Corrective Action Plans

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Corrective action plan: HHSC cannot commit to the specific designation of CAPPS-Financials as the improvement solution for FFATA reporting. However, HHSC is currently engaged in long-term planning related to improving FFATA reporting. HHSC continues to implement a quality review of selected progr...
Corrective action plan: HHSC cannot commit to the specific designation of CAPPS-Financials as the improvement solution for FFATA reporting. However, HHSC is currently engaged in long-term planning related to improving FFATA reporting. HHSC continues to implement a quality review of selected programs to assess FFATA compliance on an annual basis. Implementation dates: September 1, 2025 Responsible persons: Racheal Kane, Director, Federal Funds
Future reporting of ESSR information will be noted wherever possible either in written notation or email format to document who worked on and reviewed reporting information and submissions. We will attempt to take screenshots of any forms that are not available for printing
Future reporting of ESSR information will be noted wherever possible either in written notation or email format to document who worked on and reviewed reporting information and submissions. We will attempt to take screenshots of any forms that are not available for printing
FINDING 2024-006 - Education Stabilization Fund (ESSER) – Reporting Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ...
FINDING 2024-006 - Education Stabilization Fund (ESSER) – Reporting Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER II, and ESSER III amounts reported for the reports covering the FY22 time period ($99,969 and $251,848, respectively) did not agree to the underlying expenditure records ($105,319 and $369,743, respectively, for the period of July 1, 2021 through June 30, 2022). Additionally, we noted that the ESSER II, and ESSER III amounts reported for the reports covering the FY23 time period ($168,087 and $266,122, respectively) did not agree to the underlying expenditure records ($169,046 and $241,329, respectively, for the period of July 1, 2022 through June 30, 2023). We also noted there was no documented, secondary review of the information in the annual data reports by someone other than the preparer. Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all ESSER reports include accurate information that agree to the underlying disbursement records. Anticipated Completion Date: Next report due to IDOE.
FINDING 2024-005 – Child Nutrition Cluster - Eligibility Context: During sample testing of 60 students for eligibility, we noted 5 instances where there was no documented review by someone other than the individual making the eligibility determination. Additionally, we noted 4 instances where the ...
FINDING 2024-005 – Child Nutrition Cluster - Eligibility Context: During sample testing of 60 students for eligibility, we noted 5 instances where there was no documented review by someone other than the individual making the eligibility determination. Additionally, we noted 4 instances where the School Corporation was unable to provide the application. The issues were isolated to paper applications Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The treasurer will formally review a sample of applications and the School Corporation will ensure all supporting applications and reviews are maintained. Anticipated Completion Date: March 2025
FINDING 2024-004 – Child Nutrition Cluster - Reporting Context: We noted that for all sponsor claim reimbursements in a sample of four claims, the sponsor claim reimbursement was prepared without a secondary, documented review before the submission of the claim to ensure the accuracy of the sponsor...
FINDING 2024-004 – Child Nutrition Cluster - Reporting Context: We noted that for all sponsor claim reimbursements in a sample of four claims, the sponsor claim reimbursement was prepared without a secondary, documented review before the submission of the claim to ensure the accuracy of the sponsor claim reimbursement summary. Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The treasurer will formally review and document the review of all reimbursement claims Anticipated Completion Date: March 2025
FINDING 2024-003 - Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Context: During testing we noted the following issues in a sample of forty child nutrition cluster payroll claims: ● 6 of 40 payroll transactions where a timecard was not completed by the ...
FINDING 2024-003 - Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Context: During testing we noted the following issues in a sample of forty child nutrition cluster payroll claims: ● 6 of 40 payroll transactions where a timecard was not completed by the employee to validate their hours worked and the time charged to food service. ● 19 of 40 payroll transactions where the School Corporation was unable to provide supporting documentation for approval of the hourly rate paid to employee. The noncompliance was isolated to the payroll periods through August 4, 2023. The School Corporation corrected the issues starting with the next payroll period. Contact Person Responsible for Corrective Action: Michelle L. Keene Contact Phone Number: (812) 384-4386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: In FY24, the issue was corrected to ensure all employees were only paid for time supported by a time a card and a board approved rate schedule. Anticipated Completion Date: August 19, 2023
View Audit 348324 Questioned Costs: $1
2024-003 Adult Education - Assistance Listing Number 84.002 Recommendation: We recommend procedures to maintain records related to eligibility determinations be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken ...
