Fund Balance Waiver Request for Fiscal Year 2020 Grant Funds

Please use this form to provide the requested information regarding your fiscal year 2020 excess LSC fund balance.

Organization Name*

Enter the full name of your organization.

Recipient Identification Number (RNO)*

Enter your LSC-issued, six-digit Recipient Identification Number.

Calculate and enter LSC support amount for fiscal year 2020.*

Per 45 CFR § 1628.2(b), LSC support is the sum of: 1) the amount of financial assistance awarded by the Corporation to the recipient for the fiscal year included in the recipient's annual audited financial statement, not including one-time and special purpose grants; and 2) any LSC derivative income, as defined in 45 CFR § 1630.2(b), earned by the recipient for the fiscal year included in the recipient's annual audited financial statement, not including derivative income from one-time and special purpose grants.

Calculate and enter LSC fund balance for fiscal year 2020.*

The LSC fund balance is the excess of LSC support plus the prior year carryover amount over expenditures of LSC funds (including capital acquisitions), as each is reported in the recipient's annual financial statements.

Calculate and enter LSC fund balance percentage for fiscal year 2020.*

Divide fund balance by LSC support amount for the year.

Is your LSC fund balance percentage above 25%?*

Select or enter value

Provide the reason(s) for the excess fund balance between 10% and 25%.*

Provide the reason(s) justifying excess fund balance above 25%.*

Per 45 CFR § 1628.3(c), recipients may request a waiver to retain a fund balance in excess of 25% of a recipient's LSC support only for extraordinary and compelling circumstances, such as when a natural disaster or other catastrophic event prevents the timely expenditure of LSC funds, or when the recipient receives an insurance reimbursement, the proceeds from the sale of real property, a payment from a lawsuit in which the recipient was a party, or a payment from an LSC-funded lawsuit, regardless of whether the recipient was a party to the lawsuit.

Calculate the amount that will be carried-over into the following fiscal year.*

See 1628.4(a)(4).

Provide the narrative detail on your plan, including timeframes, to spend the excess fund balance.*

Provide the date you submitted the AFS to the OIG.*

Per 45 CFR § 1628.4(a), is your fund balance waiver request timely?*

Per 45 CFR § 1628.4(a), a recipient may request a waiver of the 10% ceiling on LSC fund balances within 30 days after the submission to LSC of its annual audited financial statements.

Select

Provide the reason(s) for late waiver request submission.*

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