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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Provider Agency Name and Address in the designated fields. Ensure that all information is accurate to avoid any issues.
- Fill in the Contact Individual and Title, along with the Telephone Number. This information is crucial for communication regarding your submission.
- Specify the Agency Fiscal Year To be Audited and provide the Federal ID No. and Charities Registration No. as required.
- List all State and Federal Financial Assistance during the fiscal year under audit, using the provided sections for each entry.
- Complete details about the Licensed Public Accountant, including Firm Name, Address, Telephone No., and License No. Attach a photocopy of the firm’s license if necessary.
- Certify your understanding of requirements by signing at the bottom of the form, ensuring that all information provided is accurate.
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