Corrective Action Plans

Finding 519116 (2024-004)

Material Weakness 2024

MI

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Federal Program, Assistance Listing Number and Name - ALN 14.239, Department of Housing and Urban Development, Home Investment Partnerships Program Condition: Original Finding Description - The City’s on-site inspections for compliance with the housing quality standards are triggered by City’s proc...

Federal Program, Assistance Listing Number and Name - ALN 14.239, Department of Housing and Urban Development, Home Investment Partnerships Program Condition: Original Finding Description - The City’s on-site inspections for compliance with the housing quality standards are triggered by City’s process to audit developers for compliance with HOME eligibility requirements. This basis is more restrictive than Federal requirements for Housing Quality Inspections At the end of an inspection cycle a certificate of completion is completed and signed by the responsible inspector. The City did not have effective controls to ensure the certificate of completion, is reviewed for completeness and accuracy. The City did not inspect the 20% of the units, as required by their policy. Contact Person Responsible for Corrective Action / Anticipated Completion Date - Julie Schneider; Anticipated completion date: June 2025 Planned Corrective Action - The City will review its processes and implement additional controls to ensure certificates of completion are reviewed for completeness and accuracy and to verify 20% of the units are inspected to comply with the HOME Program manual and federal regulations related to Housing Quality Standards.

View Audit 337640

Finding 519114 (2024-002)

Significant Deficiency 2024

City of Detroit, Michigan

MI

Subrecipient Monitoring Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.303

Federal Program, Assistance Listing Number and Name - ALN 97.036, Department of Homeland Security, Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Condition: Original Finding Description - The FEMA grant expenses are charged to various funds in the general ledger over...

Federal Program, Assistance Listing Number and Name - ALN 97.036, Department of Homeland Security, Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Condition: Original Finding Description - The FEMA grant expenses are charged to various funds in the general ledger over several years but is managed and tracked by project in a manual spreadsheet which agrees to the amount of expenses reported on the fiscal year 2024 Schedule of Expenditures of Federal Awards (SEFA). FEMA expenditures are reported on the SEFA when there is an award and expenditures. Given that the award is made subsequent to the expenditures being incurred a manual spreadsheet is used to track expenditures being charged to the grant. There were instances of duplicated costs in the manual spreadsheet. Contact Person Responsible for Corrective Action / Anticipated Completion Date - Istakur Rahman; Anticipated completion date: June 2025 Planned Corrective Action - The identified duplicate cost was an isolated occurrence caused by an oversight during the spreadsheet preparation process. While existing controls are in place, management will perform a secondary review of the end-to-end process to enhance these controls.

View Audit 337640

Finding 519103 (2024-001)

Significant Deficiency 2024

Rim of the World Unified School District

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

The District has implemented a secondary review of ESSER reports prior to final submission.

View Audit 337594

Finding 519102 (2024-003)

Significant Deficiency 2024

Baraga County Memorial Hospital

MI

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Federal Agency Name: U.S. Department of Housing and Urban Development Assistance Listing Number: 14.128 Program Name: Mortgage Insurance for Hospitals Compliance Requirement: Special Tests and Provisions Type of Finding: Significant Deficiency in Internal Control Over Compliance and Noncompliance Fi...

Federal Agency Name: U.S. Department of Housing and Urban Development Assistance Listing Number: 14.128 Program Name: Mortgage Insurance for Hospitals Compliance Requirement: Special Tests and Provisions Type of Finding: Significant Deficiency in Internal Control Over Compliance and Noncompliance Finding Summary: The Hospital has amounts due from affiliate of $697,310 that are older than 90 days and is in violation of a loan covenant from HUD. Responsible Individuals: Gail Jestila, CFO Corrective Action Plan: Management implemented a repayment plan with affiliate to reduce amounts outstanding. Anticipated Completion Date: Ongoing

View Audit 337593

Finding 519060 (2024-006)

None 2024

Montreat College

NC

Student Financial Aid Eligibility Matching / Level of Effort / Earmarking

2024-006 - Student Financial Aid Cluster- (a) Federal Supplemental Educational Opportunity Grant (b) Federal Work Study Grant (c) Federal Perkins Loan Program (d) Federal Pell Grant Program (e) Federal Direct Loan Program, Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.038 (d) 84.063 (e) 84.268...

