Pre-Award Assessment – Self-Assessment to be Completed by Prospective Subrecipient - Page 1

Pre-Award Assessment - Instructions

This document is intended to gather organizational, financial, and compliance information from a prospective subrecipient and must be
completed by the prospective subrecipient prior to signing a sub-award agreement with World Vision.
Organization Profile – TO BE COMPLETED BY PROSPECTIVE SUBRECIPIENT
Legal Name, Number*
*Required for sub-awards >$25K Legal Name Gov’t registration number (DUNS)______________

Mailing Address Headquarters (HQ): Place of Performance:

(Specify HQ address if different from Place of
Performance address)
Congressional District / Parliamentary District:
Contact Information Phone Fax Website .
Names of Board of Directors/ Chairman . CFO . Director .
Management Committee: (Please President . . Secretary . Other .
attach a copy of the photo page of passport or
ID and list address for each official)
CEO . . Treasurer . N/A .

FFATA Requirements – Top 5 For all subrecipients who receive over 80% of their budget from USG sources, receive over $25M in USG
Executives (US Grants only) funding, and the information is not already publicly available, World Vision must provide the names and
total compensation of the top 5 executives per FFATA regulations (www.fsrs.gov).
Does the organization meet all three disclosure requirements? Yes No
If ‘Yes’, please provide the names and total compensation of top 5 executives via separate attachment
Year/Place Incorporated/ Headquarters . In-Country .
Registration Tax Status Non-exempt Exempt (If exempt, please attach proof of exemption)
(Please Attach Documentation)

# of Employees Headquarters . In-Country .

Affiliate Organizations .
(Legal parent or subsidiaries– include name(s)
and Gov’t/DUNS Number(s))

Grant Experience – TO BE COMPLETED BY PROSPECTIVE SUBRECIPIENT

Most Recent Audit Fiscal Year . Most Recent Report Date .
(Please attach copy of latest audit, financial Audit Type A-133 Other Annual Audit Review
statements) Indicate “Auditee Risk” Rating Low Risk High Risk
If no Audit/Review attach: Income Statement Balance Sheet
Has the organization ever declared bankruptcy? Yes No
Bank Information Bank Name . Account # .
(Prior to award signing, specify account to be Is Bank Account Insured? Yes No Bank Account Currency: ________________
used for wire transfers)

Source of Revenues for Prior Source, Estimated Amount (USD Equivalent)

Fiscal Year (for example: 1) 3)
Private Cash, Gifts-in-kind,
2) 4)
Public Funding, etc.)
Public Grants – for Prior Year Source, Estimated Amount (USD Equivalent)
(Please Specify Largest Donors and 1) 3)
Amounts)
2) 4)

Please list the title and amount 1)

of the most recent grant 2)
projects in the proposed 3)
country or sector: 4)
Pre-Award Assessment – Self-Assessment to be Completed by Prospective Subrecipient - Page 2

Program Experience – TO BE COMPLETED BY PROSPECTIVE SUBRECIPIENT

Are reports about recent Please describe how staff manage and monitor projects:
projects available for Review?
Yes No

Control Environment – TO BE COMPLETED BY PROSPECTIVE SUBRECIPIENT

Accounting What type of accounting system does the organization use? . . .
System Enterprise system (e.g. Sun Systems) Software (e.g. Quickbooks) Manual (e.g. Excel or paper-based)

Financial Does the organization follow Generally Accepted Accounting Principles? . Yes No
Reporting Does the organization have written accounting policies and a Chart of Accounts? Yes No
Does the organization use Accrual or Cash Accounting? Accrual Cash
Does the organization track each donor separately in its general ledger? Yes No
Cash Organization reconciles Bank Statements to Accounting Records monthly? . . . Yes No
Are cash controls in place (e.g. segregation of duties, petty cash restricted, etc.)? , .. Yes No
Are there controls to approve expenditures and restrict check signing? . Yes No
Payroll Are timesheets and/or labor records maintained for all paid employees? .. Yes No
Are time sheets and/or labor records sufficient to identify effort in projects Yes No
Does the organization have payroll controls (e.g. segregation of duties, review, etc.)? Yes No
Purchasing/ Does the organization have experience with regulations concerning
Inventory costs which can be charged to grants (ex. For US Grants (A-122 “Cost Principles)? Yes No
Does the organization have a procurement policy? Yes No
Does the organization maintain invoices/vouchers/multiple supplier quotations? Yes No
Does the organization maintain inventory/fixed asset records? . .. Yes No
Allocation of Does the organization allocate shared costs? .. Yes No
Shared Costs (If the answer is “Yes”, please attach a description of the allocation methodology)

Document Briefly describe the organization’s system for filing/maintaining supporting documentation:
Retention
Will the organization be able to maintain accounting records including invoices, vouchers, and timesheets for at least
3 years (or longer if local country requirements are longer) after the final financial results are submitted?
Yes No
Initial Tier Classification – TO BE COMPLETED BY WORLD VISION STAFF
Blocked Parties and/or Excluded Party Yes Organization Not Listed as Excluded Party
Listing Search Performed (Please Attach Copy) Search Performed by on (date)

Tier 1 – Low Risk Tier 2 – Low Risk Tier 3 – Low Risk Performance Country: .
Tier 1 – High Risk Tier 2 – High Risk Tier 3 – High Risk Estimated Sub-award Amount: .
Brief Comments/Justification for Tier and/or Risk Classification:

Please see guidance in “Subrecipient Tier Classification Summary” (located in “Subgrant Village” procedures located in WVI FFM and wvcentral) to
determine the appropriate Tier Classification for the prospective subrecipient.

Reviewed by: .
(Name, Date) Finance Officer WV Nat’l Office (If Applicable)
Rev. 1-May-2014