Corrective Action Plans

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Corrective action plan: HHSC will run quarterly expenditure reports for this grant to monitor administrative earmarking thresholds. Implementation date: July 31, 2026 Responsible person: Roderick Swan, Associate Commissioner, Behavioral Health Services Operations
Corrective action plan: HHSC will run quarterly expenditure reports for this grant to monitor administrative earmarking thresholds. Implementation date: July 31, 2026 Responsible person: Roderick Swan, Associate Commissioner, Behavioral Health Services Operations
Corrective action plan: ITS will: • Work with HR and Security to analyze and validate the size and scope of the late submission of access termination requests for separated employees. Communicate the analysis results and recommendations on or before May 1, 2026. • Work with the Information Security ...
Corrective action plan: ITS will: • Work with HR and Security to analyze and validate the size and scope of the late submission of access termination requests for separated employees. Communicate the analysis results and recommendations on or before May 1, 2026. • Work with the Information Security Office for continuation of periodic reconciliation of HR data and network accounts. Schedule for reconciliation to be established on or before May 1, 2026. • Work with Human Resources to establish a schedule of periodic reconciliation for HR data and case management application accounts. Schedule for reconciliation to be established on or before May 1, 2026. • Review existing business process for offboarding separated employees and provided recommendations to HR for training and communication for staff. Recommendations to be provided by May 1, 2026. • Determine what technology solution may be needed by August 31, 2026, with consideration of effectiveness of mitigation actions, as noted above. Implementation dates: See Corrective action plan Responsible person: Angie Lindemann, Deputy Chief Information Officer
Corrective action plan: The Department will enhance current procedures for the compilation and review of the Period 1 clearance pattern calculation in accordance with the Cash Management Improvement Act (CMIA) and as required in the Texas-State Agreement. The Manager of Accounting will use the State...
Corrective action plan: The Department will enhance current procedures for the compilation and review of the Period 1 clearance pattern calculation in accordance with the Cash Management Improvement Act (CMIA) and as required in the Texas-State Agreement. The Manager of Accounting will use the State Auditor Office’s template spreadsheet provided to agencies to calculate their annual Period 1 calculation and retain the worksheet as supporting documentation. The Director of Financial Administration will review the spreadsheet and calculation prior to CMIA certification. Implementation date: August 2026 Responsible persons: Jose Guevara, Director of Financial Administration Cristina Ortega, Manager of Accounting.
Corrective action plan: • IT will coordinate with HR on strengthening the separation process, to include HR running separation reports quarterly and sending to IT to cross check. Will perform regular scheduled meetings to discuss the separation process/issues. • IT is testing automatic scripts that ...
Corrective action plan: • IT will coordinate with HR on strengthening the separation process, to include HR running separation reports quarterly and sending to IT to cross check. Will perform regular scheduled meetings to discuss the separation process/issues. • IT is testing automatic scripts that will aid in the process and will be implemented this year. • IT will document quarterly access reviews which are already done. • IT will work on enhancing automation and controls; Will utilize AI to assist. Implementation date: May 2026 Responsible person: Chris Bunton, CIO, Texas Department of Agriculture
The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.
The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.
Condition: The District's meal reimbursement claim did not align with supporting meal counts. Plan: The District will review their current review procedures around preparing meal reimbursement claims. Anticipated Date of Completion: The District will correct this for the 2025-2026 school year. Name ...
Condition: The District's meal reimbursement claim did not align with supporting meal counts. Plan: The District will review their current review procedures around preparing meal reimbursement claims. Anticipated Date of Completion: The District will correct this for the 2025-2026 school year. Name of Contact Person: Casey Susa, District Bookkeeper Management Response: The District agrees with the finding and will correct this in future years.
Management is aware and understands the importance of compliance with the federal requirements and will ensure the meal counts will be properly reported in the future.
Management is aware and understands the importance of compliance with the federal requirements and will ensure the meal counts will be properly reported in the future.
Cash Management Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; The Financial Aid Office has implemented enhanced reconciliation and cash management proced...
