**Base prints black SF-SAC, page 1, Pantone 100 Yellow, 20% tone** OMB No. 0348-0057NOT FOR SUBMISSION NOT FOR SUBMISSIONNOT FOR SUBMISSION NOT FOR SUBMISSIONNOT FOR SUBMISSION NOT FOR SUBMISSIONNOT FOR SUBMISSION NOT FOR SUBMISSIONNOT FOR SUBMISSION NOT FOR SUBMISSIONNOT FOR SUBMISSION NOT FOR SUBMISSIONNOT FOR SUBMISSION NOT FOR SUBMISSIONNOT FOR SUBMISSION NOT FOR SUBMISSIONNOT FOR SUBMISSION NOT FOR SUBMISSIONNOT FOR SUBMISSION NOT FOR SUBMISSIONNOT FOR SUBMISSION NOT FOR SUBMISSIONNOT FOR SUBMISSION NOT FOR SUBMISSION PREVIEW ONLYData Collection Form for Reporting onAUDITS OF STATES, LOCAL GOVERNMENTS, AND NON-PROFIT ORGANIZATIONSfor Fiscal Year Ending Dates in 2010, 2011, or 2012FORMSF-SAC(12-15-2009)U.S. DEPT. OF COMM.–Econ. and Stat. Admin.–U.S. CENSUS BUREAUGENERAL INFORMATION(To be completed by auditee, except for Items 6, 7, and 8)Fiscal period ending date for this submission Type of Circular A-133 audit Audit period coveredProgram-specific auditAnnual Other – MonthsBiennialPART I5.2.3.Yesb.NoAUDITEE INFORMATION6.Primary auditor contact telephonePrimary auditor contact FAXPrimary auditor contact E-mailNameTitleCityZIP + 4 Code//21231 2Month Day YearComplete this form, as required by OMB Circular A-133, "Audits of States, Local Governments, and Non-Profit Organizations."b.d.e.f.Auditee namea.Auditee addressAuditee contactc.Auditee contact telephoneNameTitle(Number and street)CityStateb.d.e.f.( )–( )–( )–4. Auditee Identification NumbersACTING AS COLLECTING AGENT FOROFFICE OF MANAGEMENT AND BUDGETg.g.Single audit1_ZIP + 4 Code__d.Data Universal Numbering System (DUNS) Number__Primary Employer Identification Number (EIN)a.Yese.No1 2c.f.AUDITOR STATEMENT –The data elements and informationincluded in this form are limited to those prescribed by OMBCircular A-133. The information included in Parts II and III of theform, except for Part III, Items 7, 8, and 9a-9g, was transferredfrom the auditor’s report(s) for the period described in Part I, Items1 and 3, andis not a substitutefor such reports. The auditorhas not performed any auditing procedures since the date of theauditor’s report(s). A copy of the reporting package required byOMB Circular A-133, which includes the complete auditor’sreport(s), is available in its entirety from the auditee at the addressprovided in Part I of this form. As required by OMB Circular A-133,the information inParts IIandIIIof this form was entered in thisform by the auditor based on information included in the reportingpackage. The auditor has not performed any additional auditingprocedures in connection with the completion of this form.Are multiple EINs covered in this report?If Part I, Item 4b = "Yes," complete Part I, Item 4con the continuation sheet on Page 4.AUDITEE CERTIFICATION STATEMENT –This isto certify that, to the best of my knowledge and belief, theauditee has: (1) engaged an auditor to perform an auditin accordance with the provisions of OMB Circular A-133for the period described in Part I, Items 1 and 3; (2) theauditor has completed such audit and presented a signedaudit report which states that the audit was conducted inaccordance with the provisions of the Circular; and, (3)the information included inParts I, II,andIIIof thisdata collection form is accurate and complete. I declarethat the foregoing is true and correct.Auditee contact E-mailAuditee contact FAXPrimary auditor contactStatePrimary auditor address(Number and street)Primary auditor namePRIMARY AUDITOR INFORMATION(To be completed by auditor)If Part I, Item 4e = "Yes," complete Part I, Item 4fon the continuation sheet on Page 4.Are multiple DUNS covered in this report?a.c.( )–7a.Add Secondary auditor information? (Optional)YesNo12b.If "Yes," completePart I, Item 8on the continuationsheet on page 5.Auditee certificationName of certifying officialTitle of certifying officialAuditor certificationDateDate1.**Base prints black SF-SAC, page 2, Pantone 100 Yellow, 20% tone**  PREVIEW ONLYIs a significant deficiency disclosed for any major program? (§ ___ .510(a)(1))Type of audit reportUnqualified opinionORQualified opinion1.Adverse opinion Disclaimer of opinionIs a significant deficiency disclosed?Yes No –SKIP to Item 53.Is any significant deficiency reported as a material weakness?Yes4.Is a material noncompliance disclosed?Yes No5.11114322No22Is a "going concern" explanatory paragraph included in the audit report?Yes2.1No2Indicate whichFederalagency(ies) have current year audit findings related todirectfunding or prior audit findings shownin the Summary Schedule of Prior Audit Findings related todirectfunding.(Mark (X) all that apply or None)8.AgricultureCommerceDefenseEducationEnergyEnvironmentalProtection AgencyHealth and Human ServicesHousing and UrbanDevelopmentInteriorJusticeLaborNational ScienceFoundationSocial SecurityAdministrationU.S. Departmentof StateTransportationTreasuryVeterans Affairs9843Small BusinessAdministrationNational Endowment forthe ArtsNational Aeronautics andSpace AdministrationCorporation for Nationaland Community Service1764161514936681841294111005475996192021Institute of Museum andLibrary Services03Office of National DrugControl Policy0789National Archives andRecords AdministrationGeneral Services Administration39National Endowment forthe Humanities06Other –Specify:Did the auditee qualify as a low-risk auditee? (§___ .530)Yes No3.12Were Prior Audit Findings related todirectfunding shown in the Summary Schedule ofPrior Audit Findings? (§___.315(b))7.Yes No12$2.What is the dollar threshold to distinguish Type A and Type B programs?(OMB Circular A-133 §___ .520(b))PART IIIFEDERAL PROGRAMS(To be completed by auditor)Are any known questioned costs reported? (§ ___ .510(a)(3) or (4))Yes No6.12Is any significant deficiency reported for any major program as a materialweakness? (§ ___ .510(a)(1))5.1Yes2No4.1Yes2No –SKIP to Item 61.Does the auditor’s report include a statement that the auditee’s financialstatements include departments, agencies, or other organizational unitsexpending $500,000 or more in Federal awards that have separate A-133audits which are not included in this audit? (AICPA Audit Guide, Chapter 12)Yes No1 2**None**00U.S. Agency for International DevelopmentAppalachian RegionalCommission23Legal Services Corporation09Homeland Security97Mark either:any combination of:_Primary EIN:FINANCIAL STATEMENTS(To be completed by auditor)PART IIFORM SF-SAC (12-15-2009)Page 2Base prints blackSF-SAC, page 3, Pantone 100 Yellow, 20% tone 

