Corrective Action Plans

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Finding 2022-001: Significant deficiency in internal control over procurement. Summary: There was no documented evidence that a contractor was required to comply with the prevailing wage requirement of the Federal Award agreement in one contract under the Federal Award. Corrective Action Planned: ...
Finding 2022-001: Significant deficiency in internal control over procurement. Summary: There was no documented evidence that a contractor was required to comply with the prevailing wage requirement of the Federal Award agreement in one contract under the Federal Award. Corrective Action Planned: Written policies and procedures regarding procurement and grant compliance will be updated and implemented to ensure compliance with procurement terms and conditions of Federal Awards. Anticipated Completion Date: By Sept 30, 2023. Name of Contact Person Responsible for Corrective Action: Tammy Rash, Administrative Services Director
Finding 2022-003 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities and Loans Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule ...
Finding 2022-003 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities and Loans Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of federal expenditures of federal awards being audited. As auditors, we were requested to assist with the preparation of the schedule. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: It is not cost effective to have an internal control system designed to prepare the schedule of expenditures of federal awards. We requested that our auditors, Eide Bailly LLP, to assist with the preparation of the schedule of expenditures of federal awards. We have designated a member of management to review the drafted schedule of expenditures of federal awards, and we have reviewed with and agree with the final Schedule of Expenditures of Federal Awards. We will begin developing a Grant Award Policy and Procedure Manual around tracking and reporting of awards to ensure accurate and up-to-date communication of award requirements. This communication will include implementing additional processes to improve our internal controls over identifying and reporting of expenditures in compliance with the Schedule of Expenditures of Federal Awards (SEFA) if applicable. We will provide staff training annually for any updates or adjustments to the policy. Anticipated Completion Date: Ongoing
Finding 2022-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities and Loans Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management maintained the reserve amount in the cash sweep general fund account which was not established as a ...
Finding 2022-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities and Loans Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management maintained the reserve amount in the cash sweep general fund account which was not established as a separate bookkeeping account or as a separate bank account. The Hospital had excess cash available to cover the required reserve amount. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Management will establish a separate bookkeeping account in the general ledger to establish the correct reserve amount of cash within its general operating bank account. The reserve account will be part of total cash in the bank to maximize interest earned on the reserve balance. Anticipated Completion Date: June 30, 2023
Finding 36487 (2022-006)
Significant Deficiency 2022
2022-006 SPECIAL PROVISIONS ? STATE ADMINISTRATIVE MATCHING GRANTS FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP CLUSTER) Recommendation: We recommend that income verification be reviewed for each eligible case files. Explanation of disagreement with audit finding: There is no disagreement wit...
2022-006 SPECIAL PROVISIONS ? STATE ADMINISTRATIVE MATCHING GRANTS FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP CLUSTER) Recommendation: We recommend that income verification be reviewed for each eligible case files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work on training new staff on requirements, and continue to perform case file reviews. Name of the contact person responsible for corrective action plan: Deborah Erickson, Administrative Services Director Planned completion date for corrective action plan: December 31, 2023
Finding 36486 (2022-005)
Significant Deficiency 2022
2022-005 ALLOWABLE COSTS AND ALLOWABLE ACTIVITIES ? STATE ADMINISTRATIVE MATCHING GRANTS FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP CLUSTER) Recommendation: We recommend the county ensures that all employees included on the random moment study listing are included on the proper line for re...
2022-005 ALLOWABLE COSTS AND ALLOWABLE ACTIVITIES ? STATE ADMINISTRATIVE MATCHING GRANTS FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP CLUSTER) Recommendation: We recommend the county ensures that all employees included on the random moment study listing are included on the proper line for reimbursement requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review their procedures to ensure the random moments studies are periodically reviewed against payroll and updated appropriately. Name of the contact person responsible for corrective action plan: Deborah Erickson, Administrative Services Director Planned completion date for corrective action plan: December 31, 2023
FINDING 2022-008 Contact Person Responsible for Corrective Action: Carrie McGuire Contact Phone Number: (574) 875 -5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Prior to the submission of the Title I application annually, the federal grants coo...
FINDING 2022-008 Contact Person Responsible for Corrective Action: Carrie McGuire Contact Phone Number: (574) 875 -5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Prior to the submission of the Title I application annually, the federal grants coordinator with consult with all non-public schools within our district boundaries as listed by the IDOE in the grant application portal. The signed consultation forms will be uploaded to the IDOE?s Title I Programs Application Center as attachments. The corporation treasurer will verify that all consultation forms are signed and uploaded in the Application Center before the initial grant application budget can be submitted for review. Anticipated Completion Date: December 31, 2022
FINDING 2022-007 Contact Person Responsible for Corrective Action: Contact Phone Number: (574) 875-5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: When required annual federal grant reports are completed for submission, they will be reviewed by t...