2024-003 Adult Education - Assistance Listing Number 84.002 Recommendation: We recommend procedures to maintain records related to eligibility determinations be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Adult Education department will now scan in the physical intake form that Adult ESL students self-report their eligibility status for MA DESE ACLS as well as have the student sign that form. This form will be stored electronically in addition to the information from the form being entered into the Adult ESL Access database and LACES . Name(s) of the contact person(s) responsible for corrective action: Dr. Kevin O’Connor, Claudia Castro Alves and Kate Fiore Planned completion date for corrective action plan: Effective as of 08/01/2024
2024-002 Adult Education - Assistance Listing Number 84.002 Recommendation: We recommend procedures to maintain records that accurately reflect the work performed for payroll charges to the grant be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement ...
2024-002 Adult Education - Assistance Listing Number 84.002 Recommendation: We recommend procedures to maintain records that accurately reflect the work performed for payroll charges to the grant be implemented/strengthened. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Adult Education department will be collecting the Time and Effort certifications for staff on Federal grants. Name(s) of the contact person(s) responsible for corrective action: Dr. Kevin O’Connor, Claudia Castro Alves and Kate Fiore Planned completion date for corrective action plan: Effective as of 10/10/2024 so will have Time and Effort certifications for all FY25 staff on Federal grant #2340
View Audit 348312 Questioned Costs: $1
FINDING 2024-003 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or...
FINDING 2024-003 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Context: During sample testing of 60 students for eligibility, we noted 14 instances where there was no documented review by someone other than the individual making the eligibility determination. The lack of review was isolated to paper applications. Contact Person Responsible for Corrective Action: Joyce Hulsman Contact Phone Number: 812-678-2781 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: A procedure has been established to ensure dual validation and paper copies are in compliance. Anticipated Completion Date: Already completed.
Information on the federal program: Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Num...
Information on the federal program: Subject: Education Stabilization Fund (ESSER) – Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013, S425D210013, S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit four Annual Data Reports to the Indiana Department of Education (IDOE) each year during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER I, ESSER III and CrossAct amounts reported on the Year 3 report ($3,070, $745,718 and 119 employees respectively) did not agree to the underlying expenditure and employee records ($7,062, $754,729 and 207 employees respectively). Additionally, we noted that the ESSER II, ESSER III and CrossAct amounts reported on the Year 4 report ($452,658, $117,344 and 117 employees respectively) did not agree to the underlying expenditure and employee records ($62,794, $459,556 and 207 employees respectively). Of the eight reports the School Corporation was required to submit during the audit period, auditable evidence of review and approval of these reports was only provided for two. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has prepared a corrective action plan.The Treasurer will work with the Grants Administrator to ensure that submissions are checked by both positions. Files will be kept with all documentation relating to the grant. A better understanding of the grant will result from regular meetings with the Treasurer and Grants Administrator to ensure accuracy. Both positions will sign off prior to submission. Responsible party and timeline for completion: The Corporation Treasurer will be responsible effective immediately.
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. CMS approved DHS’s Medicaid State Plan Amendment (SPA) requesting exemption from the RAC requirement. The waiver was approved on February 28, 2025, with an effective date of February 1, 2025. The exemption i...
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. CMS approved DHS’s Medicaid State Plan Amendment (SPA) requesting exemption from the RAC requirement. The waiver was approved on February 28, 2025, with an effective date of February 1, 2025. The exemption is effective for two years from the effective date of the SPA. Anticipated Completion Date: Complete Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. Since June 2023, DYS has made multiple changes to improve monitoring of suspension and reinstatement of Medicaid eligibility for incarcerated juveniles. For juveniles with SSI Medicaid, the Social Security A...