2024-006 - Student Financial Aid Cluster- (a) Federal Supplemental Educational Opportunity Grant (b) Federal Work Study Grant (c) Federal Perkins Loan Program (d) Federal Pell Grant Program (e) Federal Direct Loan Program, Assistance Listing No. (a) 84.007 (b) 84.033 (c) 84.038 (d) 84.063 (e) 84.268 - Year Ended June 30, 2024 Condition Found The College did not report actual loan disbursement dates to the Common Origination and Disbursement (COD) system for 2 of the 40 students in the sample (5%). We consider this condition to be an instance of noncompliance in internal control over compliance relating to the Eligibility compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2023-005. Corrective Action Plan Student Financial Services will work with PowerFaids to determine how records are returned to COD for a disbursement date update and ensure reporting is compliant. Responsible Person for Corrective Action Plan Kandi Molder, Registrar and Executive Director of Student Services Deb Beck, Managing Director of Student Financial Services Implementation Date of Corrective Action Plan January 31. 2025

View Audit 337565

Finding 519034 (2024-004)

Significant Deficiency 2024

Brooklyn Unit School District No. 188

IL

Reporting Internal Control / Segregation of Duties

Condition: We noted that 2 out of 11 quarterly expenditure reports were not filed in a timely manner. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due dates. Management Response: Managem...

Condition: We noted that 2 out of 11 quarterly expenditure reports were not filed in a timely manner. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due dates. Management Response: Management will take the necessary steps to file all quarterly reports on time in the future.

View Audit 337549

Finding 519032 (2024-001)

Significant Deficiency 2024

Mono County Office of Education

CA

Special Tests & Provisions Cash Management Eligibility

Corrective Action Plan: Anticipated Completion Date January 15, 2025 Prior to Mono County Office of Education (MCOE) taking over this program in 2022-23, another agency was responsible for the original eligibility determinations and special tests and provisions. MCOE investigated further, and it was...

Corrective Action Plan: Anticipated Completion Date January 15, 2025 Prior to Mono County Office of Education (MCOE) taking over this program in 2022-23, another agency was responsible for the original eligibility determinations and special tests and provisions. MCOE investigated further, and it was noted that the staff at the time were not following the procedures and forms that were in place. Items were either not completed or filled out correctly in many instances. When the audit finding was identified in the 2022-23 audit, MCOE took action to immediately implement new procedures to address the items noted. Although a few items were noted during the 2023-24 audit, MCOE has made significant efforts in putting procedures in place, and will continue efforts to ensure all required documentation is complete. MCOE has developed a corrective action plan as follows to adhere to strong internal control in meeting the program’s requirements: • MCOE will ensure that existing and new staff are trained to adhere to the policies and procedures for the program. • MCOE will be conducting annual reviews of all service providers and children served to ensure MCOE is maintaining the required documents on file. • MCOE has developed a double-check procedure to ensure that staff is keeping the required documentation on file for both providers and children served moving forward. I, Jennifer Weston, CBO, will be responsible for the implementation and monitoring of the corrective action plan. Sincerely, Jennifer Weston Chief Business Officer Mono County Office of Education

View Audit 337547

Finding 519019 (2024-001)

Significant Deficiency 2024

California Online Public Schools

CA

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.514

Controls will be implemented for future reporting and the Organization will have the opportunity to correct the reporting errors in the subsequent periods.

View Audit 337531

Finding 519018 (2024-001)

Material Weakness 2024

Housing Authority of the City of Norwalk

CT

Questioned Costs HUD Housing Programs Eligibility

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Moving to Work Demonstration Program to ensure that established internal control policies are being followed on a timely basis. Adam Bov...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Moving to Work Demonstration Program to ensure that established internal control policies are being followed on a timely basis. Adam Bovilsky, Executive Director, is responsible for implementing this corrective action by March 31, 2025.

View Audit 337522 Questioned Costs: $1

Finding 519017 (2024-001)

Significant Deficiency 2024

Pine Cone Manor, Inc. 092-Ee039-Wac

MN

Questioned Costs HUD Housing Programs Significant Deficiency

HUD Section 202, Capital Advance – Assistance Listing No. 14.157 Recommendation: Management should implement a review process of the management fee rate upon any changes to that rate or system utilized to calculate that rate to ensure the HUD approved rate is utilized. Management should repay the am...

