OMB No. 0348-0057 

EVIEW

NLY 

Data Collection Form for Reporting on

AUDITS OF STATES, LOCAL GOVERNMENTS, AND NON-PROFIT ORGANIZATIONS 

for Fiscal Year Ending Dates in 2010, 2011, or 2012 

FORM SF-SAC (12-15-2009) 

U.S. DEPT. OF COMM.– Econ. and Stat. Admin.– U.S. CENSUS BUREAU 

GENERAL 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 covered 

Program-specific audit 

Annual Other – Months Biennial 

PART I 

5. 

2. 3. 

b. Yes No 

AUDITEE INFORMATION 6. 

City 

ZIP + 4 Code 

// 2 

1 

2 

3 

1 2 

Month Day Year 

Complete this form, as required by OMB Circular A-133, "Audits of States, Local Governments, and Non-Profit Organizations." 

b. 

a. Auditee name

Auditee address 

c. Auditee contact

(Number and street) 

City State 

b. 

4. Auditee Identification Numbers 

ACTING AS COLLECTING AGENT FOR 

OFFICE OF MANAGEMENT AND BUDGET 

1 Single audit

ZIP + 4 Code 

_ _ 

_ 

d. Data Universal Numbering System (DUNS) Number 

_ _ 

a. Primary Employer Identification Number (EIN)

e. 1 2 Yes No

c. f. 

Are multiple EINs covered in this report? If Part I, Item 4b = "Yes," complete Part I, Item 4c on the continuation sheet on Page 4. 

Primary auditor contact 

State Primary auditor address (Number and street) Primary auditor name 

PRIMARY AUDITOR INFORMATION (To be completed by auditor) 

If Part I, Item 4e = "Yes," complete Part I, Item 4f on the continuation sheet on Page 4. Are multiple DUNS covered in this report? 

a. c. 

1. 
EVIEW

NLY Is a significant deficiency disclosed for any major program? (§ ___ .510(a)(1)) 

Type of audit report 

Unqualified opinion OR 

Qualified opinion 

1. 

Adverse opinion Disclaimer of opinion 

3. Is a significant deficiency disclosed? Yes No – SKIP to Item 54. Is any significant deficiency reported as a material weakness? Yes5. Is a material noncompliance disclosed? 1 Yes No 

1 

1 1 

3 4

2 

2 

2 No

2 

2. Is a "going concern" explanatory paragraph included in the audit report? 1 Yes 2 No

3. Did the auditee qualify as a low-risk auditee? (§___ .530) 1 Yes No 2 

$ 2. What is the dollar threshold to distinguish Type A and Type B programs? (OMB Circular A-133 §___ .520(b)) 

PART III FEDERAL PROGRAMS (To be completed by auditor) 

Is any significant deficiency reported for any major program as a material weakness? (§ 

510(a)(1)) 

5. 

1 Yes 2 No 

4. 1 Yes 2 No –SKIP to Item 6 

1. Does the auditor’s report include a statement that the auditee’s financial 

statements include departments, agencies, or other organizational units expending $500,000 or more in Federal awards that have separate A-133 audits which are not included in this audit? (AICPA Audit Guide, Chapter 12) 1 2 Yes No 

Mark either: any combination of: 

_ Primary EIN: 

PART II FINANCIAL STATEMENTS (To be completed by auditor)
Base prints black SF-SAC, page 3, Pantone 100 Yellow, 20% tone

PREV

ONL

PART III FEDERAL PROGRAMS – Continued

FEDERAL AWARDS EXPENDED DURING FISCAL YEAR 

Federal

Agency

Prefix1 

(b) 

Name of Federal

program

(e) 

9. 

TOTAL FEDERAL AWARDS EXPENDED

2 Or other identifying number when the Catalog of Federal Domestic Assistance (CFDA) number 

5 Enter the letter(s) of all type(s) of compliance requirement(s) that apply to audit findings (i.e., no

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 

F. Equipment and real property managem

Research

and

development

Y

N

(c) 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

CFDA Number

Extension 2 

1 See Appendix 1 of instructions for valid Federal Agency two-digit prefixes.

.

.

.

.

.

.

.

.

.

. 

(a) 

A3

(d) 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

Y

N 

1

2 

A

R

R 

Y

N 

1

2 

4 If major program is marked "Yes," enter only o n e letter (U = Unqualified opinion, Q = Qualified 

type of audit report in the adjacent box. If major program is marked "No," leave the type of audit 

3 American Recovery and Reinvestment Act of 2009 (ARRA). 

FORM SF-SAC (12-15-2009) Page 3 

6 N/A for NONE 
Base print black SF-SAC, page 4, Pantone 100 Yellow, 20% tone

PRE

ONL

_ 

_ 

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

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15 

_

_

_

_

_

_

_ 

16

17 

18

19

20

_

_

_

_

_

_

_

_

_

_

_

_

_ 

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37 

38

39

40

_

_

_

_

_

_

_

_

_

_

_

_

_

_

_

_

_

_

_ 

_

_

_

_

_

_

_

_

_

_

_

_

_

_

_

_

_

_

_ 

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57 

58

59

60

Item 5 Continuation Sheet PART I 

Page 4 FORM SF-SAC (12-15-2009) 
Base prints black SF-SAC, page 3, Pantone 100 Yellow, 20% tone

PRE

ON

PART I GENERAL INFORMATION – Continued

Part I, Item 8, Secondary Auditor’s Contact Information. (List the Secondary Auditor’s Co8. 

Secondary Auditor name a. 

Secondary Auditor address (Number and street) 

Secondary Auditor contact c. 

City

State 

Name

Title

Secondary Auditor contact telephone

b.

d.

e.

f. 

( )

 –

ZIP + 4 Code _ 

Secondary Auditor contact FAX

( )

Secondary Auditor contact E-mail

 – 

1. Secondary Auditor nam

a.

c. 

City

State 

Name

Title

b.

d.

e.

f. 

( )

 –

ZIP + 4 Code 

2. 

Secondary Auditor name a.

c. 

City

State 

Name

Title

b.

d.

e.

f. 

( )

 –

ZIP + 4 Code _ 

( )

Secondary Auditor contact E-mail

 – 

4. 

Secondary Auditor conc. 

Name

Title 

Secondary Auditor con

b.

d.

e.

f. 

( )

 –

ZIP + 4 Code 

Secondary Auditor con

( )

Secondary Auditor con

 – 

5. 

Secondary Auditor add

Secondary Auditor con

Secondary Auditor con

( )

 – Secondary Auditor con

Secondary Auditor con

Secondary Auditor nama. 

Secondary Auditor add

City 

State

Secondary Auditor address (Number and street)

Secondary Auditor contact 

Secondary Auditor contact telephone

Secondary Auditor contact FAX

FORM SF-SAC (12-15-2009) Page 5