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2. Disclaimer

   To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.

6. Subrecipient Risk Assessment

   Federal Uniform Guidance (2 CFR 200.206) Review of Risk – Before making an award of federal funds Jefferson County must complete a risk assessment of a subrecipient or contractor's ability to comply with federal statutes, regulations, and the terms and conditions of the sub-award at the outset of the relationship and at least annually afterward. 

   The following are questions necessary to complete the risk assessment.

8. Name of Organization or Business*
9. Employer Identification Number*

   EIN/FEIN - Federal Tax Identification Number

11. Doing Business As

    Other Names used by the Organization

13. Address*
15. City*
16. State*
17. Zip Code*
19. Contact Name*

    Name of person should Jefferson County have questions regarding your risk assessment form.

20. Contact Email*

    The best email address to reach the contact should Jefferson County have questions regarding your risk assessment.

21. Contact Phone Number*

    The best number to reach the contact should Jefferson County have questions regarding your risk assessment.

23. Most Recent Audited Financial Statement*

    Please upload the most recent audited financial statement.

27. 1. Total Amount of Operating Revenue*

    What is your total amount of revenue for operations in your last financial statement?

    1. Less than $250,000
    2. $250,000 to $499,999
    3. $500,000 to $999,999
    4. $1,000,000 to $1,999,999
    5. $2,000,000 to $4,999,999
    6. $5,000,000 +
28. 2. Federal Grants*

    Does your organization receive more than $750,000 in federal grant assistance?

    1. Yes
    2. No
29. 3. Previous Experience *

    Does your organization have previous experience in managing grants?

    1. Yes
    2. No
31. 4. Years of Experience Managing Grants*

    How many years of experience do you have in receiving and managing grants?

    1. No Experience
    2. 1 to 5
    3. 6 to 19
    4. 20 or more
32. 5. Years of Experience Managing Federal Grants*

    How many years of experience do you have in receiving and managing federal grants?

    1. No Experience
    2. 1 to 5
    3. 6 to 19
    4. 20 or more
33. 6. Years in Existence*

    How many years has your organization been in existence?

    1. 1 to 5
    2. 6 to 19
    3. 20 or more
35. 7. Previous Deliverables Met*

    Have you met your contract deliverables in the past?

    1. Yes
    2. No
    3. None
36. 8. Previous Deliverables Met (explanation)

    If answered "No", please explain. 

37. 9. Sub-Awards or Subcontracting*

    Do you intend to distribute funding to organizations outside of your Employer Identification Number (EIN) through a partnership or coalition to do some of the work for this grant?

    1. Yes
    2. No
39. 10. Significant Changes in Personnel*

    Have there been any significant changes in key personnel?

    1. Yes
    2. No
40. 11. Significant Changes in Personnel (explanation)

    If answered "Yes", please indicate where key personnel changes have occurred. 

41. 12. Office of Management and Budget Single Audit*

    Has your organization had an Office of Management and Budget (OMB) Single Audit?

    1. Yes
    2. No
43. 13. Office of Management and Budget Single Audit

    If answered "Yes", please indicate when the Office of Management and Budget (OMB) Single Audit was done.

44. 14. Office of Management and Budget Single Audit Findings

    What is the number of relevant Office of Management and Budget (OMB) single audit findings, both internal controls and program compliance, have you received?

    1. 3+
    2. <3
    3. None
    4. Not Applicable
45. 15. Auditing Standards*

    Have you had a Generally Accepted Auditing Standards (GAAS) or Generally Accepted Government Auditing Standards (GAGAS) Audit?

    An audit that is conducted under auditing standards that are used in the US to provide uniformity to all audits. For the purpose of this risk assessment ONLY, a financial review by an independent accountant is acceptable. 

    1. Yes
    2. No
47. 16. Unmodified Audit Report*

    Has an unmodified opinion been issued where the independent auditor states that the company's financial statements are sound and free from material misstatements?

    1. Yes
    2. No
    3. Not Applicable
48. 17. Accounting Records*

    Are your organization's accounting and financial records in accordance with Generally Accepted Accounting Principles (GAAP)? 

    For example, applying the matching principle by recording revenue when it is earned and expenses as they are incurred.

    1. Yes
    2. No
    3. Maybe
49. 18. Contract Funds Separately Accounted and Allocated*

    Are separate records financially maintained for each funding source and are not comingled with other funds?  

    This means that you can provide a financial report specific to each funding source.

    1. Yes
    2. No
    3. Maybe
51. 19. Source Documentation Maintained*

    Do you document and follow a procedure with internal controls to ensure proper segregation of spending between various Federal Awards and non-Federal expenditures?

    1. Yes
    2. No
    3. Maybe
52. 20. Cost Allocation Plan*

    Do you have a Cost Allocation Plan that identifies allowable direct and indirect costs; and provides the allocation method used for cost distribution to each entity, business unit, or program fairly?

    1. Yes
    2. No
53. 21. Adequate Cash Flow for Reimbursement Contract*

    Are you able to pay expenses prior to receiving payments from the grant?

    1. Yes
    2. No
    3. Maybe
55. 22. Time and Effort*

    Do you have an established system in place to track the time and effort associated with each grant?

    1. Yes
    2. No
    3. Maybe
56. 23. Prior Fiscal Performance*

    Do you have concerns regarding fiscal contract performance within the past 12 months?

    1. Yes
    2. No
57. 24. Prior Fiscal Performance (concerns)

    If answered "Yes", please explain any specific concerns you have regarding your fiscal contract performance within the last 12 months.

59. 25. Person(s) Responsible for Reporting*

    Who is the responsible person(s) for reporting?

60. 26. Person(s) Responsible for Grant Managment*

    Who is the person(s) responsible for grant management and responsible for ensuring an awarded grant is implemented effectively?

    This is the person(s) who creates and monitors application and review processes provides initial and ongoing communication with the grantor and ensures consistent grant processing, tracking, and compliance.

61. 27. Person(s) Responsible for Compliance*

    Who is the responsible person(s) for compliance?

63. 28. Provision of all Performance, Financial, and Other Reports*

    Will you as a subrecipient to the Jefferson County grant be able to provide all necessary performance, financial, or other reports? (In accordance with 2CFR §200.331)

    1. Yes
    2. No
64. 29. Attestation*

    By clicking "Agree", you represent that the information provided in this form is true, correct, and complete to the best of your knowledge. You further understand that any false or misleading statements may result in denial or revocation of the award.

    1. Agree
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66. Submit

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