Free Audit Confirmation Request - F-80479 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80479 (06/08)

STATE OF WISCONSIN

AUDIT CONFIRMATION REQUEST
Mail completed request and selfaddressed envelope directly to: Audit Confirmation Coordinator Bureau of Fiscal Services, Room 750 1 W. Wilson Street, P.O. Box 7850 Madison, WI 53707-7850
2.

Voice: (608) 267-7104 Fax: (608) 264-9874 Faxed forms accepted.
Telephone Number

1. Contact Person Name

3. Grant Recipient Name

4. CARS Agency Number

5. Program Name

6. CARS Profile Number

7. Contracts NOT on CARS: Purchase Order No. or Other Identifying Information

8. Contract Periods

9. Contract Amount

10. Amount Earned Per Contract

To
(month) (day) (year) (month) (day) (year) 11. Contract balance as of (month) (day) (year)

$
13. Catalog of Federal Domestic Assistance Number (CFDA) 14. Percentage of Federal Funds

12. Does this grant include federal financial Yes No assistance dollars?
Signature

The above information agrees with our records, except as indicated. (To be completed by Audit Confirmation Coordinator.)
Date Signed Telephone Number

Purpose of Form: At the request of CPA firms, the Department of Health and Family Services will provide confirmation of amounts paid on grants to provider agencies directly funded by the Department and will identify differences wherever possible. Photocopying of the form is encouraged. Confirmation requests of amounts paid on grants administered by other State Agencies (i.e. Department of Workforce Development) will be returned to the CPA firm and should be directed to the Agency administering the grant. The Department does not prepare schedules for grants paid to agencies. However, the Department will provide copies of the year-end F-80603 if requested by the agency or their auditors. Requests should be directed to the following address: Department of Health Services CARS Unit, Room 736 1 W. Wilson Street, P. O. Box 7850 Madison, WI 53707 Telephone: (608) 267-7104