Cash Management Responses UNR – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; The Financial Aid Office has implemented enhanced reconciliation and cash management procedures designed to strengthen internal controls and mitigate future risk. The monthly reconciliation process has been revised to ensure that each reconciliation clearly documents all outstanding items, including timing differences and variances. ● How compliance and performance will be measured and documented for future audit, management and performance review. Under the revised process, the Assistant Director for Compliance and Processing ensures drawdowns are supported by detailed reconciliation schedules, discrepancies are formally identified and tracked, and resolution occurs within established timeframes. The updated procedures have been fully implemented and are operating as designed. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The Assistant Director for Compliance and Processing and the Interim Financial Aid Director. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Cash Management Responses WNC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Western Nevada College implemented the practice of invoice review (proper segregation of du...
Cash Management Responses WNC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Western Nevada College implemented the practice of invoice review (proper segregation of duties) in October 2024, in which all invoices are reviewed from an individual separate from the preparer. This practice has been in place since our October 2024 grant billing period and has continued ever since. This audit finding resulted from the auditor selecting a transaction prior to WNC implementing the new procedure. All other transactions selected by the auditor were in compliance. ● How compliance and performance will be measured and documented for future audit, management and performance review. All grant invoices going forward will have a second level of review prior to drawing down or requesting reimbursement of funds. Documentation will be compiled for each grant invoice that will indicate that a second level of review has been obtained. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The Vice President of Finance & Administration may be held accountable in the future if repeat or similar observations are noted. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Reporting Responses TMCC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Two additional layers of review have been added to ensure that every RFR/Invoice is reviewed. On...
Reporting Responses TMCC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Two additional layers of review have been added to ensure that every RFR/Invoice is reviewed. On 4/14/25 an extra invoice review was added to Workday ensuring that they have to go through a review by someone other than the creator. During this step, the attachments including RFR and the approval email by the controller is also reviewed for accuracy. The Grant Accountant also established a log in August of 2025 that includes the Due Date, Date sent to the Controller for Approval, the Approval date and the submission date. ● How compliance and performance will be measured and documented for future audit, management and performance review. Emails documenting the review of the RFRs are kept as proof of review and saved in our files as well as Workday. The tracking document will also be made available for future review. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The Grant Accountants will be responsible for ensuring that we are in compliance with the corrective actions UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; UNLV OSP does have separation of duties from the originator of the subaward to the review of the subaward agreement in entering all of the data points into Sam.gov for FFATA reporting; however, UNLV OSP will create a process document that explicitly notes this for future documentation. ● How compliance and performance will be measured and documented for future audit, management and performance review. Cross checking of the issued subaward (originator) is reviewed and entered into the federal portal by the submitter. As the federal portal requires one party to enter and submit, OSP management perceives this to be very low risk but will ensure reviews occur. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV OSP Executive Director is accountable for exercising oversight and responsibility. WNC – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Western Nevada College implemented the practice of invoice review (proper segregation of duties) in October 2024, in which all invoices are reviewed from an individual separate from the preparer. This practice has been in place since our October 2024 grant billing period and has continued ever since. This audit finding resulted from the auditor selecting a transaction prior to WNC implementing the new procedure. All other transactions selected by the auditor were in compliance. ● How compliance and performance will be measured and documented for future audit, management and performance review. All grant invoices going forward will have a second level of review prior to drawing down or requesting reimbursement of funds. Documentation will be compiled for each grant invoice that will indicate that a second level of review has been obtained. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The Vice President of Finance & Administration may be held accountable in the future if repeat or similar observations are noted. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Cash Management Responses DRI – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Controls were implemented beginning on April 14, 2025, to require secondary approvals on al...
Cash Management Responses DRI – Agrees with the finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; Controls were implemented beginning on April 14, 2025, to require secondary approvals on all sponsored invoice transactions. NSHE’s accounting system was reconfigured to require a review step for all invoice business processes. An individual other than the preparer must now review and approve all transactions. ● How compliance and performance will be measured and documented for future audit, management and performance review. Documentation for all sponsor invoice transactions occurs through the business process history in the accounting system. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The Chief Financial Officer may be held accountable in the future if repeat or similar observations are noted. UNLV agrees with this finding. ● Detailed corrective action taken, including what will be done to avoid the identified issues in the future, and when these measures will be in place; UNLV Office of Sponsored Programs (OSP) has an internal control that requires a reconciliation form to be completed with each invoice submission. With any manual control, human error may occur, as in this case; however, the reconciliation form is used every time and is reviewed by the originator and approving authority. ● How compliance and performance will be measured and documented for future audit, management, and performance review. Reinforcement of cross-checking of the reconciliation form is enforced and will be used as documentation for review. ● Who will be responsible and may be held accountable in the future if repeat or similar observations are noted. The UNLV OSP Executive Director is accountable for exercising oversight and responsibility. Official Contact: Rhett R. Vertrees, Assistant Chief Financial Officer 2601 Enterprise Road, Reno NV 89512-1666 Phone: (775)784-3409, Fax: (775)784-1127 Email: rvertrees@nshe.nevada.edu
Lack of Review over Financial Status Reports Auditor Description of Condition and Effect. The University did not have documented review procedures in place for federal grant drawdowns nor review over monthly Financial Status Reports. Drawdowns were processed and Financial Status Reports were submitt...
