Corrective Action Plans

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The Organization is currently updating its Accounting Policies and Procedures. The revised policies will include a provision requiring that, if federal awards subject to Uniform Guidance (2 CFR Part 200) are received, all required federal financial reports will be independently reviewed and approved...
The Organization is currently updating its Accounting Policies and Procedures. The revised policies will include a provision requiring that, if federal awards subject to Uniform Guidance (2 CFR Part 200) are received, all required federal financial reports will be independently reviewed and approved prior to submission. The Board Treasurer will perform the review, or the Finance Committee Chair if the Treasurer is unavailable. Documentation of the review will be retained with the related reports.
Coronavirus State & Local Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the College evaluate its procedures and policies around suspension and debarment to ensure that checks are both performed and formally documented prior to entering into the contract. Explanation of ...
Coronavirus State & Local Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the College evaluate its procedures and policies around suspension and debarment to ensure that checks are both performed and formally documented prior to entering into the contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College verified the status of all vendors utilized in federal grant disbursements during the year ended June 30, 2025. A spreadsheet was maintained during that year which documented this. Since June 30, 2025, a procedure has been added to retain copies of the sam.gov verifications for additional documentation. Name(s) of the contact person(s) responsible for corrective action: Susan Spencer, Vice President for Finance Planned completion date for corrective action plan: Completed March 2026 If the United States Department of Treasury has questions regarding this plan, please call Susan Spencer at 660-263-4100, ext. 11274.
2. 2025-003 i. Comments on Finding: Fidelity bond coverage lapsed on September 11, 2025, during the audit period ending September 30, 2025. Coverage was reinstated on November 12, 2025. Management should ensure continuous fidelity bond coverage that meets HUD standards throughout the audit period. P...
2. 2025-003 i. Comments on Finding: Fidelity bond coverage lapsed on September 11, 2025, during the audit period ending September 30, 2025. Coverage was reinstated on November 12, 2025. Management should ensure continuous fidelity bond coverage that meets HUD standards throughout the audit period. Policies must be reviewed regularly for compliance. ii. Actions Taken or Planned: Management will ensure continuous fidelity bond coverage and verify that policies remain compliant with HUD requirements.  Responsible Person: Jill Cromartie  Anticipated Completion Date: 09/30/2026  Steps to Implement: Review of existing controls and implementation of new procedures to ensure continuous fidelity bond coverage, including timely renewal and periodic verification that coverage meets HUD requirements.
1. 2025-002 i. Comments on Finding: For the year ended September 30, 2025, the Corporation did not maintain the required amount of property insurance coverage for certain portions of the year. Management should ensure that an insurance policy is in place and that coverage amounts meet HUD requiremen...
1. 2025-002 i. Comments on Finding: For the year ended September 30, 2025, the Corporation did not maintain the required amount of property insurance coverage for certain portions of the year. Management should ensure that an insurance policy is in place and that coverage amounts meet HUD requirements consistently throughout the year. ii. Actions Taken or Planned: Insurance coverage will be reviewed and monitored to ensure that an active policy is maintained and that coverage amounts comply with HUD requirements.  Responsible Person: Jill Cromartie  Completion Date: 12/10/2024  Steps to Implement: Review of existing controls and implementation of new procedures to ensure timely premium payments and prevent future lapses in required insurance coverage.
3. 2025-004 i. Comments on Finding: Fidelity bond coverage lapsed on September 11, 2025, during the audit period ending September 30, 2025. Coverage was reinstated on November 12, 2025. Management should ensure continuous fidelity bond coverage that meets HUD standards throughout the audit period. P...