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. Since June 2023, DYS has made multiple changes to improve monitoring of suspension and reinstatement of Medicaid eligibility for incarcerated juveniles. For juveniles with SSI Medicaid, the Social Security Administration (SSA) is responsible for suspending Medicaid coverage. All incarcerations for cases noted in the findings involving SSI Medicaid were reported timely to SSA by the agency. DYS closely monitors these cases and continues to send closure requests to SSA until the cases are closed out. SSI cases account for 76% of the total questioned costs noted in the finding. The Division of Medical Services (DMS) implemented an MMIS change in September 2024 that automatically updates member profiles to accurately reflect incarceration dates. This change will resolve the remaining deficiencies noted in the finding. All payments noted as questioned costs were capitated payments made for the PASSE, Dental Managed Care, and NET programs. The agency currently has a reconciliation process for all three programs that identifies payments made after the member’s incarceration date that should be recouped. Any uncollected overpayments noted in the findings will be recouped as part of the next reconciliation process. Anticipated Completion Date: Complete Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov
View Audit 348267 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. For Sample Item 32, the agency’s revalidation date was set for March 27, 2024, and the provider submitted their application for revalidation prior to that date. System updates and monitoring controls have bee...
Views of Responsible Officials and Planned Corrective Action: DHS concurs with the finding. For Sample Item 32, the agency’s revalidation date was set for March 27, 2024, and the provider submitted their application for revalidation prior to that date. System updates and monitoring controls have been implemented to ensure correct revalidation dates are entered in MMIS. For Sample Item 15, the provider submitted a revalidation application prior to their scheduled termination date. Since there was an active application in the system, the provider was not terminated. The revalidation was successfully completed. For Sample Item 21, the provider submitted their revalidation application on October 16, 2023, which was prior to the November 11, 2023 deadlines. Multiple follow-ups and requests for additional information from the provider resulted in completion of the revalidation after the deadline date. Anticipated Completion Date: Complete Contact Person: Elizabeth Pitman Director, Division of Medical Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 244-3944 Elizabeth.Pitman@dhs.arkansas.gov
View Audit 348267 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. Corrections have been made to the affected quarterly reports for SFY2024. New program codes for Placement and Residential Licensing expenditures were not included in prior reporting for Administrative Costs...
Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. Corrections have been made to the affected quarterly reports for SFY2024. New program codes for Placement and Residential Licensing expenditures were not included in prior reporting for Administrative Costs. Documented procedures for quarterly financial reporting will be revised to include more specific instructions for reporting expenditures and additional levels of review prior to report submission. Additional training on completion of quarterly financial reporting is being developed for DCFS Finance and Managerial Accounting-Grants Management staff. Anticipated Completion Date: April 30, 2025 Contact Person: Tiffany Wright Director, Division of Children and Family Services Department of Human Services 700 Main Street Little Rock, AR 72201 (501) 396-6477 Tiffany.Wright@dhs.arkansas.gov
Views of Responsible Officials and Planned Corrective Action: Moving forward the Department will require recipients to provide a list of invoices with the invoice date, period of performance, invoice amount and amount requested/disbursed from ARPA and/or other funding sources to be included with eac...
Views of Responsible Officials and Planned Corrective Action: Moving forward the Department will require recipients to provide a list of invoices with the invoice date, period of performance, invoice amount and amount requested/disbursed from ARPA and/or other funding sources to be included with each disbursement request. Staff training will be modified to ensure staff understand allowable expenditures and period of performance restrictions. Anticipated Completion Date: June 30, 2025 Contact Person: Debby Dickson Water Development Division Manager Arkansas Department of Agriculture-Natural Resources Division 1 Natural Resources Drive Little Rock, AR 72205 (501) 225-1598 Debra.Dickson@agriculture.arkansas.gov
View Audit 348267 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: ASBO will work with our 3rd party program administrator to re-emphasize the importance of verifying the expenses for adequate supporting documentation and allowability. We will discuss the possibility of a repeat training with all federa...
