Corrective Action Plans

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2025-001-Internal Control over Financial Reporting, Health Resources and Services Administration Native Hawaiian Health Care 93.932, Significant adjusting journal entries, Due to lack of fiscal staff and high turnover, the organization fell behind on audits, and therefore, many adjusting entries wer...
2025-001-Internal Control over Financial Reporting, Health Resources and Services Administration Native Hawaiian Health Care 93.932, Significant adjusting journal entries, Due to lack of fiscal staff and high turnover, the organization fell behind on audits, and therefore, many adjusting entries were required to reconcile accounts. The audits have been completed, and all accounts have been reconciled as of July 31, 2025. In addition to the high turnover, during fiscal year ending 2024, there was an increase in donor funding to assist with the Lahaina wildfires recovery efforts. Again, our staff were challenged to meet the demands of the requirements of the funding and to continue to monitor the previous and current fiscal years financial state.
Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.
Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.
Health Center Program Cluster, Assistance Listings 93.224, 93.527 Special Tests and Provisions Recommendation: Wallace should strengthen controls over the sliding fee discount process by implementing system validations to support accurate sliding fee discount schedule (SFDS) application, requiring d...
Health Center Program Cluster, Assistance Listings 93.224, 93.527 Special Tests and Provisions Recommendation: Wallace should strengthen controls over the sliding fee discount process by implementing system validations to support accurate sliding fee discount schedule (SFDS) application, requiring documented income verification prior to billing, and performing periodic supervisory reviews to ensure consistent compliance with Section 330 requirements. Planned Corrective Action: Management agrees with the finding. Management will strengthen controls over the sliding fee discount process by requiring documented income verification prior to billing, reinforcing proper application of the sliding fee discount schedule, and performing periodic supervisory reviews of patient encounters subject to sliding fee discount requirements. These corrective actions are intended to address the specific deficiencies identified in the application of Special Tests and Provisions requirements. Contact Person Responsible for Corrective Action: Daisy Velasco, Director of Operations Anticipated Completion Date: June 30, 2026
Corrective Action Plan: A new procurement policy was developed, reviewed, and formally approved by the Board of Directors on January 20, 2026. The policy establishes procurement procedures aligned with industry best practices and strengthens internal controls to ensure transparency, accountability, ...
Corrective Action Plan: A new procurement policy was developed, reviewed, and formally approved by the Board of Directors on January 20, 2026. The policy establishes procurement procedures aligned with industry best practices and strengthens internal controls to ensure transparency, accountability, and compliance with applicable requirements. Individual(s) Responsible: Yolanda Adams Completion Date: Policy was voted on by the board and put into place subsequent to year end.
Corrective Action Plan: Training and ongoing education initiatives have been implemented to ensure reports are completed and submitted in accordance with established deadlines. The new Chief Financial Officer is actively monitoring report status and accuracy to ensure timely compliance. A defined re...
Corrective Action Plan: Training and ongoing education initiatives have been implemented to ensure reports are completed and submitted in accordance with established deadlines. The new Chief Financial Officer is actively monitoring report status and accuracy to ensure timely compliance. A defined reporting structure has been established to strengthen oversight, accountability, and adherence to all reporting requirements. Individual(s) Responsible: Yolanda Adams Completion Date: Plan has been implemented as of date of audit submission.
Finding 2025-002: Lower Income Housing Assistance Program – Section 8 New Construction/ Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development (Repeat of Finding 2024-003) Compliance Requirements: Special Tests and Provisions Type of finding: In...
Finding 2025-002: Lower Income Housing Assistance Program – Section 8 New Construction/ Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development (Repeat of Finding 2024-003) Compliance Requirements: Special Tests and Provisions Type of finding: Internal Control Over Compliance (material weakness) and Compliance (material noncompliance) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to establish a monitoring process to ensure compliance with Mortgage Restructuring Loan terms and conditions. Action Taken: Action Taken: The Organization has accepted the recommendation to strengthen internal controls regarding Mortgage Restructuring Loan terms. We are currently in active remediation, working in direct coordination with our HUD Account Exexuctive, to ensure our adopted policies align with the federal requirments. Our HUD Account Exexuctive, has been notified of the finalized 2025 Auditied financials and are currently working to set up a time to discuss a Management Action Plan regarding a recommedation for Mortgage Restructuring controls. If these are questions regarding this plan, please call the responsible part at (719)852-5578. Sincerely yours, Brenda Quintana Administrator Tri-County Senior Citizens and Housing, Inc.