3. 2025-004 i. Comments on Finding: Fidelity bond coverage lapsed on September 11, 2025, during the audit period ending September 30, 2025. Coverage was reinstated on November 12, 2025. Management should ensure continuous fidelity bond coverage that meets HUD standards throughout the audit period. Policies must be reviewed regularly for compliance. ii. Actions Taken or Planned: Management will ensure continuous fidelity bond coverage and verify that policies remain compliant with HUD requirements.  Responsible Person: Jill Cromartie  Anticipated Completion Date: 9/30/2026  Steps to Implement: Review of existing controls and implementation of new procedures to ensure continuous fidelity bond coverage, including timely renewal and periodic verification that coverage meets HUD requirements.
2. 2025-003 i. Comments on Finding: Payments were made for non-project expenses, resulting in noncompliance with HUD requirements. Management should review vendor payment procedures to ensure only Project expenses are paid. ii. Actions Taken or Planned: Payments to vendors will be reviewed to ensure...
2. 2025-003 i. Comments on Finding: Payments were made for non-project expenses, resulting in noncompliance with HUD requirements. Management should review vendor payment procedures to ensure only Project expenses are paid. ii. Actions Taken or Planned: Payments to vendors will be reviewed to ensure they relate to Project expenses and comply with HUD requirements.  Responsible Person: Jill Cromartie  Anticipated Completion Date: 9/30/2026  Steps to Implement: Review of old controls or the implementation of new controls to avoid future noncompliance with HUD
1. 2025-002 i. Comments on Finding: For the year ended September 30, 2025, the Corporation did not maintain the required amount of property insurance coverage for certain portions of the year. Management should ensure that an insurance policy is in place and that coverage amounts meet HUD requiremen...
1. 2025-002 i. Comments on Finding: For the year ended September 30, 2025, the Corporation did not maintain the required amount of property insurance coverage for certain portions of the year. Management should ensure that an insurance policy is in place and that coverage amounts meet HUD requirements consistently throughout the year. ii. Actions Taken or Planned: Insurance coverage will be reviewed and monitored to ensure that an active policy is maintained and that coverage amounts comply with HUD requirements.  Responsible Person: Jill Cromartie  Completion Date: 11/12/2025  Steps to Implement: Review of existing controls and implementation of new procedures to ensure timely premium payments and prevent future lapses in required insurance coverage.
Management has implemented additional review procedures over Pell Grant calculations, including documented manual recalculations and supervisory approval prior to disbursement. These controls will remain in place until Pell calculations are automated through the planned SIS implementation.
Management has implemented additional review procedures over Pell Grant calculations, including documented manual recalculations and supervisory approval prior to disbursement. These controls will remain in place until Pell calculations are automated through the planned SIS implementation.
The Department acknowledges the recommendation and agrees that maintaining secure and accurate documentation of beneficiary eligibility is important for program integrity and compliance. At this time, the Program is operating in accordance with the guidance provided by the federal grantor and is uti...
The Department acknowledges the recommendation and agrees that maintaining secure and accurate documentation of beneficiary eligibility is important for program integrity and compliance. At this time, the Program is operating in accordance with the guidance provided by the federal grantor and is utilizing the resources and systems currently available to the agency. Action planned/taken in response to finding: The Department has identified resource gaps affecting grant compliance and has engaged with the federal grantor to present these findings and request additional resources, including access to tools for verifying veteran appointments. The Department recognizes the importance of maintaining secure and accurate documentation to confirm eligibility for veteran benefits and will continue to work with the grantor to secure the necessary resources to support auditable appointment verification and ensure full compliance with program requirements. Name(s) of the contact person(s) responsible for corrective action: Danelle Lucero, CFO/ Jamison A. Herrera, Cabinet Secretary, and the HealthCare Director that manages oversight of the program. Planned completion date for corrective action plan: The Chief Financial Officer, ASD staff, and Federal Grant Director will collaborate with the federal grantor to secure additional resources necessary to address the audit recommendations for the next grant period beginning Sept.15, 2026
Finding 2025-003 Name of Responsible Individual: Angelo Chrisomalis, Sr. Director Grants and Contracts Corrective Action: Due to a change that occurred after the reporting period appropriately reallocating one employee’s effort to the federal funding source, the certification was not displayed on th...
