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Exhibit D – Risk Assessment
The Risk Assessment shall be completed and provided to the City of Fresno Finance Department. Information contained within the Risk Assessment is collected for contract compliance purposes.
Grantee Contact Information
Full Legal Organization/Business Name:
Address:
City, State, Zip:
Telephone number:
E-mail address:
Website:
How long has your organization been in business?
Number of employees:
EIN (Employee ID Number):
Organization fiscal year range:
Grantee Type of Organization (select one):
Government
Nonprofit
corporation
Other
corporation
Individual
Grantee Personnel Contact Information
Name:
Title:
Telephone
Number:
E-mail Address:
Attachments: Please attach the following or check N/A if not applicable.
Document Attached N/A
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a. IRS Determination Letter
(granting income tax exemption
under IRC § 501(c)(3))
b. Form 990 or 990-EZ from the
last two (2) years, including
Form 990-T and all supporting
schedules and attachments
c. List of all awards to Service
Provider from City of Fresno
during the last two (2) years
1. Has your agency operated with or managed grant funds (within the last 3 years)? Yes
No
2. Has your agency’s annual financial statements been audited by an independent audit firm? If yes, provide a copy of the statement from the last fiscal year.
Yes
No
3. If the answers to Questions 2 or 3 is yes, were there any findings or questioned costs in the last two (2) fiscal years? If yes, please explain any findings or questioned costs.
Yes
No
Not Applicable
Explanation (if applicable):
4. Are all payments properly documented with evidence or receipt of goods or performance of services?
Yes
No
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5. Has your agency had any significant changes in key personnel within the past 12 months? (e.g., Controller, Exec. Director, Program Manager, Accounting Manager, etc.) If yes, please explain.
Yes
No
Explanation (if applicable):
6. Does your agency have policies that address the following? If yes, please provide a copy.
Ethics/Professional Conduct Yes No Pay Rates and Benefits Yes No Discrimination Yes No
Purchasing/Procurement Yes No Property and Equipment Yes No Segregation of Duties Yes No Record Retention Yes No
7. Does your agency certify that they are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in this transaction by any Federal or State department or agency? Yes
No
By its authorized signatory below, your agency hereby certifies and attests to the accuracy of the above responses and all corresponding information has been transmitted to the City of Fresno Finance Department.
Signature: ______________________________________________________ Printed Name: __________________________________________________ Title: __________________________________________________________ Phone Number: __________________________________________________ Date: ___________________________________________________________