FINANCIAL QUESTIONNAIRE

FOR
PROSPECTIVE FREEDOM HOUSE SUBGRANTEES
Accepting a subgrant from Freedom House creates a legal duty for the subgrantee to use the funds
according to the Subgrant Agreement and US Federal regulations.
This Questionnaire will help Freedom House (FH) assess the financial systems of a prospective
Freedom House subgrantee. Currently, your proposal is being considered by Freedom House.
Answer each question completely, using extra pages if necessary. Return your completed questionnaire
with requested attachments to Freedom House as soon as possible. Your questionnaire must be received
by Freedom House before Freedom House can issue any potential subgrant.
If you do not understand some of the terms used in this Questionnaire, please reference the Glossary of
Terms on the last page of this questionnaire.
Complete the Questionnaire and checklist on page 13, sign and return it (along with any
attachments) to Freedom House. You may either: mail, fax, or email the Questionnaire. Please note
that Freedom House will not be able to accept any incomplete or unsigned questionnaires.
Mail:

Ms. Elizabeth Donkervoort

Freedom House
1301 Connecticut Avenue, NW
Washington, DC 20036

Fax:

Ms. Elizabeth Donkervoort

Freedom House
+1 202-293-2840

E-mail:

donkervoort@freedomhouse.org

Reviewed by:

Date:

Last Updated 11/08/2011

Page 1 of 14

CONTACT INFORMATION
Please complete this section so that we can communicate with each other.
Legal Name of Organization (that will sign the Subgrant Agreement and accept responsibility for FH
funds, if awarded):
____________________________________________________________________________________
Name of Contact: _____________________________________________________________________
Name of Individual(s) Legally Authorized to Sign on Behalf of the Organization: ________________
____________________________________________________________________________________

Mailing Address

Street Address (necessary for express delivery)

Street

Street

City

City

Country

Country

Postal Code

Postal Code

Telephone (include all country and city codes):

Country Code: ________

City Code: ________ Phone Number: ____________________

Email:

Fax:

____________________________

Skype:
1. Do you have access to the internet?

Yes:

No:

2. Do you have access to email?

Yes:

No:

3. Can your email open WORD files sent as an attachment? Yes:

No:

Additional Comments (on how we can more easily stay in touch with you):
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

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SECTION A: General Information

Please complete this section to provide general information about your organization.
1. What type of organization are you (non-profit, for profit (commercial), university, etc.)?
_______________________________________________________________________________
2. Is your organization incorporated or legally registered?
Yes:

No:

(explain)

_______________________________________________________________________________
_______________________________________________________________________________
2a. When and where was your organization incorporated or registered?
_______________________________________________________________________________
_______________________________________________________________________________
2b. Please provide a copy of your organization's incorporation or registration certificate.
Enclosed:

Not Enclosed:

(explain):

_______________________________________________________________________________
_______________________________________________________________________________
3. Is your organization required to pay taxes on revenue or income or is it exempt from paying
taxes?

Required to pay taxes on revenue or income:

Not required to pay taxes on revenue or income:
_______________________________________________________________________________

4. If based in the US, is your organization tax exempt under 501(c)(3) of the IRS code?
Please provide a copy of your IRS determination letter.
501(c)(3):

501(c)(3) letter not enclosed (explain):

Not 501(c)(3):

_______________________________________________________________________________
_______________________________________________________________________________
5. Please provide copies of any materials which describe your organization, its mission and
history.

Enclosed:
Not Enclosed:
(explain)
_______________________________________________________________________________
_______________________________________________________________________________

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6. Is your organization affiliated with any other organization?

Yes:

No:

If yes, please provide details:

_______________________________________________________________________________
_______________________________________________________________________________
7. Please list the names of the members of the Board of Directors or Board of Trustees and their
position titles (Chairman, Secretary, Treasurer, regular member, etc.) and provide an
organizational chart, if available:
Position Title

Name

__________________________________

______________________________________

__________________________________

______________________________________

__________________________________

______________________________________

__________________________________

______________________________________

__________________________________

______________________________________

__________________________________

______________________________________

8. Please list the names of principals and key personnel that will have responsibility for carrying
out the programmatic activities described in your project proposal.
Position Title

Name

__________________________________

______________________________________

__________________________________

______________________________________

__________________________________

______________________________________

9. Please list all staff members who have responsibility for accounting including budgeting and
banking. If one or more of these positions does not exist in your organization, please leave it
blank.
President: ___________________________________ paid position: _____ volunteer position: _____
Secretary-General: ___________________________ paid position: _____ volunteer position: _____
Executive Director: ___________________________ paid position: _____ volunteer position: _____
Chief Financial Officer: ________________________ paid position: _____ volunteer position: _____
Accountant: __________________________________paid position: _____ volunteer position: _____
Bookkeeper: _________________________________ paid position: _____ volunteer position: _____
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Accounting Firm: _____________________________ paid position: _____ volunteer position: _____

