F-80479 - Audit Confirmation Request - Department Of Health Services printable pdf download

F-80479 - Audit Confirmation Request - Department Of Health Services

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Enterprise Services

F-80479 (01/2013)

AUDIT CONFIRMATION REQUEST

At the request of CPA firms, the Department of Health Services will provide confirmation of amounts paid on grant contracts to provider

agencies directly funded by the Department of Health Services and will identify differences wherever possible.

Mail completed request and self-

Voice:

(608) 266-0119

Audit Confirmation Coordinator

addressed envelope directly to:

Bureau of Fiscal Services, Room 750

Fax:

(608) 264-9874

1 W. Wilson Street, P.O. Box 7850

Faxed forms accepted

Madison, WI 53707-7850

1. Contact Person Name

2. Telephone Number

3. Grant Contract Recipient Name

4. Program Name

5. Purchase Order Number or Other Identifying Information

6. Grant Contract Periods

7. Grant Contract Amount

8. Amount Earned Per Grant Contract

9. Grant Contract Balance As Of

10. Does this Grant Include Federal

11. Catalog of Federal Domestic

12. Percentage of Federal Funds

Financial Assistance Dollars?

Assistance Number (CFDA)

Yes

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

SIGNATURE

Date Signed

Telephone Number

F-80479 - Audit Confirmation Request - Department Of Health Services