Finding 2025-003 Name of Responsible Individual: Angelo Chrisomalis, Sr. Director Grants and Contracts Corrective Action: Due to a change that occurred after the reporting period appropriately reallocating one employee’s effort to the federal funding source, the certification was not displayed on the effort report. The employee has certified that this effort was charged appropriately to this award. We are reviewing our policies and procedures to ensure redistribution of labor is performed within a timely manner. We have moved to an annual effort reporting process aligned to the federal regulations and are implementing the Cayuse Effort Reporting module that will more effectively track and report effort. The system will be implemented during our next effort reporting cycle. Anticipated Completion Date: March 1, 2026
Finding 2025-004 Name of Responsible Individual: Cinnamon Bradley, Assoc Dean Student Affairs Corrective Action: The Registrar prepares the program calendars with input from the programs on an annual basis. MSM has a diversity of programs with different start and end dates. We understand that this n...
Finding 2025-004 Name of Responsible Individual: Cinnamon Bradley, Assoc Dean Student Affairs Corrective Action: The Registrar prepares the program calendars with input from the programs on an annual basis. MSM has a diversity of programs with different start and end dates. We understand that this needs to be accurately reflected in our calendars and in the Banner system or other enrollment platform. Academic calendars will be reviewed by the Registrar and program staff on an annual basis. Any changes to the academic calendars will need to be communicated to all members of the team. Updated calendars will be posted annually on the website and in the student handbook. After the Registrar’s Office confirms the academic start date and academic end date, Student Fiscal Affairs will continue to input this information in our Student Information System Banner to allow accuracy in our student records sent to the Department of Education Common Origination and Disbursement. If there is a change in the academic start dates and/or academic end dates, the Registrar’s Office will notify Student Fiscal Affairs, Admissions, and Student Accounts to allow for updates within the institution. Anticipated Completion Date: March 1, 2026
Finding 2025-001 Name of Responsible Individual: Cinnamon Bradley, Assoc Dean Student Affairs Corrective Action: Due in part to frequent turnover in the Registrar's Office, there have been reporting errors in Clearinghouse which have been reflected in NSLDS. In addition to changes in personnel, the ...
Finding 2025-001 Name of Responsible Individual: Cinnamon Bradley, Assoc Dean Student Affairs Corrective Action: Due in part to frequent turnover in the Registrar's Office, there have been reporting errors in Clearinghouse which have been reflected in NSLDS. In addition to changes in personnel, the Office of the Dean will provide joint oversight with the Office of Student Affairs on matters impacting regulatory requirements. Specifically, there will be a monthly review of the NSLDS database on the second Monday of each month with a regular tracking system. The Registrar, Associate Dean of Students and Dean’s Office representative will provide quarterly “audits” to the Dean on accuracy of data and reporting compliance. Annual NSLDS training, appropriate to the role, will be provided for all team members in the Registrar's Office and others as appropriate. Anticipated Completion Date: March 31, 2026
In Finding 2025-001, a condition was noted that a majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should “utilize the health center as their principal source of primary heal...
In Finding 2025-001, a condition was noted that a majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should “utilize the health center as their principal source of primary health care” in order for them to give substantive input into the Organization’s strategic direction and policy. Management recognizes the importance of complying with board member compliance guidelines. In response to Finding 2025-001, procedures will be established to ensure that more than 50 percent of the board members are users of the health center.
Condition: Controls in place were not sufficient to ensure subrecipients were paid consistently within 30 days of a request for reimbursement. Planned Corrective Action: Management acknowledges the finding. Delays in approvals may occur due to multiple internal and external parties involved. To prev...
Condition: Controls in place were not sufficient to ensure subrecipients were paid consistently within 30 days of a request for reimbursement. Planned Corrective Action: Management acknowledges the finding. Delays in approvals may occur due to multiple internal and external parties involved. To prevent recurrence, management will monitor all parties, issue email reminders with clear deadlines, and enforce timely processing to ensure compliance with the 30-day requirement. Contact person responsible for corrective action: Teresa Martinez, Lorena Soto, Alvaro Espino and Mariela Romo Anticipated Completion Date: 8/31/2026
2025-004 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment. Action Take...