FINDING 2022-007 Contact Person Responsible for Corrective Action: Contact Phone Number: (574) 875-5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: When required annual federal grant reports are completed for submission, they will be reviewed by the treasurer for accuracy. Both the treasurer and the grants coordinator will sign off on the reports. Anticipated Completion Date: June 30, 2022
FINDING 2022-005 Finding: Internal controls were not in place/effective in relation to the Title I Annual Expenditure Reports filed during the audit period. Subsequently, the 20-21 Title I Annual Expenditure Report did not agree with School Corporation?s ledgers. $578,452 of expenditures were report...
FINDING 2022-005 Finding: Internal controls were not in place/effective in relation to the Title I Annual Expenditure Reports filed during the audit period. Subsequently, the 20-21 Title I Annual Expenditure Report did not agree with School Corporation?s ledgers. $578,452 of expenditures were reported the Annual Expenditure Report and $677,514 from Fund 4121 on the ledgers. Contact Person Responsible for Corrective Action: Carrie McGuire Contact Phone Number: (574) 875-5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: When required annual federal grant reports are completed for submission, they will be reviewed by the treasurer for accuracy. Both the treasurer and the grants coordinator will sign off on the reports. In order to address the issue related to earmarking and set-asides within Title I not be completed, Concord Community Schools created a Grants and Assessment Coordinator position in May 2022. A person was hired to fill this position starting on July 1, 2022. One of the essential functions of this position is maintaining current and accurate records related to federal and state grants. Starting in January 2023, in addition to the Grants and Assessment Coordinator, a member of the business department will be a second reviewer and sign the semi-annual certifications. Anticipated Completion Date: December 31, 2023
FINDING 2022-006 Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the following compliance requirements: Earmarking. Of the $7,139.98...
FINDING 2022-006 Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the following compliance requirements: Earmarking. Of the $7,139.98 set-aside for the SY 20 Grant it was determined that only $2,284.50 was spent on Parent Involvement. Of the $6,817.51 set-aside for the SY 21 Grant, only $95.78 was spent during the audit period. In addition, Homeless Reservation set-asides were not me SY 20 or 21. Of the $1,900 designated for SY20, only $32.89 was spent. No amount was determined to have spent for the SY 21. Contact Person Responsible for Corrective Action: Carrie McGuire Contact Phone Number: (574) 875-5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: In order to address the issue related to earmarking and set-asides within Title I not be completed, Concord Community Schools created a Grants and Assessment Coordinator position in May 2022. A person was hired to fill this position starting on July 1, 2022. One of the essential functions of this position is maintaining current and accurate records related to federal and state grants. Starting in January 2023, in addition to the Grants and Assessment Coordinator, a member of the business department will be a second reviewer and sign the semi-annual certifications. Anticipated Completion Date: September 30, 2023
FINDING 2022-004 Finding: Non-Public School: No documentation could be found to support non-public school students qualifying for Title I on the 2020-2021 and 2021-2022 Applications. These numbers determine equitable share distributions to these non-public schools. Contact Person Responsible for Cor...
FINDING 2022-004 Finding: Non-Public School: No documentation could be found to support non-public school students qualifying for Title I on the 2020-2021 and 2021-2022 Applications. These numbers determine equitable share distributions to these non-public schools. Contact Person Responsible for Corrective Action: Carrie McGuire Contact Phone Number: (574) 875-5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Non public schools will be consulted prior to the initial Title I(a) application being submitted at the start of each grant cycle. Non-public school consultation forms and spreadsheet(s) for any equitable share calculations will be uploaded into the Title I application center as attachments. These will be verified by the corporation treasurer before the Title I application is submitted annually. Prior to the submission of the Title I application annually, the federal grants coordinator with consult with all non-public schools within our district boundaries as listed by the IDOE in the grant application portal. The signed consultation forms will be uploaded to the IDOE?s Title I Programs Application Center as attachments. The corporation treasurer will verify that all consultation forms are signed and uploaded in the Application Center before the initial grant application budget can be submitted for review. A form will be created so that when files are downloaded from the Child Nutrition Program (CNP) website and subsequently uploaded into Mealtime, there will be places for a signature of the person who downloaded the file, a signature for the person who uploaded the file, and a reviewer. Anticipated Completion Date: September 15, 2023
FINDING 2022-001 Contact Person Responsible for Corrective Action: Jim Evans Contact Phone Number: (574) 875-5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: This finding was corrected beginning July 1, 2022. Concord Community Schools hired an add...