Lack of Review over Financial Status Reports Auditor Description of Condition and Effect. The University did not have documented review procedures in place for federal grant drawdowns nor review over monthly Financial Status Reports. Drawdowns were processed and Financial Status Reports were submitted without a formal review or approval process to verify that amounts reported and requested were based on allowable expenditures. This deficiency increases the risk of drawing and reporting federal funds in excess of actual expenditures or for unallowable costs, potentially resulting in noncompliance with federal regulations. Auditor Recommendation. We recommend that the University should implement formal review procedures for all federal grant drawdowns including monthly FSRs, including enhancing policies around reviewing drawdowns, designated reviewers, and system controls to ensure drawdowns are accurate, allowable, and properly supported. Corrective Action. The University will implement a review process to ensure that all drawdowns are reviewed by a second individual prior to submission. Responsible Person. Yah-Sheba Jenkins, Controller Anticipated Completion Date. June 30, 2026
Program: Various, including AL 93.778 – Grants to States for Medicaid – Allowable Costs/Cost Principles Corrective Action Plan: OCIO - Efforts have been made to both reduce the number of rates for clarity as well as right size the rate to align with cost recovery expectations more effectively. In ad...
Program: Various, including AL 93.778 – Grants to States for Medicaid – Allowable Costs/Cost Principles Corrective Action Plan: OCIO - Efforts have been made to both reduce the number of rates for clarity as well as right size the rate to align with cost recovery expectations more effectively. In addition, OCIO will be engaging in a period of “no-bills” to customer agencies to draw down the identified federal funds OCIO had previously collected and are in excess of the 60-day allowable threshold. DAS Materiel – The Print Shop is reviewing other options to provide Printing Services to state agencies. Contact: OCIO - Noah Finlan; Materiel, Print Shop, Building Division – Ann Martinez. Anticipated Completion Date: OCIO – June 2026; Print Shop – ongoing.
Program: AL 93.575 – COVID-19 Child Care and Development Block Grant – Allowability Corrective Action Plan: In 2025, The Agency developed a subrecipient monitoring tool to ensure effective controls and processes are in place. The Agency will review all findings and take appropriate actions when warr...
Program: AL 93.575 – COVID-19 Child Care and Development Block Grant – Allowability Corrective Action Plan: In 2025, The Agency developed a subrecipient monitoring tool to ensure effective controls and processes are in place. The Agency will review all findings and take appropriate actions when warranted. Contact: Nicole Vint Anticipated Completion Date: June 30, 2026
Program: AL 84.126 – Rehabilitation Services Vocational Rehabilitation Grants to States – Reporting Corrective Action Plan: An additional review will be completed by NDE Budget and Grant Management staff to ensure accuracy. Contact: Cathy Callaway Anticipated Completion Date: Completed
Program: AL 84.126 – Rehabilitation Services Vocational Rehabilitation Grants to States – Reporting Corrective Action Plan: An additional review will be completed by NDE Budget and Grant Management staff to ensure accuracy. Contact: Cathy Callaway Anticipated Completion Date: Completed
Program: AL 12.401 – National Guard Military Operations and Maintenance (O&M) Projects – Cash Management & Reporting Corrective Action Plan: Continue to monitor program expenditures to aid in optimizing forecasting and advance request accuracy. Contact: Lauren Hargreaves Anticipated Completion Date:...
