Subrecipient Single Audit Submission Form

Uniform Guidance at 2 CFR 200 requires MSDH to collect and review the results of Single Audits of our subrecipients. Please complete the form below. If you have questions, please contact the Office of Internal Audit, Subrecipient Monitoring Unit at 601-576-7510 or SubgranteeAudit@msdh.ms.gov.

Organization Name

Employer Identification Number (EIN)

Unique Entity Identifier (UEI)

Financial Contact Name

Financial Contact Email

Financial Contact Phone Number

Phone

Most Recently Completed Fiscal Year End

mm/dd/yyyy

For the most recently completed year end listed above, was your organization required to comply with the OMB Uniform Guidance at 2 CFR 200 Subpart F - Audit Requriements?

Yes

No, we are a U.S. federal government agency.

No, we are a U.S domestic entity that is a for-profit organization.

No, we are a U.S domestic entity that did not expend $750,000 (prior to Oct. 1, 2024) or $1,000,000 (after Oct. 1, 2024) in U.S federal funds during the most recently completed fiscal year.

No, we are a non-U.S. based (foreign) entity that did not expend $750,000 (prior to Oct. 1, 2024) or $1,000,000 (after Oct. 1, 2024) in U.S. federal funds during the most recently completed fiscal year.

Name of Person Completing the Form

Title of Person Completing this Form

I certify that I am authorized to complete and submit this form to MSDH on behalf of my organization.

Please initial.

Send me a copy of my responses

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