FINDING 2022-001 Contact Person Responsible for Corrective Action: Jim Evans Contact Phone Number: (574) 875-5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: This finding was corrected beginning July 1, 2022. Concord Community Schools hired an additional staff member and that staff member reviews the information used to prepare the Monthly Sponsored Claims for reimbursement to verify that the claims are accurate, complete and prepared in accordance with the grant requirements. Once the review is complete, the Monthly Sponsored Claims are printed and signed by both the Food Service official who prepared the claims and the food service official who reviewed the claims for accuracy, completeness and compliance with grant requirements. Anticipated Completion Date: This finding has been corrected.
2022-001 Reporting: Significant Deficiency over Internal Controls over Contact person responsible for corrective action: Juan Hernandez, AVP for Finance Completion date: September 30, 2022 Summary of new and revised controls used to ensure timely posting of the special reports: Part 1: Starting with...
2022-001 Reporting: Significant Deficiency over Internal Controls over Contact person responsible for corrective action: Juan Hernandez, AVP for Finance Completion date: September 30, 2022 Summary of new and revised controls used to ensure timely posting of the special reports: Part 1: Starting with the quarter ended 9/30/2022 the AVP for Finance will send calendar reminders to Pre-Award, Post Award, Financial Aid, Finance, and other parties involved to set a reminder of submission deadlines for each quarterly report and set an internal deadline prior to such due date. Due dates are specified by OMB Control Number 1840-0849, the reporting deadline for quarterly reports is 10 days after each reporting period. Additionally, the AVP for Finance will now be the responsible party to coordinate and submit the report to the DOE and to initiate the upload to the university website with the help of all the aforementioned parties. Part 2: In addition to the calendar invitation in part 1 above, the AVP will be responsible for submitting the report to the DOE and emailing all parties involved confirming that the report was submitted to the DOE. This email will confirm that the report is final and will indicate to designated uploader (currently financial aid department) to make the information public by uploading it to the CGU CARES website. Once this is uploaded the uploader will send a follow up email to all parties involved to confirm that the upload to the website has occurred.
Management is aware and understands the importance of compliance with the federal requirements and will ensure the wage requirements are met in the future.
Management is aware and understands the importance of compliance with the federal requirements and will ensure the wage requirements are met in the future.
View Audit 28004 Questioned Costs: $1
Name of auditee: National Church Residences of Wayne County, Inc. HUD auditee identification number: 073-EE053-NP-WAH Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended August 31, 2022 CAP prepared by Name: Jill Kolb Position: Vice President of Housing Accounti...
Name of auditee: National Church Residences of Wayne County, Inc. HUD auditee identification number: 073-EE053-NP-WAH Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended August 31, 2022 CAP prepared by Name: Jill Kolb Position: Vice President of Housing Accounting Telephone number: 614-451-2151 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition #2022-001 (Assistance Listing 14.157): During the year ended August 31, 2022, a withdrawal of $335 from the reserve for replacements account without prior approval from HUD. Recommendation: Management should transfer $335 from the operating account to the reserve for replacements account. Action(s) Taken or Planned on the Finding: Management intends to transfer $335 into the reserve for replacements account.
View Audit 25851 Questioned Costs: $1
UDC OCFO agrees with the conditions and recommendations of this finding. No action is required since UDC has already implemented corrective action to maintain evidence of submission of quarterly reports to the UDC webmaster. UDC also developed a sign-off coversheet to document evidence of review by...
UDC OCFO agrees with the conditions and recommendations of this finding. No action is required since UDC has already implemented corrective action to maintain evidence of submission of quarterly reports to the UDC webmaster. UDC also developed a sign-off coversheet to document evidence of review by the preparer, the reviewer and approver of the quarterly and annual reports. See Corrective Action Plan for chart/table
OCFO concurs with the finding. In the compilation and reconciliation of the SEFA, the PAYGO ARPA Local Revenue Replacement expenditures component was inadvertently included in the draft District FY 2022 SEFA presented to the external auditors. The District SEFA Compilation Worksheet will be update...
OCFO concurs with the finding. In the compilation and reconciliation of the SEFA, the PAYGO ARPA Local Revenue Replacement expenditures component was inadvertently included in the draft District FY 2022 SEFA presented to the external auditors. The District SEFA Compilation Worksheet will be updated to include guidance on treatment of PAYGO FY 2023 ARPA Local Revenue Replacement expenditures (if any) to ensure they are not included in the draft FY 2023 SEFAs presented to the external auditors. See Corrective Action Plan for chart/table
The Department of Human Services (DHS) concurs with the findings. In response to a similar finding for the fiscal year 2021 ERA single audit where original submission data was overridden by formatting updates, DHS began saving screen shots of reported data within Treasury?s reporting portal. This p...
