Corrective Action Plans

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Northern Rocky Mountain Economic Development District (NRMEDD) agrees with the recommendation. The corrective action described in response to Finding 2 applies uniformly to disbursements of the RLF program funds, with no separate or exception process. Northern Rocky Mountain Economic Development Dis...
Northern Rocky Mountain Economic Development District (NRMEDD) agrees with the recommendation. The corrective action described in response to Finding 2 applies uniformly to disbursements of the RLF program funds, with no separate or exception process. Northern Rocky Mountain Economic Development District (NRMEDD) agrees with the recommendation. NRMEDD will establish a policy to place a secondary review on expenditures. The Executive Director approves invoices for payment and forwards them to the Bookkeeper who prepares the check for signature. Additionally, checks or disbursements exceeding $10,000 require Board approval. This uniform application ensures RLF disbursement receives the same level of control as all other organizational expenditures.
Corrective action planned Effective in fiscal year 2026, the Organization will implement a time and effort reporting process for employees whose compensation is charged, in whole or in part, to federal awards. Actual time and effort will be documented and reviewed on a regular basis to support payro...
Corrective action planned Effective in fiscal year 2026, the Organization will implement a time and effort reporting process for employees whose compensation is charged, in whole or in part, to federal awards. Actual time and effort will be documented and reviewed on a regular basis to support payroll allocations. Where budget estimates are used for interim allocations, management will perform periodic reconciliations to actual activity and make timely adjustments as necessary. Policies and procedures will be updated, and relevant personnel will receive training on Uniform Guidance requirements related to personnel expense reporting and allocation. Anticipated completion date December 31, 2026 Contact person responsible for corrective action Chief Financial Officer
REVIEW OF REPORTS Federal Agency: U.S. Department of Agriculture Federal Program Title: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Pass-Through Agency: Minnesota Department of Health Federal Award Identification and Year: 252MN0004W1...
REVIEW OF REPORTS Federal Agency: U.S. Department of Agriculture Federal Program Title: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Pass-Through Agency: Minnesota Department of Health Federal Award Identification and Year: 252MN0004W1003, 2025 Pass-Through Numbers: 252MN0004W1003 Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Recommendation: It is recommended the Agency implement policies and procedures to ensure that there are adequate controls overall all compliance requirements for federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review policies and procedures and implement change as necessary.. Name of the contact person responsible for corrective action plan: Maggie Rothstein, Administrator Planned completion date for corrective action plan: December 31, 2026
There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs with the finding. The Organization acknowledges that controls intended to ensure annual renewal of sliding fee discount applications were not consistently operating as intended. Managemen...
There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs with the finding. The Organization acknowledges that controls intended to ensure annual renewal of sliding fee discount applications were not consistently operating as intended. Management is strengthening monitoring procedures by implementing tracking mechanisms to identify expiring applications and requiring verification of eligibility documentation prior to continued application of discounts, consistent with the requirement under Section 330(k)(3)(G) of the Public Health Service Act (42 U.S.C. 254b(k)(3)(G)) that health centers establish systems for sliding fee eligibility determination. In addition, management will provide additional training to all billing and front-desk staff on the sliding fee discount program, including eligibility determination, income and household-size documentation requirements, application renewal procedures, and the proper application of discounts in the practice management system. Periodic supervisory reviews will be performed to ensure compliance with the Board-approved sliding fee discount policy, consistent with the internal control requirements of the Uniform Guidance (2 CFR 200.303). Management will also review the sliding fee discount schedule on a regular basis, no less than annually, and will update it in a timely manner whenever necessary, including upon publication of the annual Federal Poverty Guidelines, so that discounts continue to be adjusted on the basis of each patient’s ability to pay as required by 42 CFR 51c.303(f), with all updates presented to the Board of Directors for approval and communicated promptly to billing staff. Documentation of staff training, schedule reviews, and Board approvals will be retained to demonstrate compliance with HRSA Health Center Program requirements, including Chapter 9 (Sliding Fee Discount Program) of the HRSA Health Center Program Compliance Manual. Name(s) of the contact person(s) responsible for corrective action: Edward Murphy, Asante Muyungga, Charity Gutierrez, Anthony Parker, Bennett Baber, Jannell Robinson. Planned completion date for corrective action plan: December 31st, 2026
Condition: During testing of subrecipient payments, we identified 15 instances in which payments to subrecipients were made more than 30 calendar days after receipt of a complete and approved invoice. Planned Corrective Action: During the audit period, the organization experienced delays in processi...