Views of Responsible Officials and Planned Corrective Action: ASBO will work with our 3rd party program administrator to re-emphasize the importance of verifying the expenses for adequate supporting documentation and allowability. We will discuss the possibility of a repeat training with all federal grant subrecipients. Anticipated Completion Date: August 1, 2025 Contact Person: Glen Howie, Jr. Director, Ark State Broadband Office Department of Commerce 1 Commerce Way Little Rock, AR 72202 (501) 682-1123 Glen.Howie@Arkansas.gov
View Audit 348267 Questioned Costs: $1
Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The District has historically managed our Title I grant as supplemental funding. Although we have a methodology for allocating local funds to schools without regard to whether they receive Title I funds, we do n...
Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The District has historically managed our Title I grant as supplemental funding. Although we have a methodology for allocating local funds to schools without regard to whether they receive Title I funds, we do not have a formal written plan. The District will establish a written procedure to be in compliance with the Title I Supplement, Not Supplant requirement. Name of Contact Person and Completion Date: Karen DeFrancis, Executive Director of Finance Polly Golden, Title I Manager Anticipated Completion Date – March 31, 2025
View Audit 348254 Questioned Costs: $1
Finding 2024-001: Allowable costs and activities – material weakness in internal controls over compliance and compliance finding. Management Response Finding: Lack of Documented Approval for Purchases. Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management platf...
Finding 2024-001: Allowable costs and activities – material weakness in internal controls over compliance and compliance finding. Management Response Finding: Lack of Documented Approval for Purchases. Corrective Action Taken: Effective July 1, 2024, CEN implemented Ramp, an expense management platform that ensures all purchases are documented and approved before processing. Ramp provides an automated and auditable approval workflow, ensuring compliance with federal grant requirements. Steps Implemented: • Centralized Purchasing System: All purchases are now made within Ramp using a Ramp credit card, ensuring complete oversight and control over spending. • Automated Approval Workflow: Each purchase requires approval within Ramp, and approvals are documented digitally, creating an auditable trail. • Receipt Verification: Every purchase must include a receipt, which the approver reviews before granting final approval. • Grant Compliance Review: Any charges that do not meet grant requirements are not charged to the grant and are instead assigned to an appropriate non-grant funding source. • Training & Compliance: All relevant staff members have been trained on Ramp’s approval and compliance procedures to ensure adherence to purchasing protocols. Responsible Party: Kendall Guynes, CFO Completion Date: July 1, 2024 (Fully Implemented)
The District has developed and implemented internal control policies to ensure compliance with the Davis-Bacon Act any time the District is expending Federals awards. The District will post all required work site posters concerning prevailing wage rates and review and examine weekly payroll reports...
The District has developed and implemented internal control policies to ensure compliance with the Davis-Bacon Act any time the District is expending Federals awards. The District will post all required work site posters concerning prevailing wage rates and review and examine weekly payroll reports from contractors or subcontractors.
Subject: Education Stabilization Fund – Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D Federal Award Numbers and Years (or Other Identifying Numbers): S425D21001...
Subject: Education Stabilization Fund – Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425D Federal Award Numbers and Years (or Other Identifying Numbers): S425D210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Special Tests and Provisions – Wage Rate Requirements compliance requirements. Context: For 1 of 2 sample items tested, we noted the School Corporation expended approximately $212,000 on science room improvements, which was funded with ESSER II (84.425D) grant awards. The School Corporation did not properly include Davis-Bacon wage rate requirements in the vendor contract. Additionally, the School Corporation did not obtain the weekly payroll reports certifications from the construction vendor to monitor compliance with Davis-Bacon wage rate requirements. Therefore, no review was performed to ensure that pay rates complied with the federal wage rate requirements. The lack of controls and noncompliance was isolated to fiscal year 2023. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has prepared a corrective action plan. Responsible party and timeline for completion: Kendra Sandquist, Director of Finance has assessed all ESSER grant award expenditures, notably the capital projects and equipment purchases. In an effort to rectify the Davis-Bacon wage rate requirements, D&S Builders, contractor for science room improvements, was contacted. While their contract did not specify Davis-Bacon wage rate requirements, D&S Builders was aware that the project was Federally-funded and therefore Davis-Bacon requirements were adhered to including payment to laborers meeting or exceeding LaGrange County prevailing wage determinations. Certified payroll reports should have been obtained and reviewed for compliance for the duration of the project from May 2022 through August 2022. Future Federally-funded projects will specify Davis-Bacon wage rate requirement clauses within the contracts and internal controls will be followed to ensure compliance including, but not limited to, obtaining weekly certified payroll reports and comparing to the prevailing wages. This Corrective Action was completed on December 4, 2024
Finding 2024-002-Internal Control Over Compliance Needs Improvement-Eligibility Condition It appears that there was not a representative check of tenant file and waiting list functions by a qualified second party. Auditing Statement of Auditing Standards (SAS) #115 dictates that either “absent or ...