The Department of Human Services (DHS) concurs with the findings. In response to a similar finding for the fiscal year 2021 ERA single audit where original submission data was overridden by formatting updates, DHS began saving screen shots of reported data within Treasury?s reporting portal. This practice began in June 2022 and will continue for the duration of the ERA program, through ERA2 closeout reporting. This will ensure that even if Treasury reporting portal functionality changes in the future, there is clear supporting documentation of the information submitted. See Corrective Action Plan for chart/table
The Department of Human Services (DHS) agrees with the findings. DHS will reach out to the four (4) STAY DC payees to formally request the return of improper payments to the District of Columbia. This will be tracked to ensure the return is recorded against ERA within the District?s financial syste...
The Department of Human Services (DHS) agrees with the findings. DHS will reach out to the four (4) STAY DC payees to formally request the return of improper payments to the District of Columbia. This will be tracked to ensure the return is recorded against ERA within the District?s financial system. To address any documentation gaps, DHS introduced new Standard Operating Procedures (SOPs) for Family Rehousing and Stabilization Program (FRSP) in FY23. The new SOP implements stricter internal control procedures, regular audits, and streamlining the eligibility determination process. The District will reclass all identified errored payments off of the ERA fund to Local funding by the closeout of FY23, Sept. 30, 2023. DHS also completed a reconciliation of data reported to U.S. Treasury for ERA1 closeout reporting and ERA2 2023 Q2 reporting to ensure that no errored payments were included. See Corrective Action Plan for chart/table
View Audit 31369 Questioned Costs: $1
Finding 36417 (2022-002)
Significant Deficiency 2022
Finding 2022-002 Program ALN: 21.027 Program Title: COVID-19 Coronavirus State and Local Fiscal Recovery Fund Pass-Through Agency: Not applicable Award Number/year: Not applicable / 2022 Criteria: Nonfederal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), ...
Finding 2022-002 Program ALN: 21.027 Program Title: COVID-19 Coronavirus State and Local Fiscal Recovery Fund Pass-Through Agency: Not applicable Award Number/year: Not applicable / 2022 Criteria: Nonfederal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control over the Federal award to ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Review and approval of reports to be submitted under the program should be completed before submission by an individual separate from the preparer. Condition/Context: For the one report required to be submitted under the program in FY2022, the report was both prepared and reviewed by the same individual. The sample was not statistically valid. Cause: The City does not have an internal process in place to ensure all reports are reviewed by someone separate from the preparer prior to submission. Effect: Reports could be submitted that contain errors or reports may not be submitted within the allowed reporting periods. Questioned Costs: None noted. Recommendation: The City should consider enhancing its internal controls related to this program to include a review of reports by someone separate from the preparer prior to submission. Corrective Action Plan Corrective Action Planned: Finance Director will prepare the report. Deputy Treasurer/Clerk will review the report before Finance Director submits the report. Name(s) of Contact Person(s) Responsible for Corrective Action: Mark Stevens, Finance Director Anticipated Completion Date: April 2024 (at point of annual submission)
Corrective Action Plan Finding No.: 2022- 003 Condition: Audit procedures identified that the District claimed $48,150 of expenditures related to equipment on their June 30, 2022 reimbursement claim submitted to the Illinois State Board of Education, however these expenditures were...
Corrective Action Plan Finding No.: 2022- 003 Condition: Audit procedures identified that the District claimed $48,150 of expenditures related to equipment on their June 30, 2022 reimbursement claim submitted to the Illinois State Board of Education, however these expenditures were not received and paid by the District until July 2022. Plan: The District will implement an expenditure tracking system that will require all supporting documentation be uploaded to an electronic filing sharing system (OneDrive) for all quarterly reporting periods. The District will review submittals against dates for which goods and services were actually received. In addition, the District will implement a receiving protocol to coordinate payables against the receipt of materials. Anticipated Date of Completion: June 30, 2022 Name of Contact Person: James Vreeland, Business Manager Management Response: See above
Finding 36381 (2022-004)
Significant Deficiency 2022
Cvfiber
VT
View of Responsible Officials and Planned Corrective Action: Original documents are obtained and provided for all transactions, including inventory, services, and employee records. Time cards and review of salaries, time cards that reflect total time worked, and paid time off will be submitted to ...