Condition: During testing of subrecipient payments, we identified 15 instances in which payments to subrecipients were made more than 30 calendar days after receipt of a complete and approved invoice. Planned Corrective Action: During the audit period, the organization experienced delays in processing certain subrecipient invoices. As a result, some subrecipients were not paid in accordance with the requirements of 2 CFR 200.305(b)(3). To address this finding, management has implemented the following corrective actions: Revised internal procedures to ensure payments are made within 30 calendar days of the approval of subrecipient invoices, regardless of when reimbursement is received from the federal awarding agency. Implemented a weekly aging report to identify subrecipient invoices approaching payment due dates and to ensure timely resolution. Provided additional training to the program, finance and the management teams on federal payment requirements and internal procedures. Established periodic management reviews to monitor compliance with payment timeliness requirements and identify process improvements as needed. Management fully implemented all corrective actions as of June 30, 2026. Contact person responsible for corrective action: Nancy Cummins, Controller Anticipated Completion Date: June 30, 2026
MEDICAL ASSISTANCE - LACK OF CASEFILE CONTROLS Recommendation: It is recommended the County implement formal internal review procedures over casefiles to ensure required procedures are completed and adequately documented. Explanation of disagreement with audit finding: There is no disagreement with ...
MEDICAL ASSISTANCE - LACK OF CASEFILE CONTROLS Recommendation: It is recommended the County implement formal internal review procedures over casefiles to ensure required procedures are completed and adequately documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures over casefiles to ensure required procedures are completed and adequately documented. Name of the contact person responsible for corrective action plan: Kathleen Ryan, County: Auditor Planned completion date for corrective action plan: December 31, 2026
MEDICAL ASSISTANCE - LACK OF CASEFILE DOCUMENTATION Recommendation: It is recommended the County implement procedures to ensure all required documentation is: maintained on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response...
MEDICAL ASSISTANCE - LACK OF CASEFILE DOCUMENTATION Recommendation: It is recommended the County implement procedures to ensure all required documentation is: maintained on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure all required documentation is maintained on file. Name of the contact person responsible for corrective action plan: Kathleen Ryan, County Auditor Planned completion date for corrective action plan: December 31, 2026
Finding Number: 2025-006 Finding Title: Eligibility - MAXIS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Ashley VanOverbeke – Eligibility Supervisor Chantelle Fogelson – Eligibility Supervisor Correct...
Finding Number: 2025-006 Finding Title: Eligibility - MAXIS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Ashley VanOverbeke – Eligibility Supervisor Chantelle Fogelson – Eligibility Supervisor Corrective Action Planned: The planned corrective action is to continue reminding and reviewing with staff on a regular basis and at unit meetings the need to utilize checklists with all applications and renewals, so all required documentation is on file, verify income and asset requirements, and complete case transfers correctly. Supervisors and/or Lead Workers will also complete case reviews for accuracy. Anticipated Completion Date: December 31, 2026
Finding Number: 2025-002 Finding Title: Procurement Policy Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Tiffany Bailey – Fiscal Manager Corrective Action Planned: The planned correctiv...
Finding Number: 2025-002 Finding Title: Procurement Policy Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Tiffany Bailey – Fiscal Manager Corrective Action Planned: The planned corrective action is to improve and update the agency policy for procurement that ensures the required federal components are met. Anticipated Completion Date: December 31, 2026
Corrective Action Plan Section III - Federal Award Findings and Questioned Costs Finding 2025-001 Name of Contact Person: Felicia Chester, Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program elegibility requirements. Ma...
Corrective Action Plan Section III - Federal Award Findings and Questioned Costs Finding 2025-001 Name of Contact Person: Felicia Chester, Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program elegibility requirements. Mangement has established a checklist for applications and will establish checklists for move-ins and move-outs. Proposed Completion Date: Immediately
Corrective Action Plan: All files for the House of Joseph Residence are now reviewed on a quarterly basis by the case manager and the program director, and a checklist has been created so that case managers can confirm that all necessary documents are contained within a given client’s file. New inco...