2025-004 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment. Action Taken: The Board will evaluate existing review and approval processes for federal program charges and implement appropriate controls to ensure all expenditures are thoroughly reviewed, properly authorized, and fully supported before payment is made. As part of the review of charges, a daily review of invoices will be implemented to ensure that all invoices coded to WIOA are allowable costs. The Board’s allowable costs are reviewed by three members: Fiscal Coordinator, Fiscal Manager and Executive Director. These are reviewed and approved by each before the costs are paid. Evidence of these allowable costs will have reviewer’s initials and date reviewed on the bills/invoices themselves and a checklist with signatures that they have reviewed these.
2025-003 Reporting U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all required reporting is submitted accurately and in a timely fashion. Action Taken: The Board will design and implemen...
2025-003 Reporting U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all required reporting is submitted accurately and in a timely fashion. Action Taken: The Board will design and implement enhanced controls to ensure compliance with all reporting requirements by evaluating the existing reporting procedures and work to strengthen controls around preparation, review, and submission. These measures will help ensure that all reports are prepared accurately, reviewed appropriately, and submitted in a timely manner. We will proceed in this manner by training personnel in preparation and review. We will create a checklist so the breakdown in this report can be verified as correct and complete. Reports will not be submitted until these procedures have been completed.
2025-002 Earmarking U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement controls and procedures to ensure that all requirements for earmarking within the Uniform Guidance are properly followed. Action Taken: We recognize that ...
2025-002 Earmarking U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement controls and procedures to ensure that all requirements for earmarking within the Uniform Guidance are properly followed. Action Taken: We recognize that full compliance with the Uniform Guidance earmarking requirements is essential. The Board will implement additional controls and procedures to ensure adherence to these standards. We will strengthen these controls by training personnel on the specific steps required and ensuring they fully understand the compliance requirements. Additionally, we will enhance our monitoring processes to verify that all obligations are properly documented and followed. In addition, we will implement additional controls by including checklists to confirm actions and approvals for accounts payable, account reconciliations, review of the general ledger, review of deposits and journal entries. The referred to actions will be presented monthly via email to the executive committee of the Board.
Name of auditee: Niagara Community Action Program, Inc. TIN: 16-0919885 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2024 - October 31, 2025 CAP prepared by: Paul Wilson pwilson@niagaracap.org Finding 2025-001 Corrective Action Plan The Agency acknowledges and is a...
Name of auditee: Niagara Community Action Program, Inc. TIN: 16-0919885 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2024 - October 31, 2025 CAP prepared by: Paul Wilson pwilson@niagaracap.org Finding 2025-001 Corrective Action Plan The Agency acknowledges and is aware of this information in regards to the two files. Program departments are responsible for complete eligibility verification and documentation. Program personnel are trained and will continue to follow its policies and procedures to maintain complete eligibility documentation for future periods.
Authority Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program including implementation of formal policies, reconciliation procedures, and enhanced oversight of interfund activi...
Authority Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program including implementation of formal policies, reconciliation procedures, and enhanced oversight of interfund activity to ensure that established internal control policies are being followed on a timely basis. Steve Arlinghaus, Executive Director, is responsible for implementing this corrective action by June 30, 2026.
Authority Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program including implementation of formal policies, reconciliation procedures, and enhanced oversight of interfund activi...
Authority Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program including implementation of formal policies, reconciliation procedures, and enhanced oversight of interfund activity to ensure that established internal control policies are being followed on a timely basis. Steve Arlinghaus, Executive Director, is responsible for implementing this corrective action by June 30, 2026.
