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 Donkervoort
Freedom House
+1 202-293-2840
E-mail:
Reviewed by: Date:
CONTACT INFORMATION
Please 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)Street / Street
City / City
Country / Country
Postal Code / Postal 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:□ No: □
2. Do you have access to email? Yes:□ No: □
3. Can your email open WORD files sent as an attachment? Yes:□ No: □
Additional Comments (on how we can more easily stay in touch with you):
______
______
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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: □ Not Enclosed: □(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: □ Not required to pay taxes on revenue or income: □
______
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): □ 501(c)(3) letter not enclosed (explain): □ Not 501(c)(3): □
______
______
5. Please provide copies of any materials which describe your organization, its mission and history.
Enclosed: □ Not Enclosed: □ (explain)
______
______
6. Is your organization affiliated with any other organization?
Yes: □ No: □
If yes, please provide details:
______
______
7. Please list the names of the members of the Board of Directorsor Board of Trusteesand their position titles (Chairman, Secretary, Treasurer, regular member, etc.) and provide an organizational chart, if available:
Position TitleName
______
______
______
______
______
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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 TitleName
______
______
______
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: □No: □
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: □No: □
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: □No: □
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:□ No:□(explain)
______
______
16. Did 80% of funds your organization received in the previous fiscal year consist of US Government funds?
Yes: □No: □
17. Did your organization receive more than $25,000,000 in US Government funds in the previous fiscal year?
Yes: □No: □
18. If you answered “yes” for both questions 16 and 17, please provide a list of your organization’s five most highly-compensated employees.
1.______
2.______
3.______
4.______
5.______
______
SECTION B: Internal Controls
Internal controls are your procedures which make sure that: 1) expenses are approved by an authorized person as required by laws, regulations, and your organization’s 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: □ No: □
2a. If yes, identify and state relationship (spouse, child, parent, sibling, cousin, etc.)
Name / Name of relative / Relationship3. Are timesheets kept for each paid employee? Yes: □ No: □
3a. If not, will timesheets be maintained for the subgrant in fulfillment of FH requirements:
Yes: □No: □
4. Do you issue an employment letter or contract which includes the employee’s salary?
Yes: □ No: □
5. Do you have a written procurement policy?
Yes: □(if yes and English copy is available, please enclose) No: □
6. Do you keep inventory records for equipment?
Yes: □ No: □ (explain)
______
7. How often do you compare inventory records to the actual equipment?
______
______
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: □
______
SECTION C: Accounting System
The 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, FHsubgrant 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: □ (If English copies are available, please enclose) No: □
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 □No□
3d. Does this person know how to use a computerized accounting system? Yes □No□
3e. Does this person have a degree in accounting or finance? Yes □No□
3f. Can this person communicate in English? Yes □No□(State preferred languages below)
______
4. Are your financial reports prepared on a: Cash basis: □ Accrual basis: □
5. Can your accounting records keep separate the receipts and payments for anFHsubgrant from the receipts and payments for your other activities? Yes: □ No: □
6. Can your accounting records summarize costs for the FHsubgrant according to different budget categories such as salaries, space and utilities, supplies and equipment?
Yes: □ No: □
7. How often are financial reports prepared?
Monthly: □ Quarterly: □ Annually: □ Not prepared: □(explain)
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8. How would your organization make sure that 1) individual budget categories, and 2) total budget limits for anFHsubgrant would not be exceeded?
______
______
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9. Do you keep invoices, vouchers and timesheets for all payments made from subgrant funds?
Yes: □ No: □ (explain)
______
10. Are there any circumstances in which invoices, vouchers and timesheets cannot or would not be obtained for FH subgrant funds?
Yes: □ (explain) No: □
______
______
______
11. Briefly describe your organization's system for filing and keeping supporting documentation
such as invoices and timesheets.
______
______
______
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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: □ (explain) No: □
______
______
______
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: □ No: □ (explain)
______
______
______
14.Does your organization have a Negotiated Indirect Cost Rate Agreement approved by a US Government agency?
Yes: □ (If yes, please enclose copy of rate agreement) No: □
______
SECTION D: Funds Control
Freedom Housesubgrantees who receive advances of subgrant funds must maintain a separate bank account in the name of the organization. Only FHsubgrant 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: □ No: □
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: □ U.S. dollars: □
3. Are all bank accounts and check signers authorized by your Board of Directors or Trustees?
Yes: □ No: □
4. Will any cash from FHsubgrant funds be kept outside the bank (for petty cash, etc.)?
Yes: □ No: □
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?
______
______
______
6. If FHsubgrant 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: □ No: □
If yes, please explain:
______
______
6c. Does your bank automatically convert US dollars to local currency immediately after receiving them?
Yes: □ No: □
6d. How will payments for subgrant expenses be made from the separate bank account (check all that apply):
□ Checks drawn on the bank account.
□ Bank transfers to seller.
□ Withdrawals of cash from bank account, followed by payments in cash.
□ Other (please describe):
______
______
______
6e. Are there any government or bank restrictions, taxes or other fees that will be placed on the bankaccount?
Yes: □ (Explain) No: □
______
______
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6f. Are there any taxes, exchange requirements, or other charges that you will have to pay when converting US dollars to local currency?
Yes: □ (Explain). No: □
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SECTION E: Audit
If 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: □
1d. If your organization receives anFHsubgrant, would FHsubgrant funds be included in such an audit?
Yes: □ No: □
1e. If there is an audit, will the FHsubgrant appear as a separate item?
Yes: □ No: □
1f. Will the report be prepared in, or translated into English?
Y.es: □ No: □
2. 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: □ No: □
If yes, please explain:
______
______
______
Last Updated 11/08/2011
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CHECKLIST AND SIGNATURE PAGE
Freedom 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:
□ Incorporation Papers or Certificate of Registration (requested on page 3) is attached. (If available)
□ The IRS Determination Letter (requested on page 3) is attached. (If applicable)
□ Information describing your organization (requested on page 3) is attached.
□ Organizational chart (requested on page 4) is attached. (If available)
□ Current Funding & Past Performance Data Sheet (requested on page 5) is attached.
□ Written procurement policy (requested on page 6) is attached. (if available)
□Written accounting policies and procedures (requested on page 7) are attached. (if available)
□ A Negotiated Indirect Cost Rate Agreement (requested on page 9) is attached. (If applicable,)
□A Copy of your organization's most recent audit (requested on page 11) is attached. (If available)
□If 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)
□All questions have been fully answered.
□ An authorized individual has signed and dated this page.
The FinancialQuestionnaire 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 Terms
Accrual 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 reportonlyshows 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 FHsubgrant. 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 FHsubgrant, 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 FHsubgrant budget.
Last Updated 11/08/2011
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