HUD Section 202, Capital Advance – Assistance Listing No. 14.157 Recommendation: Management should implement a review process of the management fee rate upon any changes to that rate or system utilized to calculate that rate to ensure the HUD approved rate is utilized. Management should repay the amount due the Organization. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The controller will annually review the calculation of the management fee that is being billed to the property by the accounting manager to validate the amount is in compliance with HUD form 9839-B. The overpayment from fiscal year 2024 was corrected in October 2024 Name of the contact person responsible for corrective action: Troy Marschel. Planned completion date for corrective action plan: 10/1/2024

View Audit 337517 Questioned Costs: $1

Finding 518996 (2024-001)

Significant Deficiency 2024

Mizpah Assisted Living Services, INC

MO

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Section 232 Insured Mortgage Note Payable– Assistance Listing No. 14.129 Recommendation: We recommend review of controls to include processes to ensure timely submission of quarterly financial reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the a...

Section 232 Insured Mortgage Note Payable– Assistance Listing No. 14.129 Recommendation: We recommend review of controls to include processes to ensure timely submission of quarterly financial reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Submissions have been made and controls will be reviewed to ensure timely submissions in the future. Name(s) of the contact person(s) responsible for corrective action: Joe Girardi, CFO Planned completion date for corrective action plan: November 2024

View Audit 337480

Finding 518995 (2024-001)

Significant Deficiency 2024

Ahepa 78 Phase Iv, Inc.

IN

HUD Housing Programs Reporting Internal Control / Segregation of Duties

The management agent will repay the funds on behalf of the related party housing project until that property has funds available, pending HUD approval.

View Audit 337474

Finding 518993 (2024-001)

None 2024

Ahepa 60, Inc.

PA

Questioned Costs HUD Housing Programs Reporting

Management agrees with the finding and will request that the surplus cash payment be returned to the property.

View Audit 337462 Questioned Costs: $1

Finding 518992 (2024-001)

Significant Deficiency 2024

Ahepa 3, Inc.

AL

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Management deposited back the $14,068.

View Audit 337453

Finding 518902 (2024-004)

Material Weakness 2024

Lancaster County School District 145

NE

Internal Control / Segregation of Duties Material Weakness School Nutrition Programs

November 4, 2024 School District No. 55-0145, Waverly, Nebraska, respectfully submits the following corrective action plan for the year ended August 31, 2024. Name and address of independent public accounting firm: Romans, Wiemer & Associates, Certified Public Accountants, P.C., 1910 N Lincoln ...

November 4, 2024 School District No. 55-0145, Waverly, Nebraska, respectfully submits the following corrective action plan for the year ended August 31, 2024. Name and address of independent public accounting firm: Romans, Wiemer & Associates, Certified Public Accountants, P.C., 1910 N Lincoln Ave, York, NE 68467 Audit Period: September 1, 2023 through August 31, 2024 The findings from the November 4, 2024 schedule of findings and questioned cost are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2024-001 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. COMPLIANCE 2024-002 Deposit Risk Recommendation: Obtain adequate pledged securities from the financial institution. Action Taken: District personnel will contact the bank about getting additional coverage. 2024-003 Disbursements in Excess of Budget Recommendation: Either not approve disbursements over budgeted amounts or amend the budget if extra disbursements are needed. Action Taken: The District will monitor funds closer and either not approve disbursements over budgeted amounts or amend the budget if needed in the future. FINDINGS – FEDERAL AWARD PROGRAM AUDIT Nebraska Department of Education 2024-004 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. If the Nebraska Department of Education has questions regarding this plan, please call Mikal Shalikow at (402) 786-2321. Sincerely yours, Name Title School District No. 55-0145, of Waverly, Nebraska

View Audit 337383

Finding 518901 (2024-003)

Significant Deficiency 2024

Pender County, North Carolina

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Name of Contact Person: Carolyn Moser, Health & Human Services Director Corrective Action/Management’s Response: The Department of Social Services always maintains Medicaid training as a high priority due to the complexity and prevalence of the program. Best practices are addressed at all staff meet...

Name of Contact Person: Carolyn Moser, Health & Human Services Director Corrective Action/Management’s Response: The Department of Social Services always maintains Medicaid training as a high priority due to the complexity and prevalence of the program. Best practices are addressed at all staff meetings and second party review processes are considered strong, particularly for less experienced staff. This particular situation has been resolved and emphasis placed on maintaining proper documentation has been relayed to Medicaid staff. Proposed Completion Date: Immediately and ongoing.

View Audit 337377

Finding 518892 (2024-002)

Material Weakness 2024

David City Public Schools

NE

Internal Control / Segregation of Duties Material Weakness

October 29, 2024 School District No. 12-0056, David City, Nebraska, respectfully submits the following corrective action plan for the year ended August 31, 2024. Name and address of independent public accounting firm: Romans, Wiemer & Associates, Certified Public Accountants, P.C., 1910 N Lincol...