Other (list position): ___________________________ paid position:

_____ volunteer position: _____

Other (list position): ___________________________ paid position:

_____ volunteer position: _____

Other (list position): ___________________________ paid position: _____ volunteer position: _____
10. List the number of employees in your organization:
Full-Time Employees: ______ Part-Time Employees: _______ Consultants: ______ Volunteers: ____
11. Enter the beginning and ending dates of your organization's fiscal (financial) year:
From: (Month, Day) _________________

To: (Month, Day)

_______________

12. Will your organization have support from other funding sources, specifically for the project
described in your proposal to FH, during the period of the FH subgrant, if it is awarded?
Yes:

No:

12a. If yes, please complete section I of the enclosed Current Funding and Past Performance Data
Sheet.
13. Will your organization have support from other funding sources, for activities OTHER than the
project described in your proposal to FH, during the period of the FH subgrant, if it is awarded?
Yes:

No:

13a. If yes, please complete section II of the enclosed Current Funding and Past Performance Data
Sheet.
14. Has your organization previously received donor funds for past projects?
Yes:

No:

14a. If yes, please complete section III of the enclosed Current Funding and Past Performance Data
Sheet.

15. Current Funding and Past Performance Data Sheet is enclosed: Yes:
No: (explain)
_______________________________________________________________________________
_______________________________________________________________________________
16. Did 80% of funds your organization received in the previous fiscal year consist of US
Government funds?
Yes:

No:

17. Did your organization receive more than $25,000,000 in US Government funds in the previous
fiscal year?
Yes:

No:
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18. If you answered yes for both questions 16 and 17, please provide a list of your
organizations five most highly-compensated employees.
1._______________________
2._______________________
3._______________________
4._______________________
5._______________________
____________________________________________________________________________________

SECTION B: Internal Controls

Internal controls are your procedures which make sure that: 1) expenses are approved by an authorized
person as required by laws, regulations, and your organizations policies, 2) money and equipment are
kept safely, and 3) accounting records are complete, accurate and kept on a regular basis. Please
complete the following questions concerning your organization's internal controls.
1. List the name and the position title for the people responsible for the following:
Responsible for:

Name(s) and position title(s)

Cash
Bank Accounts
Equipment
Approving Expenses
Checking expenses to make sure
they are allowable
Keeping all invoices and other
expense documentation for this
grant
Signing checks and/or authorizing
bank transfers
Maintaining accounting records
Reconciling bank statements to
the accounting records
Preparing financial reports
Preparing narrative reports
2. Are any members of the staff or board related? Yes:

No:

2a. If yes, identify and state relationship (spouse, child, parent, sibling, cousin, etc.)
Name
Name of relative
Relationship

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3. Are timesheets kept for each paid employee?

Yes:

No:

3a. If not, will timesheets be maintained for the subgrant in fulfillment of FH requirements:
Yes:

No:

4. Do you issue an employment letter or contract which includes the employees salary?
Yes:

No:

5. Do you have a written procurement policy?

Yes:

(if yes and English copy is available, please enclose)

No:

6. Do you keep inventory records for equipment?

Yes:
No:
(explain)
____________________________________________________________________________________
7. How often do you compare inventory records to the actual equipment?
____________________________________________________________________________________
____________________________________________________________________________________
8. Is your organization familiar with US government regulations concerning costs which can be
charged to US grants (OMB Circular A-122 "Cost Principles for Nonprofit Organizations" or OMB
Circular A-21 "Cost Principles for Educational Institutions")?
Yes:

No:

____________________________________________________________________________________

SECTION C: Accounting System

The purpose of an accounting system is to: 1) accurately record all financial transactions, and 2) ensure
that all financial transactions are supported by invoices, timesheets and other documentation. The type of
accounting system often depends on the size of the organization. Some organizations may have
computerized accounting systems, while others use a manual system to record each transaction in a
ledger. In either case, FH subgrant funds must be properly authorized, used for the intended purpose and
recorded in an organized and regular manner.
1. Briefly describe your organization's accounting system including: a) any manual ledgers used
to record transactions (general ledger, cash disbursements ledger, etc.); b) any computerized
accounting system used (please indicate the name of the accounting program); and c) how
transactions are summarized in your financial reports.
(a)_________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
(b)_________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
(c)__________________________________________________________________________________
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____________________________________________________________________________________
____________________________________________________________________________________
2. Does your organization have written accounting policies and procedures?
Yes:

(If English copies are available, please enclose)

