Sample Summary Report Form

* Indicates required fields

Fiscal Year End Information

Grantee Information

Executive Director





Fiscal Officer / Chief Financial Officer





IPA Contact Information








Please answer the following questions:

Does the audit indicate that the auditee qualified as "high-risk"? If not, please refer to page 3 of the Compliance Supplement which states that the LSC grant is to be considered high-risk. 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 CFR §200.510(a)

LSC Reporting Requirements: Separate Reporting of LSC Funds
Are LSC funds categorized by type (e.g., grants, interest income, rental income, etc.)

LSC Reporting Requirements: Property Reported Separately from LSC Funds
Is property presented in the financial statements by the class of net assets that were used to purchase the property (i.e., LSC vs. non-LSC)

LSC Reporting Requirements: Separate Disclosure of PAI Expenditures.
Are funds expended toward PAI, both LSC and non-LSC, clearly documented

Opinion on the Financial Statement(s) 2 CFR §200.515(a)

GAS Reports on Internal Control and Compliance 2 CFR §200.515(b-c)

Reports on Compliance and Internal Control Over Major Programs 2 CFR §200.515(b-c)

Schedule of Expenditures of Federal Awards 2 CFR §200.510(b)

Schedule of Findings and Questioned Costs 2 CFR §200.515(d)

GAS and Uniform Guidance Reports on Illegal Acts 2 CFR §200.516(a)

Summary Schedule of Prior Audit Findings 2 CFR §200.511(b)

Corrective Action Plan Findings 2 CFR §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 CFR 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?
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 includes unresolved findings from prior years?
Yes No

Were there one or more 5-Day Letters, as defined by the LSC 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 Grant:

Total LSC Interest Income:

Total LSC Rental Income:

LSC Net Assets (Fund Balance), exclusive of property:
Fund balance can not exceed total LSC support.

Total PAI Expenditures:
  • Include non-LSC fund expenditures for PAI.
  • Include only cash outlays/disbursements.
  • Do NOT include donated services.

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.