Wisconsin Fast Forward (WFF) Pre-Award Risk Assessment This form must be completed and submitted with the grant application. DWD will use responses to assess the applicant organization's ability to manage grant funds successfully and appropriately. If a grant is awarded, DWD may implement measures to ensure the integrity of grant funds (for example, establishing additional contractual provisions and monitoring procedures) based on the responses provided. Legal Business Name: FEIN: Organization Background 1. In what year was your organization established? What is your organization's primary product or service? 2. Please provide ownership details. For privately held companies, list the names of all owners with ownership greater than 5%. For publicly traded companies, list the names of all shareholders with ownership interest more than 20%. If not applicable, enter "None." 3. List the names of parent, subsidiary, or other organizations which share common ownership (i.e., more than 50% ownership interest) with your organization. If not applicable, enter "None." 4. List the names of the members of your organization's governing board. If not applicable, enter "None." 5. Explain if your organization is undergoing a merger or acquisition with another company, or if you anticipate doing so within the next 12 months. If not applicable, enter "None." 6. List the name(s) and position(s)/title(s) of any key or senior management member(s) of your organization that are Public Officials. If not applicable, enter "None." 7. Explain the nature of any significant changes in ownership, key personnel, or contracted accounting provider in the last two years (e.g. Controller, Executive Director, Accounting Manager, Program Manager, etc.). If not applicable, enter "None." 8. Provide the website address for your organization. If not applicable, enter "None." 1 WFF Pre-Award Risk Assessment, continued Financial Capacity 9. Describe any significant changes in accounting systems and practices at your organization occurring in the last year. If not applicable, enter "None." 10. Describe the circumstances if your organization, or any owner, subsidiary, or affiliate have been involved in bankruptcy or insolvency proceedings, or face any pending proceedings. If not applicable, enter "None." 11. Can your accounting system do the following? Yes No Differentiate WFF grant revenues and expenditures from other transactions Record revenues and expenditures by specific budget cost categories (such as those included in your WFF approved budget) Report time and effort for employees who charge to WFF grants/cost centers (if applicable) Assign costs between reimbursement and match expenditures 12.Has the applicant organization received state or federal grants? Yes No Grant Administration If so, please disclose the names and details of the three most recent state or federal grants. 13. GRANT 1 Project Title Granting Agency Contact Information Award Amount $ Timefram Grant Status e *Grant Status: Active, Closed-Completed, Closed-Withdrawn, Closed-Terminated 14. GRANT 2 Project Title Granting Agency Contact Information Award Amount $ Timefram Grant Status e *Grant Status: Active, Closed-Completed, Closed-Withdrawn, Closed-Terminated 15. GRANT 3 Project Title Granting Agency Contact Information Award Amount $ Timeframe Grant Status *Grant Status: Active, Closed-Completed, Closed-Withdrawn, Closed-Terminated 2 WFF Pre-Award Risk Assessment, continued 3 WFF Pre-Award Risk Assessment, continued Legal and Regulatory Compliance 16. If you, any key employee, or senior management member of your organization has ever been charged with or convicted of a felony, or any other state or federal crime(s) involving fraud or misconduct, please list name(s) and charges. If not applicable, enter "None." 17. Describe any outstanding or concluded litigation, civil, criminal, or administrative proceedings to which your organization is, or was, a party during the last seven years. If not applicable, enter "None" in each column. Parties Nature of Claim Case Number Date and Method Commenced Amount of Damages Sought/Paid Disposition 18. Disclose any pending, threatened, or concluded governmental violations, investigations, proceedings, and/or arbitrations, occurring during the last five years that involve your organization, any officer, or director acting in their capacity on behalf of your organization. If not applicable, enter "None." 19. D