Form Doh 4426 PDF Details

Managing compliance and ensuring financial accountability are critical aspects that agencies operating in New York State must navigate diligently. The New York State Department of Health's Audit Report Extension Request Form, known as DOH-4426, serves as a vital tool in this process, offering agencies a structured pathway to request additional time for submitting their audit reports. This form caters to various types of entities, including government, not-for-profit, and for-profit organizations, and requires comprehensive information such as agency name, fiscal year-end date, and contact details. Moreover, it necessitates details about the audit firm engaged, including the CPA’s name and New York State license number, along with the engagement letter date, total audit fees, and the number of years the auditor has been engaged. The form also distinguishes between different reports, such as A-133, entity-wide, or contract-specific audits, asking for original and requested due dates. Additionally, the instructions emphasize the importance of attaching an auditor’s engagement letter, a separate letter stating the reason for the extension request, and, for A-133 reports, specific documentation related to federal funding. Submission details, including where and how to submit the request, underscore the procedural nature of acquiring an audit report extension, reflecting the Department's commitment to oversight and financial integrity within the state.

QuestionAnswer
Form NameForm Doh 4426
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdoh 4426 nys department of health audit unit form

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NEW YORK STATE DEPARTMENT OF HEALTH Audit Unit

Audit Report Extension Request Form

Instructions: See reverse.

Agency

AGENCY NAME

FEIN(s) (include all related FEINS)

FISCAL YEAR END DATE

ADDRESS

TYPE OF ENTITY (check one)

Government

Not for Profit

For Profit

CONTACT NAME

TITLE

SIGNATURE

DATE

TELEPHONE

FAX

E-MAIL

Auditor

FIRM NAME

CPA NAME

 

 

 

 

NEW YORK STATE LICENSE NUMBER

 

 

 

 

 

 

 

 

 

 

CPA SIGNATURE

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

TELEPHONE

 

 

FAX

E-MAIL

 

 

 

 

 

 

 

 

 

ENGAGEMENT LETTER DATE (Attach copy)

 

TOTAL AUDIT FEES

TOTAL NON-AUDIT FEES

CONSECUTIVE YEARS ENGAGED

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

Audit Report (Choose only ONE: A, B or C)

 

 

 

 

 

 

ORIGINAL DUE DATE*

REQUESTED DUE DATE

 

 

 

 

 

 

 

 

 

A

A-133

FISCAL YEAR END DATE:

 

 

 

 

 

 

 

 

 

 

FEDERAL OVERSIGHT AGENCY:

 

 

 

 

 

 

 

TOTAL FEDERAL EXPENDITURES:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

Entity Wide

FISCAL YEAR END DATE:

 

 

 

 

 

YELLOW BOOK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTRACT NUMBER:

 

 

 

 

 

Contract Specific

 

 

 

 

 

 

 

C

 

START DATE:

 

 

 

 

YELLOW BOOK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

END DATE:

* Fiscal Year End Date or Contract End Date Plus Nine Months. (NOTE: The request must be filed in advance of the due date.)

Attach engagement letter, draft financial statements, reason for request, and submit to:

NEW YORK STATE DEPARTMENT OF HEALTH

Tel: (518) 474-1458

AUDIT UNIT

Fax: (518) 473-4610

Room 2266Corning Tower

Email: fmgau@health.state.ny.us

Albany, NY 12237-0041

 

DOH USE ONLY:

FORM

ENG

F/S

REASON

AGENCY

CPA

PGM. APPROVE/DENY. BY/ DATE____________________

DOH-4426 PAGE 1 OF 2 (4/12)

Instructions

1.Attach a copy of the Auditor’s Engagement Letter. The letter must reference the report type, scope and intended completion date.

2.Attach a separate letter describing the good cause reason for the request. The letter must specifically explain why the report will not be completed by the due date. If the agency is unprepared, the letter must include a list of tasks yet to be completed. If the auditor is unavail- able, the request must include a copy of the unaudited financial statements. The letter must be typed on agency letterhead, addressed to the Department, include a commitment to meet the revised date, and include the signature of the agency official responsible for preparing the financial statements.

3.For A-133 Reports:

a.Attach a copy of the draft Schedule of Expenditures of Federal Awards.

b.If all Federal funding is from a pass-through agency, include a written statement endorsing the request from the pass-through grantor providing the majority of funding.

c.Submit the Form, including the Engagement Letter and the reason for the request, to your Federal cognizant agency. Your cognizant agency is the Federal agency which provides your agency the most Federal funding, direct or pass-through. Selected Federal agency addresses are listed below:

USDA

Regional Audit Director, USDA FNS 10 Causeway St, Rm 501 Boston MA 02222

Tel (617) 565-6462/ Fax (617) 565-6472 E-Mail – agostinho.nunes@fns.usda.gov

DHHS

Manager, DHHS Audit Resolution

1100 Walnut Street, Room 850

Kansas City MO 64106

Tel (816) 426-3204/ Fax (816) 426-7745

Email – jfisher@oig.hhs.gov

HUD

National Single Audit Coordinator, HUD

Wanamaker Building, Suite 1005, 100 Penn Square East

Philadelphia, PA 19107-3380

Tel (215) 430-6733

If your agency is not listed, refer to: http:/www.whitehouse.gov/omb/circulars/a133_Compliance/08/appx_3/pdf

ii.Submit a copy to NYSDOH at the address below.

iii.If the Federal agency approves the request, submit a copy of the Federal approval letter to NYSDOH at the address below.

4.For Yellow Book (Entity-Wide or Contract-Specific) Audit Reports: Submit the Extension Request Form, including the Engagement Letter and the reason for the request, to NYSDOH at the address below. NYSDOH will notify you if the request is approved.

NEW YORK STATE DEPARTMENT OF HEALTH

Tel: (518) 474-1458

AUDIT UNIT

Fax: (518) 486-1405

Room 2266Corning Tower

Email: fmgau@health.state.ny.us

Albany, NY 12237-0041

 

DOH-4426 PAGE 2 OF 2 (4/12)

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