Program: AL 12.401 – National Guard Military Operations and Maintenance (O&M) Projects – Cash Management & Reporting Corrective Action Plan: Continue to monitor program expenditures to aid in optimizing forecasting and advance request accuracy. Contact: Lauren Hargreaves Anticipated Completion Date: Ongoing
2025-001 Finding – Significant Deficiency in Internal Controls over Cash Management Context and Cause – It was noted during the audit that there was not a documented review of the selected cash draws for the program tested. Internal controls should be designed to include a documented supervisory rev...
2025-001 Finding – Significant Deficiency in Internal Controls over Cash Management Context and Cause – It was noted during the audit that there was not a documented review of the selected cash draws for the program tested. Internal controls should be designed to include a documented supervisory review of cash draw requests to ensure accuracy, proper authorization, and compliance with program requirements and the Code of Federal Regulations 200.303. PYB is aware of our Policy for a documented review, but due to competing priorities and impact on workload, the Fiscal Director did not consistently perform the control during the time period that was tested. Auditor Recommendation – Kern & Thompson recommend that PYB re-implement the procedure noted in the prior year, where a supervisor’s initials and date of review was documented on the support for each cash draw, prior to draw down of federal funds. Action Taken – PYB implemented a similar, improved review procedure effective with the October 2025 draw, submitted December 17, 2025. The new procedure uses email to provide documents for review and to document approval of the draw. The Fiscal Director is responsible for submitting cash draws and must send the email to both the Executive Director and the Accountant for review. Each month's emailed documentation includes the DOL income statement for the month (showing the amount for reimbursement); a confirmation that supporting documentation has been attached to the draw request; and a draw confirmation confirming the date of submission, the amount, the date funds should be deposited to PYB’s account, and the justification required for the payment. The Fiscal Director also includes information about the amount of funds remaining on the grant award. After reviewing the documents, the Executive Director replies with approval.
Finding 2025-004 a. Program Name: Head Start and Early Head Start b. Criteria or Specific Requirement: Failure to comply with the grant agreement’s terms and applicable regulations: The Organization did not comply with grant compliance requirements such as timeliness of submitting reports to funding...
Finding 2025-004 a. Program Name: Head Start and Early Head Start b. Criteria or Specific Requirement: Failure to comply with the grant agreement’s terms and applicable regulations: The Organization did not comply with grant compliance requirements such as timeliness of submitting reports to funding agencies and meeting matching requirements. c. Condition: The Organization had inconsistent performance on the submission of periodic grant reports in a timely matter. This submission pattern conflicts with grant timelines outlined in the Notice of Awards. Specifically, it was noted for one of Organization’s major programs, Head Start and Early Head Start, that reports were submitted outside of defined due dates. The Form SF-429 was not filed for the 2025 fiscal year. Further, Head Start and Early Head Start experienced 2 delayed reports. Management informed us that the delays in reporting were attributable to submission issues on the federal reporting platform, which temporarily prevented timely filling despite management’s attempts to complete the report. Once access to submission was granted, management promptly submitted the required report. d. Response: Turnover in the personnel responsible for submitting reports lead to the initial late submission. The management will ensure all the reports to be submitted within the defined due dates. In terms of matching, the Organization has made a waiver request and believes in the success of obtaining the waiver.
The Organization has transitioned from QuickBooks to Sage Intacct accounting software, which now requires digital attachments for all transactions to ensure proper documentation. The Organization continues to review and improve processes and procedures as we grow as an organization. We will reinforc...
The Organization has transitioned from QuickBooks to Sage Intacct accounting software, which now requires digital attachments for all transactions to ensure proper documentation. The Organization continues to review and improve processes and procedures as we grow as an organization. We will reinforce adherence to the Organization's policies.
2025-002 – 10.558 – Child and Adult Care Food Program –Eligibility Condition Two providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State...
2025-002 – 10.558 – Child and Adult Care Food Program –Eligibility Condition Two providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State for reimbursement. Comments on the Finding Given Sunshine Connections, Inc.’s limited staffing structure, full segregation of duties within the meal claims process is not always possible. However, the organization has implemented practical internal controls to reduce the risk of errors and ensure accurate claims are submitted. All meal count and attendance records submitted are reviewed for completeness and accuracy before being entered into the claim system. Meal counts are checked against enrollment, attendance, and licensed capacity to ensure they are reasonable and allowable. Action Taken Whenever possible, someone other than the Director will prepare the monthly claim. The Director will then review the claim for accuracy and compare totals between the Excel spreadsheet and the Little Organizer program before submission to ensure the information is correct.