No:

3. Complete the following information concerning the person who will maintain your accounting
records:
3a. How many years of experience does this person have?
_______
3b. How many years has this person been with your organization?
_______
3c. Does this person know how to use Excel? Yes

No

3d. Does this person know how to use a computerized accounting system? Yes
3e. Does this person have a degree in accounting or finance? Yes

No

No

3f. Can this person communicate in English? Yes

No (State preferred languages below)
____________________________________________________________________________________
4. Are your financial reports prepared on a:

Cash basis:

Accrual basis:

5. Can your accounting records keep separate the receipts and payments for an FH subgrant from
the receipts and payments for your other activities? Yes:

No:

6. Can your accounting records summarize costs for the FH subgrant according to different
budget categories such as salaries, space and utilities, supplies and equipment?
Yes:

No:

7. How often are financial reports prepared?

Monthly:

Quarterly:

Annually:

Not prepared:

(explain)

____________________________________________________________________________________
____________________________________________________________________________________
8. How would your organization make sure that 1) individual budget categories, and 2) total
budget limits for an FH subgrant would not be exceeded?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9. Do you keep invoices, vouchers and timesheets for all payments made from subgrant funds?

Yes:
No:
(explain)
____________________________________________________________________________________
____________________________________________________________________________________

Last Updated 11/08/2011

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10. Are there any circumstances in which invoices, vouchers and timesheets cannot or would not
be obtained for FH subgrant funds?

Yes:
(explain)
No:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
11. Briefly describe your organization's system for filing and keeping supporting documentation
such as invoices and timesheets.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
12. FH requests its subgrantees to submit supporting financial documents with financial reports.
Are there any circumstances where original invoices, receipts and timesheets cannot be
forwarded to FH? Please note that copies are required if originals cannot be sent.

Yes:
(explain)
No:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
13. Would your organization be able to keep accounting records including invoices, vouchers and
timesheets for at least three years after the final financial report is submitted to FH?

Yes:
No:
(explain)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
14. Does your organization have a Negotiated Indirect Cost Rate Agreement approved by a US
Government agency?
Yes:

(If yes, please enclose copy of rate agreement)

No:

____________________________________________________________________________________

SECTION D: Funds Control

Freedom House subgrantees who receive advances of subgrant funds must maintain a separate bank
account in the name of the organization. Only FH subgrant funds can be kept in that bank account. The
Last Updated 11/08/2011
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bank account may be in local currency or US dollars. FH normally pays subgrantees periodically by wire
transfer of US dollars to the separate bank account. Access to the bank account must be limited to
authorized people. Bank balances should be compared each month with your accounting records. If
cash cannot be kept in a bank, it is very important to keep the cash in a strong safe and have strict
controls over it.
1. Can a separate bank account, registered in the name of your organization, be established for FH
subgrant funds only?

Yes:

No:

1a. If not, how do you plan to receive funds from a possible subgrant?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. Will funds in the bank account be in:
Local currency:

U.S. dollars:

3. Are all bank accounts and check signers authorized by your Board of Directors or Trustees?
Yes:

No:

4. Will any cash from FH subgrant funds be kept outside the bank (for petty cash, etc.)?
Yes:

No:

4a. If yes, please explain the amount of funds to be kept, the name and position title of the
person responsible for the cash, and how cash will be maintained.
Amount:____________________________________________________________________________
Name:______________________________________________________________________________
Position Title:_________________________________________________________________________
How is cash kept secure?:_______________________________________________________________
____________________________________________________________________________________
5. If your organization does not have a bank account, how is cash kept safely?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
6. If FH subgrant funds will be held in a non-US bank, please answer questions 6a through 6f.
6a. Are bank deposits insured by the government?

Yes:

No:

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6b. Are there any government restrictions on the number of bank accounts an organization may
have?

Yes:
If yes, please explain:

No:

___________________________________________________________________________________
___________________________________________________________________________________
6c. Does your bank automatically convert US dollars to local currency immediately after
receiving them?
Yes:

No:

6d. How will payments for subgrant expenses be made from the separate bank account (check
all that apply):

Checks drawn on the bank account.

Bank transfers to seller.
Withdrawals of cash from bank account, followed by payments in cash.
Other (please describe):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
6e. Are there any government or bank restrictions, taxes or other fees that will be placed on the
bank account?

Yes:
(Explain)
No:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
6f. Are there any taxes, exchange requirements, or other charges that you will have to pay
when converting US dollars to local currency?