ASTHO concurs with this recommendation. The CFO/Vice President, Finance will: 1. Update subrecipient monitoring procedures to determine at time of subaward: a. If subrecipient has a history with ASTHO b. If subrecipient is required to conduct a single audit c. Obtain copies of single audits for the ...
ASTHO concurs with this recommendation. The CFO/Vice President, Finance will: 1. Update subrecipient monitoring procedures to determine at time of subaward: a. If subrecipient has a history with ASTHO b. If subrecipient is required to conduct a single audit c. Obtain copies of single audits for the applicable period. 2. Require no later than September 15, 2026, Program Operations will ensure for all subrecipients included on preliminary SEFA as of July 31, 2026, that any single audit reports have been collected and reviewed. 3 Require that upon completion of the final SEFA for the year ended September 30, 2026, single audits have been obtained and reviewed for any subrecipients that were not reported on the preliminary July 31, 2026 SEFA. 4. These processes will be repeated for years subsequent to 2026.
The Florida School Nutrition Association, Inc. (FSNA) acknowledges the audit finding regarding the misalignment between the pass-through entity’s grant agreement and the OMB Compliance Supplement for ALN 10.185. While the Association operated in accordance with the terms of the executed agreement wi...
The Florida School Nutrition Association, Inc. (FSNA) acknowledges the audit finding regarding the misalignment between the pass-through entity’s grant agreement and the OMB Compliance Supplement for ALN 10.185. While the Association operated in accordance with the terms of the executed agreement with the Florida Department of Agriculture and Consumer Services, it was subsequently determined that certain administrative costs permitted under that agreement were not allowable under the Uniform Guidance (2 CFR Part 200). Finding 2025-001: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Upon identification of this discrepancy, FSNA has taken immediate and decisive action: Program Termination & Strategic Shift: FSNA has formally concluded its participation in the Local Food for Schools Cooperative Agreement Program and has ceased all related activities. The Association has made the strategic decision not to pursue or engage in federal grant programs of this nature moving forward. This determination ensures alignment with the organization’s operational capacity and mitigates compliance risk associated with complex federal cost principles. Final Resolution: The identified material weakness has been addressed through the discontinuation of the applicable program, thereby removing the operational conditions under which the noncompliance occurred. Future Funding Consideration (If Applicable): While FSNA does not anticipate pursuing similar federal awards, the organization has established an internal standard that any future funding opportunities, if considered, will undergo a comprehensive compliance review to ensure alignment with the Uniform Guidance (2 CFR Part 200), the OMB Compliance Supplement, and all grantspecific terms and conditions. Record Retention: FSNA will maintain all financial and supporting documentation related to the FY25 audit period in accordance with applicable federal record retention requirements.
View of Responsible Officials and Planned Corrective Actions: In actual practice, the resettlement case managers make their best efforts to respond to the refugees' needs fully. That is why they are usually too short of time to make complete case notes. As a corrective action, we have arranged for t...
View of Responsible Officials and Planned Corrective Actions: In actual practice, the resettlement case managers make their best efforts to respond to the refugees' needs fully. That is why they are usually too short of time to make complete case notes. As a corrective action, we have arranged for the department director and supervisor to receiive regular training sessions with our funding source's grant specialist.
Finding 2025-004: Finding of Significant Deficiency in Internal Control over Eligibility and Subrecipient Monitoring and Finding of Non-compliance ALN 14.241 Housing Opportunities for Persons with AIDS (HOPWA) Award #TXH22-F004, TXH23-F004 and TXH24-F004, 2025, U.S. Department of Housing and Urban D...
Finding 2025-004: Finding of Significant Deficiency in Internal Control over Eligibility and Subrecipient Monitoring and Finding of Non-compliance ALN 14.241 Housing Opportunities for Persons with AIDS (HOPWA) Award #TXH22-F004, TXH23-F004 and TXH24-F004, 2025, U.S. Department of Housing and Urban Development ALN 93.686 Ending the HIV Epidemic: A Plan for America - Ryan White HIV/AIDS Award # 5 UT8HA33918-05-00 and 5 UT8HA33918-06-00, 2025, U.S. Department of Health & Human Services Contact Person – Adrienne Sturrup, Director, Austin Public Health Management Response – Concur. Management has taken the following steps to address this finding: 1. Process Improvement: The department is: • reviewing the interlocal agreement to update the language for greater clarity on requirements. • mapping the process for requesting, receiving and requiring financial audits and single audits. • identifying the appropriate party to review and follow-up on any areas of concern identified in a Single Audit. 2. Internal Control: Periodic supervisory verification that audits are obtained and reviewed. 3. Additional training: • After mapping out the process for tracking and requiring financial and single audits, training will be provided to staff and vendors. • If department staff will be reviewing and following-up on financial and single audits, appropriate level of staff and aligned trainings will be identified and provided. Estimated Completion – September 30, 2026.