Finding: #2025-002- Time and Effort Reporting Assistance Listing/Program Title: #84.027 A/IDEA Flow Through and #84.173A/Preschool Entitlement (Special Education Cluster) Federal Agency/Pass-Through Entity: U.S Department of Education/Wisconsin Department of lnstruction Award Numbers/Year: 2025-1333...
Finding: #2025-002- Time and Effort Reporting Assistance Listing/Program Title: #84.027 A/IDEA Flow Through and #84.173A/Preschool Entitlement (Special Education Cluster) Federal Agency/Pass-Through Entity: U.S Department of Education/Wisconsin Department of lnstruction Award Numbers/Year: 2025-133332-DPI-FLOW-341 and 2025-133332-DPI-PRESCH-347/2024-2025 Criteria: In accordance with the federal Uniform Guidance, charges to federal awards for salaries and benefits must be based on records that accurately reflect the work performed. Such records must be supported by time and effort documentation. Condition: During the auditors' testing of payroll charges, it was noted that the District did not maintain adequate time and effmi documentation to support the allocation of salaries and benefits to the Special Education Cluster. Specifically, one employee's time was coded to the Special Education Cluster at a fixed 10% allocation. Cause: The District did not have adequate internal controls to ensure required time and effort documentation was consistently obtained and maintained for all employees whose salaries and benefits were charged to the Special Education Cluster. Staff turnover and lack of training contributed to inconsistent application of federal requirements. Effect: Because required time and effort documentation was not properly maintained, salaries and benefits charged to the Special Education Cluster may not accurately reflect actual time spent working on the program. As a result, these costs are unallowable under the Uniform Guidance. Questioned Costs: The absence of proper documentation results in questioned costs of $7,037, representing the salary and benefit amounts charged to the program for the one employee without adequate support. Recommendation: The auditor recommends that the District strengthen internal controls over time and effort reporting to ensure all employees funded in whole or in part by federal programs complete required documentation in accordance with Uniform Guidance. Additionally, a monitoring process should be implemented to ensure time distribution report is are completed accurately and retained in accordance with record-keeping requirements. Response: Management concurs with the finding and will implement internal control improvements to ensure full compliance with federal time and effort documentation requirements.
Malama Honua Public Charter School Foundation (“MHPCS Foundation”) acknowledges the observation noted by the auditors regarding the timing of the advance drawdown received on February 7, 2025 and the subsequent disbursement on April 29, 2025. As described in the audit finding, the funds remained on ...
Malama Honua Public Charter School Foundation (“MHPCS Foundation”) acknowledges the observation noted by the auditors regarding the timing of the advance drawdown received on February 7, 2025 and the subsequent disbursement on April 29, 2025. As described in the audit finding, the funds remained on hand for approximately 81 days prior to disbursement, which exceeds the expectation under 2 CFR §200.305(b) that non-Federal entities minimize the time between the transfer of federal funds and their disbursement. Management notes that the timing of the disbursement occurred during a period of heightened uncertainty related to federal appropriations and funding continuity. During 2024 and early 2025, the federal government operated under a series of short-term Continuing Resolutions due to delays in the passage of full-year appropriations legislation. In early 2025, the federal government faced a potential shutdown while operating under temporary funding authority that extended through March 14, 2025. The uncertainty associated with these circumstances contributed to adjustments in project timelines, vendor invoicing schedules, and payment coordination. While these conditions affected the timing of project-related expenditures, MHPCS Foundation recognizes the importance of ensuring that federal drawdowns are aligned as closely as possible with immediate disbursement needs. MHPCS Foundation maintains internal financial management practices designed to support compliance with federal cash management requirements and has taken steps to strengthen documentation and oversight related to drawdown requests. As part of its corrective action plan, the Foundation has implemented procedures to ensure that advance payment requests are generally limited to anticipated expenditures expected to occur within approximately five to seven days, consistent with the objective of minimizing the time between the receipt and disbursement of federal funds. Prior to requesting a drawdown, the Project or Program Director prepares an itemized expenditure schedule identifying the anticipated immediate cash needs