October 29, 2024 School District No. 12-0056, David City, Nebraska, respectfully submits the following corrective action plan for the year ended August 31, 2024. Name and address of independent public accounting firm: Romans, Wiemer & Associates, Certified Public Accountants, P.C., 1910 N Lincoln Ave, York, NE 68467 Audit Period: September 1, 2023 through August 31, 2024 The findings from the October 95, 2024 schedule of findings and questioned cost are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2024-001 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. FINDINGS – FEDERAL AWARD PROGRAM AUDIT Nebraska Department of Education 2024-002 Internal Control Structure Design Recommendation: While considering the cost of any benefits derived, activities should be segregated and handled by different employees. Action Taken: The cost of implementing a complete set of controls far outweighs the benefits derived by such. It is not financially feasible to have a complete set of controls. If the Nebraska Department of Education has questions regarding this plan, please call Chad Denker at (402) 367-4590.

View Audit 337347

Finding 518886 (2024-003)

Significant Deficiency 2024

Northeast Oregon Housing Authority

OR

Questioned Costs HUD Housing Programs Special Tests & Provisions

Authority Response: The Authority has recognized the deficiencies in the Housing Voucher Cluster and will implement internal control procedures that will ensure compliance with federal regulations. Sarah Parker, Executive Director, was designated to be responsible for implementing this corrective ac...

Authority Response: The Authority has recognized the deficiencies in the Housing Voucher Cluster and will implement internal control procedures that will ensure compliance with federal regulations. Sarah Parker, Executive Director, was designated to be responsible for implementing this corrective action by March 31, 2025.

View Audit 337316 Questioned Costs: $1

Finding 518885 (2024-002)

Significant Deficiency 2024

Northeast Oregon Housing Authority

OR

Questioned Costs HUD Housing Programs Significant Deficiency

Authority Response: The Authority has recognized the significant deficiency in the Housing Voucher Cluster and will implement internal control procedures that will ensure compliance with federal regulations. Sarah Parker, Executive Director, was designated to be responsible for implementing this cor...

Authority Response: The Authority has recognized the significant deficiency in the Housing Voucher Cluster and will implement internal control procedures that will ensure compliance with federal regulations. Sarah Parker, Executive Director, was designated to be responsible for implementing this corrective action by March 31, 2025.

View Audit 337316 Questioned Costs: $1

Finding 518874 (2024-001)

Significant Deficiency 2024

Santa Ana Unified School District

CA

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

The Budget Manager will ensure that the corrected Full-Time Equivalent (FTE) positions will be reported in the 2025 District’s ESSER Annual Data Collection.

View Audit 337308

Finding 518855 (2024-002)

Material Weakness 2024

Cape Girardeau County, Missouri Transit Authority

MO

Internal Control / Segregation of Duties

Name of Contact Person: Kathy Mangels, Board President. Recommendation: We recommend the Authority separate the employee's ability to write checks, sign checks, and full access to the accounting software. Corrective Action: The Authority has updated the accounting software and reorganized the o...

Name of Contact Person: Kathy Mangels, Board President. Recommendation: We recommend the Authority separate the employee's ability to write checks, sign checks, and full access to the accounting software. Corrective Action: The Authority has updated the accounting software and reorganized the organization chart which will allow for enhanced controls. Proposed Completion Date: Immediately.

View Audit 337263

Finding 518854 (2024-004)

None 2024

William Jessup University

CA

Internal Control / Segregation of Duties

Pell Awards Planned Corrective Action: The system configuration has been reviewed and updated to ensure students Pell eligibility is are accurately awarded based on attendance. A review process will be implemented to manually verify Pell awards for students who withdraw from classes to ensure that a...

Pell Awards Planned Corrective Action: The system configuration has been reviewed and updated to ensure students Pell eligibility is are accurately awarded based on attendance. A review process will be implemented to manually verify Pell awards for students who withdraw from classes to ensure that adjustments are made appropriately Person Responsible for Corrective Action Plan: Deborah Rezene, Associate Vice President of Student Financial Services Anticipated Date of Completion: 1/3/2025

View Audit 337234

Finding 518735 (2024-001)

Significant Deficiency 2024

The Housing Authority of the City of Atlanta, Georgia

GA

Eligibility HUD Housing Programs Significant Deficiency

U.S. Department of Housing and Urban Development 2024-001 - Eligibility Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that management implement controls over in-house and external housing specialists to ensure all documents are obtained by tenan...

