Sample Summary Report Form

* Indicates required fields

Fiscal Year End Information

Recipient Information

Executive Director





Fiscal Officer / Chief Financial Officer





IPA Contact Information








Please answer the following questions:

Does the audit indicate that LSC funds were considered major programs? If not, please refer to page 2 of the Audit Guide or page 3 of the Compliance Supplement which states that all LSC funds are considered major programs regardless of spending threshold. You must correct and resubmit the audit.
Yes No

Are the following report components included in the audit report?
If so, click under "included" and indicate the page numbers.
Page #
Financial Statement(s) 2 C.F.R. §200.510(a)

LSC Reporting Requirements: Separate Reporting of LSC Funds (LSC Financial Guide (January 2023), 3.1.1)
Are LSC funds categorized by type (e.g., grants, attorney fees, interest income, rental income, and other derivative income)?

LSC Reporting Requirements: Property Reported Separately from LSC Funds (LSC Financial Guide (January 2023), 3.6.1)
Is property presented in the financial statements by the value of LSC-funded vs. non-LSC funded property and equipment, including accumulated depreciation?

LSC Reporting Requirements: Separate Disclosure of Private Attorney Involement (PAI) Expenditures
Are funds expended toward PAI Expenditures, both LSC and non-LSC, clearly documented?

Opinion on the Financial Statement(s) 2 C.F.R. §200.515(a)

GAS Reports on Internal Control and Compliance 2 C.F.R. §200.515(b-c)

Reports on Compliance and Internal Control Over Major Programs 2 C.F.R. §200.515(b-c)

Schedule of Expenditures of Federal Awards 2 C.F.R. §200.510(b)

Schedule of Findings and Questioned Costs 2 C.F.R. §200.515(d)

GAS and Uniform Guidance Reports on Illegal Acts 2 C.F.R. §200.516(a)

Summary Schedule of Prior Audit Findings 2 C.F.R. §200.511(b)

Corrective Action Plan 2 C.F.R. §200.511(c)

Management Letter (If a management letter was issued, it must be included in the audit report submission.)
Did you perform the prior year annual audit of this recipient?
Yes No

Did you perform this year's audit under OMB 2 C.F.R. Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) Subpart F?
Yes No

Is this a close-out audit?
Yes No

Is a "going-concern" explanatory paragraph included in the audit report?
Yes No

Does the auditee have a subrecipient(s) that receives LSC funds?
Yes No
If 'Yes', please report the following: subrecipient(s) name(s), subgrant amount(s), and indicate whether the subgrant(s) are reported in the audited financial statements of the recipient, or in a separate audited financial statements of the subrecipient (up to 1000 characters allowed).

Did you note any related party and/or related-party transactions (LSC Financial Guide (January 2023), 3.7.4)?
Yes No
If 'Yes', please provide the page number where you reported this.

Did the recipient buy or sell real property during the period covered by this audit?
Yes No

Were you denied access to records during this audit?
Yes No
Did the recipient invoke attorney-client privilege or any other privilege for denying access?
If you answered 'Yes' to 11a, then the answer to 11 should also be 'Yes'.
Yes No
If you answered YES to Question 11 or 11a, describe the circumstances and how this issue was resolved:(up to 255 characters)

Does the audit include unresolved findings from prior years?
Yes No

Were there one or more 5-Day Letters, as defined by the LSC OIG Audit Guide, provided to grant recipient management?
Yes No

Audit Opinions

Please answer the following questions:

14. Audit Opinions

* 14a.
Financial Statements Audit Opinion:
Unmodified - Unqualified
Modified - Qualified
Modified - Adverse
Modified - Disclaimer

* 14b.
Compliance Audit Opinion:
Unmodified - Unqualified
Modified - Qualified
Modified - Adverse
Modified - Disclaimer

If either opinion was other than "Unmodified - Unqualified", please explain (up to 255 characters allowed):

Recipient Financial Information

NOTE: You must enter whole dollar amounts.

Total LSC Support: Please include the total and subtotals for the following categories:

Total LSC Basic Field, Agricultural Worker, and Native American Grants:

Total LSC Interest Income:

Total Other LSC Derivative Income (attorney fees, rental income, and other, see LSC Financial Guide (January 2023), 3.1.4 Derivative Income):

LSC Fund Balance, exclusive of property:
Fund balance cannot exceed total LSC support.
Note: If the excess fund balance exceeds 10% of LSC Support, the recipient must request a waiver within 30 days of submitting the Financial Statements (45 § 1628.4(a)).

If the fund balance exceeds 10% of LSC support, the recipient must request a waiver within 30 days of submitting the audit report or repay the fund balance in excess of 10% to LSC (LSC Financial Guide (January 2023). Please provide the date the recipient requested a waiver or date the recipient will request a waiver. If not applicable, leave blank.

Total PAI Expenditures (LSC Financial Guide (January 2023), 3.4 and footnote 12)
  • Include LSC and non-LSC fund expenditures for PAI.
  • Include only cash outlays/disbursements.
  • Do NOT include donated in-kind goods or services.

If the recipient requested a waiver, enter the date here. If not applicable, leave blank.

Total (not just the LSC portion of) current year program Audit Costs:
  • Do not include the cost of bookkeeping, tax or other services unrelated to the annual audit of recipient.


Submit Findings

Check the following if they following applies:

There Are No Instances of Non-Compliance:

There Are No Reportable Conditions (whether material or not material):

If either box is unchecked, you must complete at least one finding. All fields are required.
*Findings Code:
*Report Page:

*Question Cost:
*# Of Instances:

*Sample Size:

*Recipient Response:




Check the following boxes if they apply:

Additional Deficiencies / Recommendations are noted in audit reports and/or management letter.
Yes No

Number of Significant Deficiencies.


Number of Material Weaknesses.