Finding 2024-002-Internal Control Over Compliance Needs Improvement-Eligibility Condition It appears that there was not a representative check of tenant file and waiting list functions by a qualified second party. Auditing Statement of Auditing Standards (SAS) #115 dictates that either “absent or inadequate segregation of duties within a significant account or process” are defined by the Standard as at least a significant deficiency, if not a material weakness. The lack of a documented check noted in the first sentence is considered an inadequate segregation of duties. Corrective Action Planned: We will comply with the auditor’s recommendation. Person Responsible for Corrective Action: Rita Love, Executive Director Telephone: (580) 353-7392 Housing Authority of Lawton Fax: (580) 353-6111 609 SW F Avenue Lawton, OK 73501 Anticipated Completion Date- June 30, 2025
Condition: Time and effort certifications were not maintained for grant employees. Corrective Action Planned: We will utilize the template provided by the auditors to ensure time and effort certifications are maintained going forward. Anticipated Completion Date: July 1, 2025 Contact: Martin ...
Condition: Time and effort certifications were not maintained for grant employees. Corrective Action Planned: We will utilize the template provided by the auditors to ensure time and effort certifications are maintained going forward. Anticipated Completion Date: July 1, 2025 Contact: Martin Anguelov, Chief Financial Officer for Nantucket Public Schools and Deb Gately, Director of Special Education for Nantucket Public Schools
View Audit 347918 Questioned Costs: $1
Condition: Four vendors were awarded a contract without a competitive procurement process. Corrective Action Planned: We acknowledge the finding and will ensure to attempt to secure three quotes for such services going forward. It is extremely difficult, however, as operating on Nantucket presen...
Condition: Four vendors were awarded a contract without a competitive procurement process. Corrective Action Planned: We acknowledge the finding and will ensure to attempt to secure three quotes for such services going forward. It is extremely difficult, however, as operating on Nantucket presents unique challenges. We will ensure going forward to obtain quotes for every professional services contract we apply to federal grants and will follow the federal office guidelines closely going forward. Anticipated Completion Date: July 1, 2025 Contact: Martin Anguelov, Chief Financial Officer for Nantucket Public Schools and Deb Gately, Director of Special Education for Nantucket Public Schools
View Audit 347918 Questioned Costs: $1
Mangum Public Schools has no plans to use any federal funds for construction projects in the future. The contracts and expenditures were all in place before I became Superintendent. I am fully aware of all that is required of the Davis-Bacon Act now and although we have no construction plans using...
Mangum Public Schools has no plans to use any federal funds for construction projects in the future. The contracts and expenditures were all in place before I became Superintendent. I am fully aware of all that is required of the Davis-Bacon Act now and although we have no construction plans using federal funds, if something were to change, we know the requirements and would ensure that we would remain compliant.
The VP of Admin has secured access to the reporting capability in the NSLDS to generate enrollment reports on a timely basis. The univeristy has already provided timely updates of enrollment status to NSLDS every 30-60 days. Additionally, once enrollment status are updated, the Director of Financial...
The VP of Admin has secured access to the reporting capability in the NSLDS to generate enrollment reports on a timely basis. The univeristy has already provided timely updates of enrollment status to NSLDS every 30-60 days. Additionally, once enrollment status are updated, the Director of Financial Aid will receive the updated enrollment report and will certify that the statuses have been accurately reflected. These reports will be securely maintained by the office of administration.
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