View of Responsible Officials and Planned Corrective Action: Original documents are obtained and provided for all transactions, including inventory, services, and employee records. Time cards and review of salaries, time cards that reflect total time worked, and paid time off will be submitted to the company?s outsourced accountant regularly with signature and supervisory approval. Reporting of these items for employees will be on a monthly basis, and stipend personnel on a quarterly basis. Planned Implementation Date of Corrective Action: Implemented Person Responsible for Corrective Action: Jennille Smith, Executive Director
Grant expenditures that specify a period of coverage and/or performance will be amortized based on the service contract terms. Amortization costs that go beyond a grant?s expiration date will not be recorded against the expired grant.
Grant expenditures that specify a period of coverage and/or performance will be amortized based on the service contract terms. Amortization costs that go beyond a grant?s expiration date will not be recorded against the expired grant.
View Audit 26949 Questioned Costs: $1
The district does not agree with the finding in that a correction has been made prior to the audit. The district ensures to collect prevailing wage reports from current contractors that are paid using Federal grant funds. At this point, the only contractor being used is Gardiner for HVAC systems. Th...
The district does not agree with the finding in that a correction has been made prior to the audit. The district ensures to collect prevailing wage reports from current contractors that are paid using Federal grant funds. At this point, the only contractor being used is Gardiner for HVAC systems. The finding is from a company that sold their book of business during or immediately after the school project was completed. The company did not send prevailing wage reports to the district and the new company did not have payroll records for the company that did the project.
Condition Found: During audit fieldwork, the auditors spoke to City Staff about the Illinois Environmental Protection Agency (IEPA) Loan reimbursements the City had received during FY2022. The question was whether or not the expenditures we asked to be reimbursed for were eligible because the expens...
Condition Found: During audit fieldwork, the auditors spoke to City Staff about the Illinois Environmental Protection Agency (IEPA) Loan reimbursements the City had received during FY2022. The question was whether or not the expenditures we asked to be reimbursed for were eligible because the expense was incurred prior to the loan being approved. The expenditures in question had already been reimbursed to the City from the IEPA and were considered eligible expenditures. When the request from the auditors came for the account numbers that the expenditures had been paid out of, City Staff realized that the majority of these older invoices had been paid with proceeds from the 2015 GO Note issuance, and as such were not eligible to be reimbursed by the IEPA. City Staff relayed this discovery to the auditors and recorded an adjustment to reduce the receivable from the IEPA ($260,749.30) that were not eligible. The City has worked with the consultant managing the project at Baxter and Woodman, and the IEPA, to remedy the issue with a reduction to the City's next distribution. The IEPA loan has not been closed out as of this date, allowing for the reduction without significant impact. Corrective Action Plan: Going forward, the Public Works Department will forward the IEPA Loan draw requests to the Finance Department to be reviewed before being submitted to the IEPA for reimbursement. The Finance Department was not included in the draw request prior to this finding. By having the Finance Department review the draw requests, we can ensure that all items submitted for reimbursement are eligible. Staff at Baxter and Woodman, who package invoices for submittal to the IEPA on behalf of the City, will also be reviewing invoices more closely before submittal as an independent verification. Implementation Date: This change is effective immediately and the Finance Department has already started reviewing the next invoices being submitted to the IEPA for reimbursement.
View Audit 26960 Questioned Costs: $1
The OCFO/OFT for DHS concurs with this finding. As a result of the findings, OCFO/OFT is committed to working with Fidelity National Information Services (FIS) to ensure: ? Strict procedures and practices are in place to ensure contract compliance. Quarterly management reviews of UPO practices ha...
The OCFO/OFT for DHS concurs with this finding. As a result of the findings, OCFO/OFT is committed to working with Fidelity National Information Services (FIS) to ensure: ? Strict procedures and practices are in place to ensure contract compliance. Quarterly management reviews of UPO practices have been conducted to ensure proper handling of DHS referral forms. OFT will ensure UPO up-holds policy and procedures that govern receiving proper signature on the referral forms; this should mitigate errors that appear in the current process. ? All Intake Procedures and Processes found in the EBT Manual are followed thoroughly by all employees. UPO will continue to enforce the progressive disciplinary process for errors or omissions identified during daily operations. ? The Division of Program Operations (DPO) along with the Office of Information Systems (OIS) are working to automate the Electronic Benefit Transfer (EBT) photo identification process. DPO will use the new EBT Portal to complete all photo identification referral online. This new process will be more streamlined and reduce any errors. See Corrective Action Plan for chart/table
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