Corrective Action Plans

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Finding 501047 (2023-004)
Significant Deficiency 2023
Contact Person Responsible for Corrective Acton Plan: Debbie Nelson County AuditorCondition During testing, we note 1 material charge-out transaction where the item taken out of inventory was not supported with a signed requisition slip. Corrective Action Plan We agree. We will review the internal c...
Contact Person Responsible for Corrective Acton Plan: Debbie Nelson County AuditorCondition During testing, we note 1 material charge-out transaction where the item taken out of inventory was not supported with a signed requisition slip. Corrective Action Plan We agree. We will review the internal control process to verify all requisition slips get signed. Anticipated Completion Date Fiscal Year 2024
Views of Responsible Officials and Planned Corrective Actions The Organization have experienced turnover of staff in the Organization as well as changes in leadership. In response to this finding the Organization has put together a corrective action plan that targets training of staff and puts into ...
Views of Responsible Officials and Planned Corrective Actions The Organization have experienced turnover of staff in the Organization as well as changes in leadership. In response to this finding the Organization has put together a corrective action plan that targets training of staff and puts into place a monthly audit for ensuring compliance to the sliding fee discount policy. Responsible persons: Nichole Henderson, Quality Improvement Quality Assurance Director and Demetria Johnson, Billing Manager will be in charge of implementing the corrective action. Expected Implementation Date: Started August 1, 2024.
View Audit 323284 Questioned Costs: $1
REFERENCE # 2023-002 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY Program WIOA CLUSTER: WIOA ADULT PROGRAM (Assistance Listing Number 17.258) WIOA YOUTH ACTIVITIES – (Assistance Listing Number 17.259) WIOA DISLOCATED WORKER FORMULA GRANTS – (Assistance Listing Number 17.278) Identific...
REFERENCE # 2023-002 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY Program WIOA CLUSTER: WIOA ADULT PROGRAM (Assistance Listing Number 17.258) WIOA YOUTH ACTIVITIES – (Assistance Listing Number 17.259) WIOA DISLOCATED WORKER FORMULA GRANTS – (Assistance Listing Number 17.278) Identification Number(s) VARIOUS AND AA-36336-21-55-A-36 Finding The Suffolk County Department of Labor (the “Department”) receives WIOA Adult; Youth and Dislocated Worker Formula Grants from New York State Department of Labor (the “Agency”). The Department reports to the Agency on an accrual basis, as required by the Agency. The County’s Schedule of Expenditures of Federal Awards (the “SEFA”) is presented on the accrual basis of accounting. The Department provides all supporting documents to the Agency for reimbursement. We noted that the Department included expenditures in the amount of $373,855, which were incurred and dated in the prior year. The Department recorded the expenditures and revenue in the 2023 financial statements. These expenditures were also added to the SEFA in calendar year ended December 31, 2023. Questioned Costs Cannot be determined. Recommendation We recommend the Department report expenditures on the SEFA on the accrual basis of accounting, which is the basis the County utilizes for other federal programs. Corrective Action Plan Throughout the year, the Department will regularly reconcile vouchers to ensure that expenditures and associated revenue are reported in the correct year on the SEFA. Two staff members in the department (one as the primary, the other as the alternate) will be assigned the responsibility of tracking the SEFA reconciliation process. When preparing the annual SEFA, the department will reconcile expenditure reports with the expenditures reported on the annual SEFA. During year-end processing, the Department, when entering vouchers into the financial system, will ensure items to be accrued will contain the letter “A” as a prefix to the voucher number. The Department will also check to ensure all items that should be accrued, are in fact accrued prior to year-end closing. In addition, the Department will confirm the date entered in the financial system, reflects the proper year in which the expenditure and associated revenue should be recorded. Action Date This process will commence on September 16, 2024. Final Implementation Date Implementation of this plan will be completed by 2/28/25. We recognize that since this is a continuous improvement process, we will review the success of our implemented procedures on an annual basis. Name And Phone No. Of Person Responsible For Implementation Paul Goerke (primary) 631.853.6606 Yvonne Spreckels (alternate) 631.853.6628
View Audit 323277 Questioned Costs: $1
Finding 2023-002 - Source Documentation (Significant Deficiency) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management CFDA Title and Number: 20...