Finding 2025-002: ALN 93.686 Ending the HIV Epidemic: A Plan for America - Ryan White HIV/AIDS, 5 UT8HA33918-05-00 & 5 UT8HA33918-06-00, U.S. Department of Health & Human Services — Significant Deficiency in Internal Control over Reporting and Finding of Non-compliance Contact Person – Adrienne Stur...
Finding 2025-002: ALN 93.686 Ending the HIV Epidemic: A Plan for America - Ryan White HIV/AIDS, 5 UT8HA33918-05-00 & 5 UT8HA33918-06-00, U.S. Department of Health & Human Services — Significant Deficiency in Internal Control over Reporting and Finding of Non-compliance Contact Person – Adrienne Sturrup, Director, Austin Public Health Management Response – Concur. Management has taken the following steps to address this finding: 1. Submission Completed: The required FFATA subaward report has since been submitted to Sam.gov as of March 3, 2026. 2. Process Improvement: Austin Public Health has established/updated procedures for FFATA reporting, including a clearly assigned responsibility to the appropriate staff for monitoring and submitting grant-required reports. 3. Internal Control: We will be adding more staff to the authorized list, which now includes the program's Financial Analyst. This analyst will be able to submit and upload documentation to SAM.gov. He/she will also coordinate with the Admin Support Finance team to ensure the accuracy of FFATA information before uploading any documents. Estimated Completion – June 30, 2026.
Ocosta School District No. 172 September 1, 2024 through August 31, 2025 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Pri...
Ocosta School District No. 172 September 1, 2024 through August 31, 2025 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2025-01 Finding caption: The District did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of District contact person: Robert Butler 2580 S. Montesano St. Westport, WA 98595 360.268.9125 ext. 1004 Corrective action the auditee plans to take in response to the finding: The District acknowledges the finding and appreciates the opportunity to strengthen our documentation practices related to suspension and debarment verification. We would like to clarify that the District did perform suspension and debarment checks through SAM.gov for the vendors in question on an annual basis. While these procedures were consistently completed, the District did not retain independent documentation of those checks. The District relied on SAM.gov as the authoritative federal system of record, including its historical tracking and notification features, rather than maintaining locally stored or printed copies. At the time, staff were not aware that compliance requirements required retention of documentation evidencing these checks. As a result, this finding reflects a documentation deficiency rather than the absence of the control itself. As confirmed during the audit, all vendors tested were in good standing and not suspended or debarred. Therefore, the District was not at risk of contracting with an ineligible vendor, and no questioned costs were identified.
Finding #2025-001 Comments on the Finding and Each Recommendation: During the year ended September 30, 2025, three of the thirteen resident files selected for testing under the OMB Compliance Supplement lacked properly executed and documented resident eligibility forms. WHN Property Management shoul...
Finding #2025-001 Comments on the Finding and Each Recommendation: During the year ended September 30, 2025, three of the thirteen resident files selected for testing under the OMB Compliance Supplement lacked properly executed and documented resident eligibility forms. WHN Property Management should complete recertifications for the two residents still residing at the Property, ensure that all resident files are maintained at the site for each resident of the Property, and ensure that the resident files include all properly executed and documented resident eligibility forms. Action(s) taken or planned on the finding: WHN Property Management concurs with the finding and recommendation. WHN Property Management is in the process of completing recertifications for two of the residents still residing at the Property. One of the resident files noted in the statement of condition was for a resident who moved out of the Property in November 2025. No further action is required related to this resident's file. WHN Property Management intends to review and update, as necessary, the other resident files during the year ended September 30, 2026 to ensure the Property is in compliance with the OMB Compliance Supplement and the HOME loan agreement.
2025-002 – Late Submission of Uniform Guidance Report Cluster: Not applicable Sponsoring Agency: Tennessee Emergency Management Agency Award Name: All awards on the SEFA Award Number: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the...