Corrective Action Plan: All files for the House of Joseph Residence are now reviewed on a quarterly basis by the case manager and the program director, and a checklist has been created so that case managers can confirm that all necessary documents are contained within a given client’s file. New income certifications, which are part of the checklist for documents that need to be in a client’s file, have been completed as well and the two files lacking documentation to support the annual income reported by the tenant have been corrected. Contact Person Responsible for Corrective Action: Eugene Halus (COO), John Bates (Deputy Director, Programs), and Eugene Watson (Program Manager) Anticipated Completion Date of Corrective Action: Corrections were completed in August 2026.
Corrective Action Plan: The Organization had discovered the issue of one of the tenants of House of Joseph Residence exceeding 30% of the area median income when we assisted him in applying for Medicaid in early 2026, for which he was initially denied due to income. The individual in question was wo...
Corrective Action Plan: The Organization had discovered the issue of one of the tenants of House of Joseph Residence exceeding 30% of the area median income when we assisted him in applying for Medicaid in early 2026, for which he was initially denied due to income. The individual in question was working part-time, and we had him scale back his working hours accordingly so that in the future he would not exceed the threshold of the 30% area median income going forward and eventually qualify for Medicaid. We also emphasized with the tenant the consequences of exceeding the 30% limit as well. Contact Person Responsible for Corrective Action: Eugene Halus (COO), John Bates (Deputy Director, Programs), and Eugene Watson (Program Manager) Anticipated Completion Date of Corrective Action: Completed in early 2026.
Finding 2025-005: SFSAC Submission Contact Person – Keith Trego, Executive Director Corrective Action Plan – This finding is noted together with the Board. The Trust agrees with the finding and recognizes the importance of timely submission of the Single Audit reporting package and Data Collection F...
Finding 2025-005: SFSAC Submission Contact Person – Keith Trego, Executive Director Corrective Action Plan – This finding is noted together with the Board. The Trust agrees with the finding and recognizes the importance of timely submission of the Single Audit reporting package and Data Collection Form to the Federal Audit Clearinghouse. To address this issue, management will establish procedures to monitor all Single Audit reporting deadlines Completion Date – The Trust will incorporate procedures into the year -end financial reporting process beginning with the current fiscal year.
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Condition and context: Boys & Girls Club was unable to produce a report from its general ledger system that supported the expenditures reported in the schedule of expenditures of federal awards. Repeat of finding #2024-002. Recommen...
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Condition and context: Boys & Girls Club was unable to produce a report from its general ledger system that supported the expenditures reported in the schedule of expenditures of federal awards. Repeat of finding #2024-002. Recommendation: Establish policies and procedures to record all federal expenditures in the general ledger system by class code in order to generate a report of expenditures by grant. Planned corrective action: Government funded transactions will be recorded in our general ledger in a manner which facilitates advanced reporting by federal awards. Management will further modify accounting system and review grant reports monthly to ensure transactions are properly recorded. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2026.
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Condition and context: In a sample of 30 vendor payments, we found three instances of reimbursement by the grantor totaling approximately $9,600 received approximately three to five months before payments were made to the vendors. R...
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Condition and context: In a sample of 30 vendor payments, we found three instances of reimbursement by the grantor totaling approximately $9,600 received approximately three to five months before payments were made to the vendors. Repeat of finding #2024-004. Recommendation: Strengthen controls to ensure that invoices are paid in a timely manner to ensure federal reimbursements are not being held for an excess period of time. Planned corrective action: As part of our enhanced review of government transactions, we will be on the alert to disburse federal funds received in a timely/reasonable manner. Accounts payable report will be reviewed with a heightened priority to quickly disbursing federal funds received. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2026.
Housing Choice Voucher Program – Assistance listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that failed HQS inspections are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in r...