FINDING 2025-007 Finding Subject: BRIC: Building Resilient Infrastructure and Communities – Internal Controls Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We ...
FINDING 2025-007 Finding Subject: BRIC: Building Resilient Infrastructure and Communities – Internal Controls Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: This grant was fully expended in 2024. Going forward, the current treasurer will work closely with the grant administrator, whether within corporation or an outside source, when compiling all claims, disbursements and reporting for any given project, including BRIC programs. Internal controls will be incorporated at the Corporation level for future grants that use an outside Grant Administrator. Anticipated Completion Date: 2/16/2026
FINDING 2025-005 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding ...
FINDING 2025-005 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Internal controls for reimbursement requests will include necessary documentation of expenditures from the accounting program attached to the reimbursement form for all grants. Each reimbursement request will be checked and approved by two school employees. The treasurer will keep the packet until funds are received and receipted and then the packet, with the receipt, will be filed in two places; the respective grant folder and in the monthly receipt folder. Anticipated Completion Date: 2/16/2026
Finding 2025 – 001: Restatement to Fund Balance/Net Position Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct retainage payable and capital assets that were improperly recorded in prior years. Plan: The City will implement effective interna...
Finding 2025 – 001: Restatement to Fund Balance/Net Position Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct retainage payable and capital assets that were improperly recorded in prior years. Plan: The City will implement effective internal controls in order to provide an accurate assessment of reporting requirements. This implementation of improved controls would result in the appropriate recognition for financial reporting requirements Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Elizabeth Hannan, CFO/HR Director Management Response: Management acknowledges this comment and will work to implement and correct by the anticipated date of completion noted above.
The District acknowledges the finding regarding inaccuracies in meal counts reported for the Child Nutrition Program reimbursement claims. To address this issue, the District will strengthen internal controls over the meal count reporting and claim preparation process. The food service department wi...
The District acknowledges the finding regarding inaccuracies in meal counts reported for the Child Nutrition Program reimbursement claims. To address this issue, the District will strengthen internal controls over the meal count reporting and claim preparation process. The food service department will ensure that daily meal count documentation is properly maintained and reconciled to the monthly claim totals prior to submission. In addition, the Director of Business Operations will implement a formal management review process prior to submission of each monthly claim for reimbursement to the Arizona Department of Education. This review will include verification that reported meal counts agree to supporting documentation and that all reconciliations have been completed and documented. Any discrepancies identified during the review will be investigated and corrected before the claim is submitted. These procedures will provide additional oversight and help ensure the District maintains compliance with federal regulations and the reporting requirements of the Child Nutrition Program. The Director of Business Operations is responsible for implementing and monitoring this correction action, which will be completed at the end of the next fiscal year.
Finding 2025-003 Duplicate expenditures charged to same grant Recommendation: We recommend the District establish and maintain proper review procedures for expenditures charged to grants prior to submission for reimbursement. Management’s View: The District will strengthen internal controls over pay...
Finding 2025-003 Duplicate expenditures charged to same grant Recommendation: We recommend the District establish and maintain proper review procedures for expenditures charged to grants prior to submission for reimbursement. Management’s View: The District will strengthen internal controls over payroll expenditures charged to federal grants by implementing a standard operating procedure that will be conducted by the Payroll Specialist of verifying payroll distribution reports, funding codes, and supporting documentation prior to submission for payment. Before each payroll is finalized, the payroll specialist will run a payroll report that will be generated and sorted by employee to verify that no duplicate charges have been applied to the same grant within the same payroll period. This review will ensure that all costs charged to federal grants during the pay period are accurate, allowable, properly coded, and not duplicated. No payroll adjustments will be keyed until timesheets have been verified against previously submitted timesheets and that they are reviewed to confirm that prior entries have not already been charged to the same grant. Additionally, a secondary review by the accountant will be conducted prior to finalizing grant-related payrolls. Effective March 1, 2026, the Payroll Accountant and Chief Financial Officer will review grant-related payroll transactions to ensure accuracy, proper funding allocation, and compliance with applicable federal requirements. Effective Date: March 1, 2026 Contact Person: Sylvia Garza, Chief Financial Officer, Edcouch-Elsa Independent School District
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