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Public Assistance Applicant Survey – Federal Requirement for Risk Assessments
NOTE: This form only needs to be completed once per disaster, per applicant.
Public Assistance Applicant Survey
Contact Information
Applicant
*
Municipality or Organization Name
Primary Applicant Authorized Representative Name
*
First
Last
Please indicate or verify the Authorized Representative for this disaster.
Title within Organization
*
Email
*
Enter Email
Confirm Email
Phone
*
What Disaster Are You Completing This Form For?
Select
DR 4316 - March 2017 Severe Winter Storm
DR 4329 - July 2017 Severe Storms and Flooding
DR 4355 - October 2017 Severe Storm and Flooding
DR 4370 - March 2018 Severe Storm and Flooding
DR 4371 - March 2018 Severe Winter Storm and Snowstorm
DR 4457 - July 2019 Severe Storm and Flooding
DR 4516 - COVID-19 Pandemic
DR 4622 - July 17-19 Severe Storm and Flooding Cheshire County
DR 4624 - July 29-Aug 2 Severe Storm and Flooding Cheshire/Sullivan County
DR 4693 - December 22-25 Severe Storm and Flooding
DR 4740 - July 9-17 Severe Storm and Flooding
Other
Does your Municipality or Organization have prior experience with the Public Assistance grant program?
*
Please select the option that best represents your Municipality or Organization.
Participated in 3 or more disasters within the last 5 years.
Participated in 1-2 disasters within the last 5 years.
No prior experience with the Public Assistance Grant Program within the last 5 years.
Has your Municipality or Organization experienced turnover of any staff who manage the Public Assistance grant since your most recent involvement in the Public Assistance Program?
*
Yes
No
Please explain the key position(s) that experienced turnover and briefly describe each position's role in managing the Public Assistance Program.
*
Audit Certification
In accordance with 2 CFR 200 Uniform Administrative Requirements, Cost Principles and Audit Requirements, found in §200.501(a), audit requirements for Federal awards, non-federal entities that expend $750,000 or more in federal awards from all federal funding sources during their fiscal year, must agree to have a Single Audit conducted in accordance with §200.514 Scope of Audit. Further, §200.512 requires that the final report for such audit be completed within nine (9) months of the entity’s fiscal year end.
Are you a NH State agency?
*
Yes, we are a state agency
No, we are not a state agency
What is your Organizations current fiscal year?
*
(Month/Year - Month/Year)
Check the Appropriate Box:
*
We did NOT exceed the federal expenditure threshold of $750,000 for the fiscal year referenced above. A Single Audit is not required for this fiscal year. (However, you are still required to submit your organization's most recent audit for review)
We DID meet or exceed the federal expenditure threshold of $750,000 for the fiscal year referenced above.
We are exempt from the Single Audit Requirement – explain below
Please Explain why your Organization is exempt from the Single Audit Requirement:
*
Check the appropriate box:
*
We completed our Single Audit/other audit type for the above fiscal year and our report is attached.
Our Single Audit/other audit type for our fiscal year referenced above will be completed at a future date.
Attach your Organization's Single Audit/other audit documentation.
*
Max. file size: 1 GB.
The Single Audit/other audit type for our fiscal year referenced above will be completed on:
*
MM slash DD slash YYYY
The Single Audit/other audit type for our fiscal year referenced above will be submitted to NHPA@dos.nh.gov by:
*
MM slash DD slash YYYY
Attach your Organization's most recent Single Audit/other audit documentation.
*
This is for applicants who have not yet completed an audit for the most recent fiscal year. While your audit is being completed, please upload the most recent audit that has been completed.
Max. file size: 1 GB.
*
I certify that I am an individual authorized to complete this form. I further certify that the above information is accurate and, if required, the audit report will be submitted no later than nine (9) months after the fiscal year ending noted above.