Finding 2023-002 - Source Documentation (Significant Deficiency) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (5311) CARES 5311 Operating Assistance. Formula Grants for Rural. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management Criteria: 2 CFR Part 200.302(b)(1) The financial management system of each non-federal entity must provide for the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. 200.302(b)(2) Accurate, current, and complete disclosure of the financial results of each Federal award or program in accordance with the reporting requirements set forth in 200.328 and 200.329. Condition: The District prepared reimbursement calculations according to an internally developed spreadsheet tool, rather than using amounts directly obtained from the general ledger and supporting documentation. Cause: General ledger data used to prepare spreadsheets, then used to complete reimbursement requests added unnecessary complexity and potential for errors in the reimbursement and request and grant reporting process. Internal control procedures assuring accurate and timely review of reports and filing of the reimbursement requests were not designed or implemented. Effect or Potential Effect: The lack of effective internal control activities over financial reporting could allow for inadvertent errors, such as calculation errors, payments for unauthorized purposes, and result in improper grant accounting, reporting, and reimbursement. Questioned Cost: No Context: Internal disputes regarding grant reimbursement request procedures were evident. The weak or nonexistent controls over the reimbursement request procedures created a potential for inaccurate, incomplete reporting. Repeat of a Prior-Year Finding: Yes, Findings and Questioned Costs 2022-003 Recommendation: The District should continue to improve grant accounting efforts, and establish a more simplified and effective process for the review and approval of grant accounting and reimbursement requests. Additional training of management should occur to ensure they fully understand all compliance regulations and have the skills to assist in designing and implementing effective controls. Monitoring of the control procedures related to the grant accounting and reimbursement request should be performed regularly to ensure reports are filed accurately and timely. Information and communication regarding identified weaknesses and opportunities to improve the policies and procedures should occur among management and the individual performing the monitoring of the procedures. District's Response: The District’s Finance Manager and District Manager are working towards using general ledger reporting exclusively for reimbursement request reporting. General ledger activity became more timely as improvements were implemented based on prior year findings. Management acknowledges delays in that process that continued as a result, to some extent, of the use of the self-developed spreadsheet reports then used for completing grant reimbursement requests. Corrective Action Plan: The District’s Finance Manager will continue to make improvements in general ledger recording and reporting systems so that those reports can then be used without intermediary report methods to prepare reimbursement request forms. Review of the reimbursement requests will take place within data reports generated directly from the general ledger. The district will engage an individual or firm to ensure that the timing and overall processes related to grant reimbursement and reporting does not result in reporting errors or omissions. . Planned Implementation Date: September 30, 2024 Responsible Person: General Manager, Umpqua Public Transit District
2023-006 - Significant Deficiency - Recording Expenses in Proper Period WPHW understands this finding and recognizes that correction that were planned for FY23 were not able to be fully implemented. WPHW accounting department went through some staffing position shifts in the Q2 of FY24 to assist wit...
2023-006 - Significant Deficiency - Recording Expenses in Proper Period WPHW understands this finding and recognizes that correction that were planned for FY23 were not able to be fully implemented. WPHW accounting department went through some staffing position shifts in the Q2 of FY24 to assist with separation of duties, which will help address the expense recording process. The follow process will be implemented to address this finding: 1) Accounting Specialists, AR/AP Manager, Accounting Manager, and Accountants will be trained by the Director of Accounting on the appropriate manner of recording expenses in the proper period. a. Follow up trainings will occur quarterly as part of the Accounting Team Meetings b. Team training will cover accrual process and the process to enter invoices as received vs incurred. This process has been implemented within FY24 and as it continued process in which this WP HW team is continuing to hone and define for the organization to ensure transactions are being properly recorded revenue recognition entry for restricted and non-restricted revenue into QuickBooks, the supporting documentation process, and the review process 2) Accounting Director will look for additional outside training to ensure all staff have development opportunities 3) Accounting Specialists will enter expenses into to system and the Accounting Manager, Accountant, and Accounting Director will all review the entry to ensure the correct categorization of expenses a. WPHW has implemented this step earlier in the review process, and with multiple people, avoid said issues This process will be implemented during Q4 FY24 and all prior entries will be reviewed by the Director of Accounting for accuracy.
2023-010- Significant Deficiency in Internal Control and Non-material Noncompliance – Inaccurate Reporting WPHW understands this finding and has already taken steps to ensure this issue does not happen again. The following process has been put into place to ensure all expenses are appropriately acc...