2025-002 – Late Submission of Uniform Guidance Report Cluster: Not applicable Sponsoring Agency: Tennessee Emergency Management Agency Award Name: All awards on the SEFA Award Number: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: Not applicable We acknowledge the late submission of the Uniform Guidance report. The delay is attributed to the delayed release of the Office of Management and Budget Compliance Supplement and business disruptions experienced by NES as a result of the catastrophic Winter Storm Fern in January 2026. In conjunction with our storm response post-incident analysis, we are including staffing redundancies to ensure timely compliance with future reporting requirements. For inquiries regarding this finding, please contact Tabitha Beach at tbeach@nespower.com who is responsible for the corrective action.
CWA management is in agreement with this finding. They will develop and implement procedures ensure the timely submittal of required reports.
CWA management is in agreement with this finding. They will develop and implement procedures ensure the timely submittal of required reports.
Management of CWA agrees with this finding and intends to develop and implement written internal control policies and procedures by December 31, 2026. Applicable employees will be trained in these policies and procedures by December 31, 2026.
Management of CWA agrees with this finding and intends to develop and implement written internal control policies and procedures by December 31, 2026. Applicable employees will be trained in these policies and procedures by December 31, 2026.
2025-003. Special Tests and Provisions United States Department of Education, passed through New York State Department of Education: Education Stabilization Fund COVID-19: American Rescue Plan – Elementary and Secondary School Emergency Relief ALN: 84.425U Condition: The District did not have formal...
2025-003. Special Tests and Provisions United States Department of Education, passed through New York State Department of Education: Education Stabilization Fund COVID-19: American Rescue Plan – Elementary and Secondary School Emergency Relief ALN: 84.425U Condition: The District did not have formal contracts with the contractors for some of the construction projects funded with ARP ESSER 3 funds. Although the contractors indicated in their submitted proposals that their quoted price was based on prevailing wages, there was no legally-enforceable contractual language requiring the contractors and their subcontractors to comply with the federal Wage Rate Requirements clauses and DOL regulations. Recommendation: The District should review and revise its existing procedures for reviewing and approving capital construction projects to ensure that fully-executed contracts are obtained, and that such contracts contain clauses related to the compliance with the federal Wage Rate Requirements. Planned Corrective Action: The District will review and revise its existing procedures for reviewing and approving capital construction projects to ensure that fully-executed contracts are obtained with clauses mandating compliance with federal Wage Rate Requirements. Responsible Contact Person: Mr. Chaim Wercberger District Treasurer Kiryas Joel Union Free School District 48 Bakertown Road Suite 401 Monroe, NY 10950 Anticipated completion date: June 30, 2026.
Statement of Condition #2025-001 (CFDA 14.157): During 2025, the Corporation did make its required residual receipts deposit of $44,817. In addition, the Corporation made a payment on the CRA loan of $44,817 without HUD approval. Recommendation: The Corporation and management should deposit surplus ...
Statement of Condition #2025-001 (CFDA 14.157): During 2025, the Corporation did make its required residual receipts deposit of $44,817. In addition, the Corporation made a payment on the CRA loan of $44,817 without HUD approval. Recommendation: The Corporation and management should deposit surplus cash into the residual receipts reserve upon receipt of the audited financial statements. Management should then seek HUD approval via HUD Form 9250 for payment on the CRA loan after the invoice is received. Action(s) taken or planned on the finding: The Corporation and management agree with the recommendation. No further action is required.
Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters as noted below and have described our planned actions as a result. 2025-001: FINANCIAL REPORTING OF FEDERAL PROGRA...
Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters as noted below and have described our planned actions as a result. 2025-001: FINANCIAL REPORTING OF FEDERAL PROGRAMS Management Assessment: We concur with the audit assessment regarding this matter. Planned Corrective Action: The County will implement procedures to help ensure required reports are submitted timely. Responsible Party: Moses Sanzo, Administrator/Controller and Jacky Bennett, Interim Chief Financial Officer Date of Planned Corrective Action: September 30, 2026
Finding Number: 2025-002 The District should review its reporting internal control processes and procedures and emphasis the need for timely reporting to ensure compliance. Response: Administration will implement a formal compliance calendar mandating the Grant Administrator to monitor and verify al...
Finding Number: 2025-002 The District should review its reporting internal control processes and procedures and emphasis the need for timely reporting to ensure compliance. Response: Administration will implement a formal compliance calendar mandating the Grant Administrator to monitor and verify all expenditure reports. This internal schedule will ensure all findings are submitted no later than 20th day following the close of each quarter to maintain compliance with reporting requirements.
Finding Number: 2025-004 It is recommended that that district review the design of its internal control over compliance to ensure the documentation requirements are incorporated into the control design. Response: To enhance internal controls to ensure the segregation of duties, the Assistant Directo...
