Single Audit Act Information

Application must provide the following information as required by OMB Circular No. A-133 "Audit of States, Local Governments, and Non-Profit Organization".

Period of Fiscal Year_________________________________
(Example: 07/01/95-06/30/96 or 10/30/95-09/30/96)

Name and Address of designated Cognizant Federal Agency
(Example: HHS, DOL, HUD, DOJ, DOI, DOJ, Agriculture)

______________________________________________________
Name

______________________________________________________
Title

______________________________________________________
Address

______________________________________________________
City, State, and ZIP Code