Yes:
(Explain)
No:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

SECTION E: Audit
If your organization is awarded a subgrant, Freedom House requires that you submit a copy of the most
recent financial audit report, if one was conducted. An audit is a review of your accounting records by an
Last Updated 11/08/2011
Page 11 of 14

independent accountant someone who does not work for you. An audit report contains your financial
statements as well as an opinion by the accountant stating that your financial statements are correct.
Please provide the following information on prior audits of your organization.
1. Does your organization have regular audits which you pay for?
Yes:

(please provide the most recent copy)

No audits performed:

1a. If yes, who performs the audit?

____________________________________________________________________________________
1b. How often are audits performed?
Quarterly:

Yearly:

Every 2 years:

Other:

(explain)

____________________________________________________________________________________
1c. What type of audit is performed?
Financial:

A-133:

Program:

Other:

1d. If your organization receives an FH subgrant, would FH subgrant funds be included in such
an audit?
Yes:

No:

1e. If there is an audit, will the FH subgrant appear as a separate item?

Yes:

No:

1f. Will the report be prepared in, or translated into English?

Yes:

No:

2. If your organization does not have a recent audit, please provide a copy of the following
financial information, if available:
a. A "Balance Sheet" for your prior fiscal year; and
b. A "Revenue and Expense Statement" for your prior fiscal year.
3. Are there any reasons (local conditions, laws, or institutional circumstances) that would prevent
an independent accountant from performing an audit of your organization?

Yes:
If yes, please explain:

No:

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

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CHECKLIST AND SIGNATURE PAGE

Freedom House requests that your organization submit a number of documents along with the
completed Financial Questionnaire. Complete this page to ensure that all requested information
has been included.
1. Place an X in the box next to the documents you will be sending to FH:

Incorporation Papers or Certificate of Registration (requested on page 3) is attached. (If

available)

The IRS Determination Letter (requested on page 3) is attached. (If applicable)

Information describing your organization (requested on page 3) is attached.
Organizational chart (requested on page 4) is attached. (If available)
Current Funding & Past Performance Data Sheet (requested on page 5) is attached.
Written procurement policy (requested on page 6) is attached. (if available)
Written accounting policies and procedures (requested on page 7) are attached. (if available)
A Negotiated Indirect Cost Rate Agreement (requested on page 9) is attached. (If applicable,)
A Copy of your organization's most recent audit (requested on page 11) is attached. (If
available)

If your organization does not have a recent audit, a "Balance Sheet" and "Revenue and
Expense
Statement" for the prior financial year (requested on page 12). (If available)

All questions have been fully answered.

An authorized individual has signed and dated this page.
The Financial Questionnaire must be signed and dated by an authorized person who has
either completed or reviewed the Questionnaire.
Approved by:
Print Name

Signature

Title

Date

Organization

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Glossary of Terms
Accrual based accounting system: An accounting system where your financial report shows payments which
have been made as well as invoices which have been received but not yet paid.
Actual cost: Any type of expense which has been paid for.
Allowable costs: Expenses which are for subgrant activities and which are reasonable and legal.
Balance sheet: A report which lists your assets (income to be received, cash, equipment) and your liabilities
(payments to be made).
Cash based accounting system: An accounting system where your financial report only shows payments which
have been made.
Expenses: Costs charged to the subgrant.
Expenditures: Another name for expenses or costs.
Financial statement: A report containing your balance sheet, and revenue and expense statement.
Financial report: A report which shows the money which an organization has spent on the subgrant for the
period, usually three months. FH requires a financial report for each three month period (quarter).
Fiscal year: The financial year of your organization. Most fiscal years are from January 1 to December 31. Other
fiscal years end on March 31, June 30, or September 30.
Funds: Money.
Incurred cost: Any type of expense which has been made but not yet paid.
Internal controls: A system set up by an organization to make sure that money is received and spent in the
correct manner.
Manual ledgers: Accounting records which are maintained by hand (without a computer) and which record similar
transactions such as cash receipts, cash payments, salaries, inventory, etc.
Narrative report: A written report developed by an organization describing the subgrant activities for the period,
usually three months. FH requires a narrative report for each three month period (quarter).
Petty cash: Small amounts of cash used to pay small expenses (taxi, bus, office supplies).
Revenue and expense statement: A report which shows the money which your organization received (revenue)
and how the money was spent (expense).
Separate bank account: A bank account in the name of your organization set up for your FH subgrant. Only FH
funds are deposited into the account and only FH program expenses are paid from the account.
Subgrant: An award given to an organization to complete a project.
Subgrantee: An organization which receives a subgrant.
Unallowable costs: Expenses which are not related to the FH subgrant, which are unreasonable, and not
accepted by law. These include but are not limited to alcohol (beer, wine, cocktails), cigarettes, fines, parking
tickets, bribes, etc. and all expenses which are not approved in the FH subgrant budget.

Last Updated 11/08/2011

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