Housing Choice Voucher Program – Assistance listing No. 14.871 Recommendation: We recommend the Authority implements controls to ensure that failed HQS inspections are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The HQS inspections are outsourced to a third party vendor. HALC will be meeting with the vendor to present the audit findings, and will have better oversight on their work moving forward. Name(s) of the contact person(s) responsible for corrective action: Irma Jimenez, Housing Programs Manager Planned completion date for corrective action plan: Meeting with the vendor will be held in October, with the expectation that performance will be adjusted immediately.
Housing Choice Voucher Program – Assistance listing No. 14.871 Recommendation: We recommend the Authority implement processes to ensure that all proper documentation is being maintained during the rent reasonableness determination process for every tenant. Explanation of disagreement with audit find...
Housing Choice Voucher Program – Assistance listing No. 14.871 Recommendation: We recommend the Authority implement processes to ensure that all proper documentation is being maintained during the rent reasonableness determination process for every tenant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HALC has implemented additional training to the Housing Program Administrators as well as increased auditing of the tenant files in 2026. Name(s) of the contact person(s) responsible for corrective action: Robyn Cole, Deputy Director Planned completion date for corrective action plan: Implemented immediately
Auditor’s Recommendation: It is recommended that the Organization consistently implement and document the review and approval controls established by its policies, including continued Board/Treasurer oversight over expenditures. It is also recommended that the Organization continue use of formal tim...
Auditor’s Recommendation: It is recommended that the Organization consistently implement and document the review and approval controls established by its policies, including continued Board/Treasurer oversight over expenditures. It is also recommended that the Organization continue use of formal timesheets to document and support employee time. Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding and agrees with the recommendation. The Organization implemented Board/Treasurer oversight during the middle of 2025 and formal timesheets effective October 27, 2025. Management will continue to maintain documented review and approval controls and utilize formal timesheets to support payroll activity.
Auditor’s Recommendation: It is recommended that Hearts for the Invisible Charlotte Coalition develop and implement a suspension and debarment procedure to review the eligibility of vendors before entering into contracts. Training should be provided to all relevant staff to ensure awareness and comp...
Auditor’s Recommendation: It is recommended that Hearts for the Invisible Charlotte Coalition develop and implement a suspension and debarment procedure to review the eligibility of vendors before entering into contracts. Training should be provided to all relevant staff to ensure awareness and compliance with Federal requirements. Additionally, periodic monitoring and internal audits should be conducted to ensure adherence to the established procedures. Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding and agrees with the recommendation. Hearts for the Invisible Charlotte Coalition is in the process of developing and implementing a formal suspension and debarment procedure, which is intended to be implemented in October 2026. Furthermore, periodic reviews will be instituted to monitor adherence to these requirements and to prevent the recurrence of this issue.
CITY OF FRAMINGHAM, MASSACHUSETTS CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 The City of Framingham, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 1, 2024 – June 30, 2025 The finding from the schedule of findings and...
CITY OF FRAMINGHAM, MASSACHUSETTS CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 The City of Framingham, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 1, 2024 – June 30, 2025 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING—FEDERAL AWARD PROGRAMS AUDIT U.S. Department of Education 2025-001 Title I Distribution - Assistance Listing Number 84.010 Recommendation: We recommend procedures be strengthened to document all student removals from the cohort. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Framingham High School (FHS) reviewed its existing internal guidance on student withdrawals and developed a revised Student Withdrawal Prevention/Process & Post-Withdrawal Support Guide. The revised guidance establishes a tiered process for student-initiated and attendance-initiated withdrawals, including student and caregiver outreach, attendance and credit review, barrier identification, re-engagement planning, alternative pathways, and required documentation before a withdrawal is finalized. Based on this finding, FHS will standardize documentation of all withdrawal prevention and removal efforts. Staff will record outreach, meetings, interventions, and re-engagement efforts in the student information management system using the Journal feature and will also enter each case directly into a district-wide tracking form upon withdrawal. These practices will become the standard and will provide a consistent record of efforts made before a student is removed from the cohort. The revised process will be reviewed with appropriate staff during professional development on October 15th, 2026. Name(s) of the contact person(s) responsible for corrective action: Mark Albright, Principal of Framingham High School Planned completion date for corrective action plan: Training on the revised withdrawal and documentation procedures will take place on October 15th, 2026 and be in full effect as of 07/01/2027.
