCE \d2
ADVANCE \u2
ADVANCE \d2ADVANCE \u2 An authorized individual has signed and dated this page.
The Financial Questionnaire must be signed and dated by an authorized person who has either completed or reviewed the Questionnaire.
Approved by:
Print NameSignature
TitleDate
Organization
Glossary of TermsAccrual based accounting system: An accounting system where your financial report shows payments which have been made as well as invoices which have been received but not yet paid. Actual cost: Any type of expense which has been paid for.
Allowable costs: Expenses which are for subgrant activities and which are reasonable and legal.
Balance sheet: A report which lists your assets (income to be received, cash, equipment) and your liabilities (payments to be made).
Cash based accounting system: An accounting system where your financial report only shows payments which have been made.
Expenses: Costs charged to the subgrant. Expenditures: Another name for expenses or costs.Financial statement: A report containing your balance sheet, and revenue and expense statement.
Financial report: A report which shows the money which an organization has spent on the subgrant for the period, usually three months. FH requires a financial report for each three month period (quarter).
Fiscal year: The financial year of your organization. Most fiscal years are from January 1 to December 31. Other fiscal years end on March 31, June 30, or September 30.
Funds: Money.Incurred cost: Any type of expense which has been made but not yet paid.Internal controls: A system set up by an organization to make sure that money is received and spent in the correct manner.Manual ledgers: Accounting records which are maintained by hand (without a computer) and which record similar transactions such as cash receipts, cash payments, salaries, inventory, etc.
Narrative report: A written report developed by an organization describing the subgrant activities for the period, usually three months. FH requires a narrative report for each three month period (quarter).
Petty cash: Small amounts of cash used to pay small expenses (taxi, bus, office supplies).
Revenue and expense statement: A report which shows the money which your organization received (revenue) and how the money was spent (expense).
Separate bank account: A bank account in the name of your organization set up for your FH subgrant. Only FH funds are deposited into the account and only FH program expenses are paid from the account.
Subgrant: An award given to an organization to complete a project.
Subgrantee: An organization which receives a subgrant.Unallowable costs: Expenses which are not related to the FH subgrant, which are unreasonable, and not accepted by law. These include but are not limited to alcohol (beer, wine, cocktails), cigarettes, fines, parking tickets, bribes, etc. and all expenses which are not approved in the FH subgrant budget.
Last Updated 11/08/2011Page 15 of 15