2023-010- Significant Deficiency in Internal Control and Non-material Noncompliance – Inaccurate Reporting WPHW understands this finding and has already taken steps to ensure this issue does not happen again. The following process has been put into place to ensure all expenses are appropriately accrued into the correct period and ensure that reporting is correct. 1) The Accounting and AR/AP Specialist will review all incoming expenses for a period of 90 days after grant end to determine appropriate grant year for the expense 2) Accounting Manager and Director of Accounting will conduct monthly grant review to ensure all expenses are in the appropriate period 3) Director of Accounting and Director of Grants Management will meet on a monthly basis to review all grants due to close a. Director of Grants Management will review all financial reports to ensure programmatic dates match and expenses are correctly allocated
2023-008 - Significant Deficiency in Internal Control and Non-material Noncompliance - Schedule of Expenditures of Federal Award Awareness and Preparation WPHW understands this finding and has already taken steps to ensure this issue does not come back up for FY24. The follow process has been put i...
2023-008 - Significant Deficiency in Internal Control and Non-material Noncompliance - Schedule of Expenditures of Federal Award Awareness and Preparation WPHW understands this finding and has already taken steps to ensure this issue does not come back up for FY24. The follow process has been put in place to ensure compliance: 1) Director of Accounting and Grants Director will ensure they have appropriate training and work collaboratively to develop documentation process a. The Grant Director will update all grants as they are received, to ensure an accurate list of grants b. The Director of Accounting will update all of the financial data for each grant 2) The Director of Accounting will be responsible for the review and submitting document to the auditing firm For FY24, the Director of Accounting and Grant Director will jointly build the document and review to ensure completeness and accuracy. In FY25, the schedule of expenditures of federal award will be prepared as the year progresses.
2023-003- Significant Deficiency - Segregation of Duties WPHW understands this finding and recognizes that corrections that were planned for FY23 were not able to be fully implemented. Our prior year corrective actions and business process were redesigned to work with our new financial management ...
2023-003- Significant Deficiency - Segregation of Duties WPHW understands this finding and recognizes that corrections that were planned for FY23 were not able to be fully implemented. Our prior year corrective actions and business process were redesigned to work with our new financial management system, NetSuite. It was our plan to have the FY23 audit completed in both NetSuite and QuickBooks, and the NetSuite changes would have demonstrated our corrective action for the segregation of duties, since this was part of the software’s functionality. However, we encountered several issues with the implementation of the new system and WPHW decide to move away from NetSuite in May 2024. Since that time, we have fully committed to QuickBooks and have started engaging in systematic business process redesign of our financial system. WPHW has implemented the following process to ensure the separation of duties: 1) AR/AP Specialists and Accounting Specialists will have access to the accounting software and will not have any access to the bank accounts for entry of information. 2) Accountants, Accounting Manager and AR/AP Manager will have read-only access to the bank accounts and full access to the accounting software to verify and review day-to-day transactions. 3) The Director of Accounting will have full access to the bank and review only access to the accounting software to do the proper review process. 4) Tasks can be handed off between staff within each level, but to ensure appropriate separation of duties, task cannot cross levels With these implemented there will be clear separation of duties this will allow mitigating of procedures to be formed by somebody who has full access to both systems to help ensure that there is no cross between any possible chance of fraud and decrease risk of significant errors and/or misstated financial statements. Access for the Director of Accounting to make adjustments will be cut off by October 1, 2024, at which time the process will be fully implemented. With this process in place, we anticipate this issue being fully resolved in FY25.
Planned Corrective Action: We will implement a process to ensure FSRS reporting is completed on a timely basis. It will be included in the monthly drawdown activities. Specific to 2023, this was filed by Lisa Daniels on 9/27/2024. Rhonda will oversee the submission of this reporting requirement goin...
Planned Corrective Action: We will implement a process to ensure FSRS reporting is completed on a timely basis. It will be included in the monthly drawdown activities. Specific to 2023, this was filed by Lisa Daniels on 9/27/2024. Rhonda will oversee the submission of this reporting requirement going forward. Name of Contact Person: Lisa Daniels, Program Director & Rhonda Conn, Program Director Anticipated Completion Date: October 1, 2024
Planned Corrective Action: We will implement a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. This will be completed with each drawdown that is request where a cost match is reported. Name of Contact Person: Lisa Daniels, Pro...
Planned Corrective Action: We will implement a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. This will be completed with each drawdown that is request where a cost match is reported. Name of Contact Person: Lisa Daniels, Program Director & Rhonda Conn, Program Director Anticipated Completion Date: October 1, 2024
Finding 500429 (2023-005)
Significant Deficiency 2023
ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sa...
ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sample and perform a quality review on a quarterly basis to ensure case workers are accurately assessing eligibility. Review will be documented. Supervisor will review at least 1 casefile for each caseworker per quarter and randomly pull additional cases from new caseworkers. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2024
Finding 500426 (2023-004)
Significant Deficiency 2023
REPORTING Recommendation: The County should design procedures and controls to ensure all reports are formally reviewed, all deadlines are met, and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in ...
REPORTING Recommendation: The County should design procedures and controls to ensure all reports are formally reviewed, all deadlines are met, and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will review procedures and implement changes as needed to ensure reports are formally reviewed, submitted timely, and proper documentation is retained. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2024
Tom Keller, Executive Director, Jill Liebelt, CFO, & Chris Brungardt, CEO Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CA...
Tom Keller, Executive Director, Jill Liebelt, CFO, & Chris Brungardt, CEO Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2024
The Authority will update their internal control policies over eligibility to require a review of the tenant file from another qualified personel and have a checklist to ensure compliance.
The Authority will update their internal control policies over eligibility to require a review of the tenant file from another qualified personel and have a checklist to ensure compliance.
View Audit 323183 Questioned Costs: $1
Finding 500405 (2023-003)
Significant Deficiency 2023
Management of the Town will work to adopt a formal federal reporting policy and monitoring system that will ensure accurate and timely reporting of all grants. The Town will also assign a reporting leader to become familiar with all reporting requirements and monitor the timeline of the reporting r...
Management of the Town will work to adopt a formal federal reporting policy and monitoring system that will ensure accurate and timely reporting of all grants. The Town will also assign a reporting leader to become familiar with all reporting requirements and monitor the timeline of the reporting requirements.
Contact Person: Justin Gibson Management’s Response: Effective September 30, 2023, United Summit Center’s Grants G230723 Regional Jail and G230772 were renewed and as part of that renewal the monthly grant reporting date was moved from the 25th of the month to the 15th of the month. Management di...
Contact Person: Justin Gibson Management’s Response: Effective September 30, 2023, United Summit Center’s Grants G230723 Regional Jail and G230772 were renewed and as part of that renewal the monthly grant reporting date was moved from the 25th of the month to the 15th of the month. Management did not identify the earlier required monthly reporting deadline as part of the renewal and continued to submit monthly grant reports following the former reporting timeline which caused the monthly reports to be submitted late for the months of October 2023 through March 2024. Management identified the discrepancy and began submitting the monthly reporting timely with reporting for April. Going forward Management reviews the reporting timely requirements of all new grant agreements and grant agreement renewals to ensure required monthly reporting deadlines are met. Completion Date: 04/15/2024
Management established formalized internal controls in the second quarter of 2023, approved by the Board of Directors, with all fund requests approved by the Executive Director and the CFO.
Management established formalized internal controls in the second quarter of 2023, approved by the Board of Directors, with all fund requests approved by the Executive Director and the CFO.
View Audit 323160 Questioned Costs: $1
Finding No. 2023-004 - Reporting; Significant Deficiency (All Federal Programs) Auditee's Response and Planned Corrective Action The late filing of the 12-31-22 REAC occurred under prior Authority management. We expect the 12-31- 23 REAC to be filed on time. Person Responsible for Corrective Action:...
Finding No. 2023-004 - Reporting; Significant Deficiency (All Federal Programs) Auditee's Response and Planned Corrective Action The late filing of the 12-31-22 REAC occurred under prior Authority management. We expect the 12-31- 23 REAC to be filed on time. Person Responsible for Corrective Action: Earl Fay, Executive Director (617) 698-2169
Finding No. 2023-003 - Special Tests and Provisions: The Milton Housing Authority has contracted a consultant to update the Administrative Plan. The Administrative Plan updates will include section 4.0 and will present the entire plan to the Board of Commissioners for their approval. Planned Impleme...
Finding No. 2023-003 - Special Tests and Provisions: The Milton Housing Authority has contracted a consultant to update the Administrative Plan. The Administrative Plan updates will include section 4.0 and will present the entire plan to the Board of Commissioners for their approval. Planned Implementation Date of Corrective Action: October 1, 2024 Person Responsible for Corrective Action: Earl Fay, Executive Director (617) 698-2169
Finding No. 2023-002 - Reporting; Significant Deficiency (HCV Cluster #14.871 and #14.879) Auditee's Response and Planned Corrective Action The Milton Housing Authority will develop better internal controls over the performance and documentation of SEMAP. To that end, a consultant has been contracte...