U.S. Department of Housing and Urban Development 2024-001 - Eligibility Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that management implement controls over in-house and external housing specialists to ensure all documents are obtained by tenants and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As it relates to the 2024-001 Eligibility finding, Atlanta Housing (AH) reached out to the Corbin family in one last attempt to gather the required information to address the participant’s file. The family has until Close of Business on Monday, November 4, 2024 to resolve the issues identified in the file. Failure to provide the required documents by the date noted will result in AH beginning the pro-termination process for failure to provide the required documentation to complete the recertification. Additionally, if the family does not comply, AH will correct the recertification, remove the educational exclusion, reinstate the income from the excluded income, and repay the Housing Assistance Payment via a Tenant Payment Agreement with the family. Name(s) of the contact person(s) responsible for corrective action: (1) Tracy D. Jones, Senior Vice President, Housing Choice Voucher Program Recommended correction: Ensure that management implement controls over in-house and external housing specialists to ensure all documents are obtained by participants. Corrective Actions: AH has a comprehensive six-week onboarding training program for all new hires that provides an overview of Housing Choice's end-to-end eligibility process for program participants. This training includes collecting, reviewing, and processing documentation necessary to complete the required certification for all programs. • Additionally, AH has a Quality Assurance program in place, which ensures that 100% of all new applicants' files are reviewed, along with 50% of all annual and interim recertifications. • AH employs a Quality Control Management System to track all corrections and manage the closure of those corrections effectively. • Furthermore, AH has utilized data from the Quality Control Management System to develop refresher training for current staff. Preventive Actions: • The Quality Assurance Manager will use the HCVP Operational procedures to conduct random reviews of previously audited and/or corrected files to ensure consistency and accuracy. • Key responsibilities include: ➢ Ensuring that the required checklist is utilized for each processed file. ➢ Reviewing the files of newly onboarded hires at a higher percentage than those of current staff. ➢ Providing a report on any abnormalities and documenting files of staff members who may require additional attention and one-on-one training. *Note: The issue for the file in question was addressed during the Audit and resolved November 4, 2024.

View Audit 337170

Finding 518707 (2024-003)

Significant Deficiency 2024

Mt. Hood Community College

OR

Student Financial Aid Reporting Significant Deficiency

Finding 2024-003 Federal Agency Name: U.S. Department of Education Pass-Through Entity: n/a Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Program Name: Student Financial Assistance (SFA) Cluster Finding Summary: In auditor testing of 60 samples, 1 student was not reported to the COD sy...

Finding 2024-003 Federal Agency Name: U.S. Department of Education Pass-Through Entity: n/a Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Program Name: Student Financial Assistance (SFA) Cluster Finding Summary: In auditor testing of 60 samples, 1 student was not reported to the COD system within 15 days of disbursement. Corrective Action Plan: The Director of Financial Aid will: • Review and update the disbursement reporting process to ensure timely and accurate reporting to COD and agreement with college records. • Train staff on the new process. • Conduct a second check on COD reports within 14 days for student files with FAFSA-related holds or delays to ensure accuracy. Responsible Individual(s): Christopher Natelborg, Director of Financial Aid Anticipated Completion Date: February 2025.

View Audit 337161

Finding 518703 (2024-002)

Significant Deficiency 2024

Mt. Hood Community College

OR

Special Tests & Provisions Student Financial Aid Significant Deficiency

Finding 2024-002 Federal Agency Name: U.S. Department of Education Pass-Through Entity: n/a Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Program Name: Student Financial Assistance (SFA) Cluster Finding Summary: In auditor testing of 60 samples, 9 students did not receive a timely noti...

Finding 2024-002 Federal Agency Name: U.S. Department of Education Pass-Through Entity: n/a Assistance Listing Number: 84.007, 84.033, 84.063, 84.268 Program Name: Student Financial Assistance (SFA) Cluster Finding Summary: In auditor testing of 60 samples, 9 students did not receive a timely notification of their award from the College Corrective Action Plan: The Director of Financial Aid will implement procedures to ensure timely notification of financial aid awards: • In August 2024, the Director collaborated with IT to fix a notification system glitch. • IT added a control that sends an email alert to IT, the Director, and tech support if there is a mismatch between student IDs for loan disbursement and notifications sent. This ensures immediate review and resolution of any missed notifications. Responsible Individual(s): Christopher Natelborg, Director of Financial Aid Anticipated Completion Date: February 2025.

View Audit 337161

Corrective Action Plans

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