Finding Number: 2025-004 It is recommended that that district review the design of its internal control over compliance to ensure the documentation requirements are incorporated into the control design. Response: To enhance internal controls to ensure the segregation of duties, the Assistant Director of Food Services will be responsible for the initial preparation and completion of all the claims. Subsequently, a secondary review and approvable will be preformed by either the Director or the Chief School Business Official (CSBO) prior to submission.
Item: 2025-002 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2...
Item: 2025-002 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2026 Compliance Requirement: Subrecipeint Monitoring Criteria: A Pass-Through Entity (PTE) is required to monitor the activities of subrecipients as necessary to ensure that the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals (2 CFR 200.332(d) through (f)). In addition to procedures identified as necessary based upon the evaluation of subrecipient risk or specifically required by the terms and conditions of the award, subaward monitoring must include the following: (a) reviewing financial and programmatic (performance and special reports) required by the PTE, (b) following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the federal award provided to the subrecipient from the PTE detected through audits, on-site reviews, and other means, and (c) issuing a management decision for audit findings pertaining to the federal award provided to the subrecipient from the PTE as required by 2 CFR 200.521. Condition: The Foundation did not complete the required subrecipient monitoring related to review of subrecipient Single Audits and financial statements. Specifically, we noted no evidence that the Foundation verified whether certain subrecipients met the Single Audit threshold under 2 CFR 200.501 or obtained the subrecipients’ Single Audit reporting packages from the Federal Audit Clearinghouse. Additionally, the Foundation did not obtain or document a review of the subrecipients’ audited financial statements (or other financial information) to inform the subrecipient risk assessment under 2 CFR 200.332(b). Name of Contact Person Steve Zylstra, President & CEO Phone Number: (602) 422-9447 Anticipated Completion Date: July 31, 2026 Views of Responsible Officials and Corrective Actions: For the current audit period, the Foundation has obtained the missing single audit reports and financial statements and is in the process of completing and documenting the required reviews, updating subrecipient risk ratings and performing any necessary follow-up or management decisions by April 30, 2026. Additionally, the Foundation will establish formal written procedures to comply with 2 CFR 200.332(b), (d), and (f), 2 CFR 200.501, and 2 CFR 200.521, including clear steps and timelines for verifying Single Audit applicability, obtaining and reviewing Single Audit reports, and issuing management decisions when applicable. Lastly, the Foundation will provide periodic training to finance and program staff on subrecipient monitoring requirements under the Uniform Guidance.
Item: 2025-001 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2...
Item: 2025-001 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2026 Compliance Requirement: Reporting - FFATA Criteria: The Federal Funding Accountability and Transparency Act (FFATA), as implemented by OMB at 2 CFR Part 170, requires prime recipients of federal awards to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Condition: The Foundation did not complete the required FFATA reporting in FSRS for applicable first-tier subawards. Name of Contact Person Steve Zylstra, President & CEO Phone Number: (602) 422-9447 Anticipated Completion Date: July 31, 2026 Views of Responsible Officials and Corrective Actions: The Foundation has corrected missed FFATA reporting by submitting outstanding subaward information to FSRS as of February 2026. Additionally, the Foundation will establish and document a FFATA reporting policy that defines the FFATA threshold and timing requirements. The Foundation will also assign clear responsibility for FFATA compliance and implement a monthly reconciliation of subaward obligations to FSRS submissions. Lastly, the Foundation will provide periodic training to grants, procurement, and finance staff on FFATA requirements and FSRS processes.
Finding 2025-001: Comments on the Finding and Each Recommendation: The Former Agent did not obtain a HUD approved Project Owner's/Management Agent's Certification (Form HUD-9839-B) and the Property paid unapproved management fees to the Former Agent. The Agent should obtain a HUD-approved Project Ow...
Finding 2025-001: Comments on the Finding and Each Recommendation: The Former Agent did not obtain a HUD approved Project Owner's/Management Agent's Certification (Form HUD-9839-B) and the Property paid unapproved management fees to the Former Agent. The Agent should obtain a HUD-approved Project Owner's/Management Agent's Certification. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. Management of the property transitioned to the Agent on June 1, 2025 and the Agent received a HUD-aproved Project Owner's/Management Agent's Certification for the Property.
FINDING 2025-003: Title I Eligibility Response: To ensure all records are correctly filed and maintained, the district is establishing new protocols for documenting Title eligibility.
FINDING 2025-003: Title I Eligibility Response: To ensure all records are correctly filed and maintained, the district is establishing new protocols for documenting Title eligibility.
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