Finding 1236918 (2025-004)
Material Weakness 2025
RANDOM MOMENT STUDY (RMS) EMPLOYEES LISTING Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2505MN5ADM and 2505MN5MAP, 2025 Pass-Through A...
RANDOM MOMENT STUDY (RMS) EMPLOYEES LISTING Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2505MN5ADM and 2505MN5MAP, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5ADM and 2505MN5MAP Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the County review the RMS listings and employees within the department and account codes to ensure the proper employees are included on the listing and general ledger accounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has implemented procedures and policies to have a person ensure account coding is made to the correct accounts. Name of the contact person responsible for corrective action plan: Anne Broskoff, Human Services Director Planned completion date for corrective action plan: December 31, 2026
Finding 1236916 (2025-003)
Material Weakness 2025
CONTROLS OVER ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2505MN5ADM and 2505MN5MAP, 2025 Pass-Through Agency: Minnesota De...
CONTROLS OVER ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2505MN5ADM and 2505MN5MAP, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5ADM and 2505MN5MAP Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the County increase review over casefiles and ensure that there are performed on a periodic basis throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action plan: Anne Broskoff, Human Services Director Planned completion date for corrective action plan: December 31, 2026
Audit Finding Reference: 2025-001 Description of Finding: The audit revealed that a time and effort record was incomplete, and documented hours worked were not approved by the Supervisor prior to payroll processing. Planned Corrective Action: The District will strengthen its current review procedure...
Audit Finding Reference: 2025-001 Description of Finding: The audit revealed that a time and effort record was incomplete, and documented hours worked were not approved by the Supervisor prior to payroll processing. Planned Corrective Action: The District will strengthen its current review procedures for all timesheets supporting payroll costs charged to federal grants. Until the new electronic timekeeping system is implemented, employees will be required to complete and sign their timesheets, and the timesheets will be reviewed and approved by the appropriate supervisor prior to submission for payroll processing. The Business Manager will also review timesheets as part of the payroll warrant review and approval process to verify that required employee and supervisory approvals are documented. These requirements have been reviewed and reinforced with the employee responsible for payroll processing, as well as with supervisors responsible for reviewing and approving timesheets. Periodic monitoring will be performed by the Business Manager to ensure that established timesheet procedures are being consistently followed and that payroll costs charged to federal awards are supported by appropriate documentation. The District has also purchased absence and time management software and will implement the timekeeping component by January 2027. The new electronic system will eliminate paper timesheets and provide a consistent process for recording, reviewing, and approving employee time. All electronic timesheets will be reviewed and approved by the appropriate supervisor prior to submission for payroll processing. Name of Contact Person and Completion Date: Liz Bouchard, Business Manager Franklin County Technical School Completion Date: January 2027
The Borough has implemented procedures to ensure Federal Single Audit requirements are identified, monitored, and completed within required deadlines. Finance staff will maintain a schedule of applicable federal reporting and audit requirements, monitor federal expenditures throughout the fiscal yea...
The Borough has implemented procedures to ensure Federal Single Audit requirements are identified, monitored, and completed within required deadlines. Finance staff will maintain a schedule of applicable federal reporting and audit requirements, monitor federal expenditures throughout the fiscal year, and coordinate with the Borough's auditors to ensure Single Audit requirements are identified and addressed timely. The Finance Director will provide oversight of this process and ensure required documentation and filings are completed within applicable deadlines. These procedures are expected to fully resolve this finding during FY2026. Expected Completion Date: June 30, 2026.
TTCD will review and revise our policies and procedures to ensure that they align with the reporting requirements of Uniform Guidance. As part of the Organization’s internal control structure over compliance with FFATA requirements, this will include establishing a monitoring/compliance checklist to...
TTCD will review and revise our policies and procedures to ensure that they align with the reporting requirements of Uniform Guidance. As part of the Organization’s internal control structure over compliance with FFATA requirements, this will include establishing a monitoring/compliance checklist to ensure that required reports are submitted in the required timeframe. This policy changes will be submitted to the Board of Director for approval at our November 2026 meeting. The 2025 subaward to the State of Alaska Department of Fish & Game, as well as any relevant 2026 subawards, will be reviewed for compliance.
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