# PREVIEW ONLY PART III FEDERAL PROGRAMS – Continued

FEDERAL AWARDS EXPENDED DURING FISCAL YEAR Major program Federal Agency Prefix **1** (b) Type(s) of compliance requirement(s) **5** (a) 

### Y N Audit finding reference number(s) **6** Name of Federal program (e) (f) 

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**2** Or other identifying number when the Catalog of Federal Domestic Assistance (CFDA) number is not available. (See Instructions)

**5** Enter the letter(s) of all type(s) of compliance requirement(s) that apply to audit findings (i.e., noncompliance, significant deficiency (including material weaknesses), questioned

costs, fraud, and other items reported under §___ .510(a)) reported for each Federal program. A. Activities allowed or unallowed B. Allowable costs/cost principles C. Cash management D. Davis – Bacon Act E. Eligibility G. Matching, level of effort, earmarking H. Period of availability of Federal funds I. Procurement and suspension and debarment L. Reporting M. Subrecipient monitoring N. Special tests and provisions O. Program income Real property acquisition and J. K. F. Equipment and real property management 10. Direct award 

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**4** If major program is marked "Yes," enter only o n e letter ( U = Unqualified opinion, Q = Qualified opinion, A = Adverse opinion, D = Disclaimer of opinion) corresponding to the

type of audit report in the adjacent box. If major program is marked "No," leave the type of audit report box blank. **3** American Recovery and Reinvestment Act of 2009 (ARRA). If yes, type of audit report **4** Major program 

### _ Primary EIN:FORM SF-SAC (12-15-2009)Page 3 relocation assistance P. Other **6** N/A for NONEBase print blackSF-SAC, page 4, Pantone 100 Yellow, 20% tone 

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_ _ List the multiple Employer Identification Numbers (EINs) covered in this report. c. 

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38 39 40 37 _ Primary EIN: Item 5 Continuation Sheet 

### PART IPage 4FORM SF-SAC (12-15-2009)Base prints blackSF-SAC, page 3, Pantone 100 Yellow, 20% tone 

### _ Primary EIN: 

# PREVIEW ONLY PART I GENERAL INFORMATION – Continued

Part I, Item 8, Secondary Auditor’s Contact Information. (List the Secondary Auditor’s Contact information) 8. Secondary Auditor name a. Secondary Auditor address (Number and street)

Secondary Auditor contact c.

Secondary Auditor contact telephone Name
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### _ 2. Secondary Auditor name a. Secondary Auditor address (Number and street)

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# ( ) – 6. Secondary Auditor address (Number and street)

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Secondary Auditor contact FAX Secondary Auditor contact telephone Secondary Auditor contactFORM SF-SAC (12-15-2009)Page 5