associated with the project or program budget. The itemized expenditure schedule is submitted to the Foundation’s Accountant for review. The Accountant verifies that the projected expenditures are consistent with the approved program budget and prepares a Drawdown Authorization Form documenting the requested advance payment. The Drawdown Authorization Form is then reviewed and approved by the Foundation’s Board President prior to submission of the draw request through the applicable federal payment system (e.g., G5). Following submission, confirmation of the draw request is attached to the authorization documentation and retained for accounting and audit purposes. This process provides documented support for draw requests, establishes multiple levels of review, and ensures that advance payments are supported by near-term disbursement forecasts. Advance payments outside of regular payroll cycles may occur only when supported by documented project or program expenditures and must follow the same authorization and documentation procedures described above. These strengthened procedures are intended to ensure that future drawdowns are aligned with immediate program needs and supported by documented payment schedules, thereby reinforcing compliance with 2 CFR §200.305(b) and related Uniform Guidance requirements. Management believes the procedures outlined above address the circumstances described in the finding and enhance the Foundation’s internal controls over federal cash management. The Foundation remains committed to maintaining strong financial stewardship and ensuring continued compliance with applicable federal regulations governing advance payments and cash management.
Develop a Strategic Plan of Action ensuring data accuracy and timely transmission of Enrollment Status Reports & Degree Verification Reports to the National Student Clearinghouse for further submission to NSLDS. The plan will establish a structured, repeatable process to:  Validate the accuracy of ...
Develop a Strategic Plan of Action ensuring data accuracy and timely transmission of Enrollment Status Reports & Degree Verification Reports to the National Student Clearinghouse for further submission to NSLDS. The plan will establish a structured, repeatable process to:  Validate the accuracy of student enrollment and degree data prior to NSCH submission.  Ensure timely transmission of Enrollment Status Reports (ESRs) and Degree Verification Reports (DVRs).  Strengthen internal controls, documentation, and audit readiness with system-generated audit reports and dual review.  Improve communication among Registrar, IT, Institutional Research, and Financial Aid. Susan W. Gibson, University Registrar James Stotts, Associate VP Financial Aid Tansha Gillins, Principal Analyst June 30, 2026 Due to BANNER SaaS system upgrade in progress, this action will be completed by June 30, 2026, to allow for report writing in the new reporting tool postimplementation Immediate action: To ensure timely reporting to National Student Clearinghouse and NSLDS, reports will be generated bi-weekly. ISE scheduler will be used to extract baseline data from BANNER for uploading the Enrollment Status Report to National Student Clearing biweekly with off-cycle adjustments as needed. Initial errors will be identified and corrected using a dual-review process before uploading the report to NSCH. Martha Henderson, Associate Registrar Tansha Gillins, Principal Analyst On-going activity Beginning March 30, 2026 The Degree Verification Report will be generated monthly to ensure that graduation status is reported within the timeframe required by NSLDS. Graduation lists will be forwarded to the Office of Financial Aid for dual review and validation to confirm the accuracy of the data and the timeliness of certification to NSLDS. Martha Henderson, Associate Registrar Palmira Wakhisi, Financial Aid On-going activity Beginning May 20, 2026
To prevent future errors in reporting, the School District will establish a simple monthly reconciliation procedure in which reported meal counts are compared to daily meal service records to identify and correct discrepancies before submission.
To prevent future errors in reporting, the School District will establish a simple monthly reconciliation procedure in which reported meal counts are compared to daily meal service records to identify and correct discrepancies before submission.
To prevent future errors in eligibility determinations, the School District will implement a secondary review process. All eligibility applications will be reviewed by a second qualified staff member to verify household size, income calculations, and comparison to the National Income Eligibility Gui...
To prevent future errors in eligibility determinations, the School District will implement a secondary review process. All eligibility applications will be reviewed by a second qualified staff member to verify household size, income calculations, and comparison to the National Income Eligibility Guidelines before final approval.
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