Finding No. 2023-002 - Reporting; Significant Deficiency (HCV Cluster #14.871 and #14.879) Auditee's Response and Planned Corrective Action The Milton Housing Authority will develop better internal controls over the performance and documentation of SEMAP. To that end, a consultant has been contracted and continues to train Employees. Staff is working with local HUD representatives for additional support. MHA will also consider outsourcing this to a reputable third party. Planned Implementation Date of Corrective Action: September 27, 2024 Person Responsible for Corrective Action: Earl Fay, Executive Director (617) 698-2169
Finding No. 2023-001 - Tenant Eligibility: The Milton Housing Authority will continue its implementation of increased oversight for the Housing Choice Voucher Program's tenant compliance requirements. To that end, a consultant has been contracted and continues to train Employees on procedures and do...
Finding No. 2023-001 - Tenant Eligibility: The Milton Housing Authority will continue its implementation of increased oversight for the Housing Choice Voucher Program's tenant compliance requirements. To that end, a consultant has been contracted and continues to train Employees on procedures and documentation mandated by HUD. Additionally, the Milton Housing Authority will review each file to ensure all documentation is complete. Planned Implementation Date of Corrective Action: September 27, 2024 Person Responsible for Corrective Action: Earl Fa_y, Executive Director (617) 698-2169
Finding 500343 (2023-003)
Significant Deficiency 2023
Management of the City will work with their contractors, both the construction contractors and the engineering firms hired to oversee and monitor the construction projects, to ensure they understand the wage rate requirements that must be followed for federally funded construction projects. The City...
Management of the City will work with their contractors, both the construction contractors and the engineering firms hired to oversee and monitor the construction projects, to ensure they understand the wage rate requirements that must be followed for federally funded construction projects. The City will implement a periodic monitoring program where the City verifies the contracted engineering or compliance vendors are adhering to the City’s contractual requirements such as obtaining the weekly certified payrolls.
The System returned the remainder of funds required. Firelands Regional Medical Center School of Nursing has implemented the following control to prevent this error in the future. The Financial Coordinator will submit a copy of the Return of Title IV funds report to the business office when retur...
The System returned the remainder of funds required. Firelands Regional Medical Center School of Nursing has implemented the following control to prevent this error in the future. The Financial Coordinator will submit a copy of the Return of Title IV funds report to the business office when returning funds. The business office will use this report to make sure the appropriate amount is posted to the student's account.
View Audit 323097 Questioned Costs: $1
Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. Solut...
Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. Solution: With the guidance and authority outlined in the Department’s internal policies and in accordance with 2 CFR, Part 200, Subpart D, Property Standards, The non-Federal entity must submit annually an inventory listing of federally-owned property in its custody to the Federal awarding agency as defined within existing governing statues, regulations, or terms and conditions of the award. Procedures for the delegated staff administering these regulatory activities will follow the minimum requirements of maintaining property records. Final review of inventory will have final reviewed by Department’s CFO of approval and will be documented annually. Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. The Department entered into a professional agreement with Financial Service Advisors, LLC to assess current policies to update standards of management by identifying credentials and experience of senior finance staff who will oversee these activities. Revisions to the policies will provide the Department’s government an extensive manual that will be developed into a fiscal management training. Training will include but not be limited to reviewing procurement methods, fiscal review of ledger activity, and audit responsibility on a quarterly basis and reporting to tribal council. Responsible: Anthony Madera, Chief Financial Officer, Lummi Indian Business Council Anticipated completion date: 06/30/2025
Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility polic...
Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility policy. Solution: Implement a standardized process for verifying, documenting, and maintaining proof of required documents (e.g. proof of residency, insurance, etc.) in the patient's file during each visit. This will involve revising and implementing the new procedures manual to verify and document patient intake. The procedures manual will support appropriate communication from data collection to when information is uploaded into EPIC to verify if clients have insurance. Our training plan will incorporate these new methods of collecting data from the clients and outline regular internal auditing of patient files to assist the Tribal Assisters to properly verify documents and communicate with providers to assist clients in enrolling with insurance providers such as but not limited to Washington Apple Health (WAH). Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. Responsible: Kathryn Halverson, Health and Human Services CEO, Lummi Indian Business Council Anticipated completion date: 06/30/2025
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