Corrective Action Plans

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Management's Response: We concur. View of Responsible Officials and Corrective Action Plan. Return of Funds - The Campus Business Office and the Financial Aid Office met to review the untimely return of funds. We determined and immediately implemented a restructured process where the R2T4 speciali...
Management's Response: We concur. View of Responsible Officials and Corrective Action Plan. Return of Funds - The Campus Business Office and the Financial Aid Office met to review the untimely return of funds. We determined and immediately implemented a restructured process where the R2T4 specialist in financial aid will review student accounts that require R2T4 calculations on a weekly basis. The students will be posted to the shared database between Financial Aid and the Business Office. The dedicated weekly time will expedite the calculation process. The Business Office, as part of the updated process will continue to treat the R2T4 award adjustments as a priority. In addition to the existing process of end of month reconciliation and return of funds, a mid-month returning of funds was added and implemented. The dedicated weekly timeline to calculate, as well as the added mid-month return of funds, will ensure that we meet the required return of funds within the 45-day window. The offices will meet to review this updated process and make any additional changes should they be necessary to maintain compliance. Calculations - To ensure compliance with calculations processed timely, we will relieve the R2T4 specialist of other responsibilities so he can dedicate 100% of his time to calculate within the required timeframe. In addition, there will be additional staff assisting with calculations because the institution closes for a 10- day period which impacts the 30-day timeframe. This will ensure that all calculations are done. Implementation Date: 11/15/2023
Finding 2023.002 Response: The information reported on filing for Period 6 will be reviewed internally by others in the Finance department to ensure the expenses are reported accurately. Responsible Party: Terry Lutz, CFO at Scheurer Hospital Estimated Completion: 03/31/2024
Finding 2023.002 Response: The information reported on filing for Period 6 will be reviewed internally by others in the Finance department to ensure the expenses are reported accurately. Responsible Party: Terry Lutz, CFO at Scheurer Hospital Estimated Completion: 03/31/2024
Finding 2023.001 Response: Scheurer Hospital plans to save the documentation noting the overstated expenses along with the unused lost revenue in the audit file. In the event of a further audit, Scheurer Hospital will have the documentation to support the federal awards expended. Responsible Party...
Finding 2023.001 Response: Scheurer Hospital plans to save the documentation noting the overstated expenses along with the unused lost revenue in the audit file. In the event of a further audit, Scheurer Hospital will have the documentation to support the federal awards expended. Responsible Party: Terry Lutz, CFO at Scheurer Hospital Estimated Completion: 02/21/2024
Reporting for Education Stabilization Fund Federal program: ALN 84.425U&D Education Stabilization Fund Federal agency: U.S. Department of Education Pass-through entity: Colorado Department of Education Criteria: As an LEA, the LEA is required to submit certain annual financial reports...
Reporting for Education Stabilization Fund Federal program: ALN 84.425U&D Education Stabilization Fund Federal agency: U.S. Department of Education Pass-through entity: Colorado Department of Education Criteria: As an LEA, the LEA is required to submit certain annual financial reports to the SEA on an annual basis. Condition: While the Organization submitted the required annual financial reports, these reports did not tie back to the accounting records in a material amount. Management Response and Planned Corrective Actions Criteria: Management agrees with this finding and is working on implementing an annual financial report reconciliation process as staffing allows. Responsibility for Corrective Action: Christina Vetromile, Business Manager Anticipated Completion Date: Unknown
Activities Allowed or Unallowed, and Allowable Costs and Cost Principles for Education Stabilization Fund Federal program: ALN 84.425U&D Education Stabilization Fund Federal agency: U.S. Department of Education Pass-through entity: Colorado Department of Education Criteria: A non-fede...
Activities Allowed or Unallowed, and Allowable Costs and Cost Principles for Education Stabilization Fund Federal program: ALN 84.425U&D Education Stabilization Fund Federal agency: U.S. Department of Education Pass-through entity: Colorado Department of Education Criteria: A non-federal grant recipient should set reasonable budgets for programs to minimize incentives to miscode expenses. The recipient should compare budgeted and actual allowable costs and investigate variances where applicable. Condition: While the Organization created a budget for overall activities, they did not input the budget into their accounting system or create an outside tool to track actual grant expenditures with the budget. Management Response and Planned Corrective Actions Criteria: Management agrees with this finding and is working on implementing a budget to actual reporting process as staffing allows. Responsibility for Corrective Action: Christina Vetromile, Business Manager Anticipated Completion Date: Unknown
The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Award Program Audit Finding 2023-001 Federal Agency: U.S. Department of Housing and Urban Develo...
The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Award Program Audit Finding 2023-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs Federal Catalog Numbers: 14.871 and 14.879 Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Section 8 Housing Choice Vouchers Program - No Mainstream Vouchers Program - Yes Material Weaknesses in Internal Control over Compliance for Eligibility for the Mainstream Vouchers Program Significant Deficiency in Internal Control over Compliance for Eligibility Section 8 Housing Choice Vouchers Program Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 5,295 units. Of a sample size of seventy-one (71) tenant files, the following was noted: • HUD 9886 Form was missing in 1 file • Annual HUD 50058 recertification form and related verification of income and assets was missing in 1 file Our sample size is statistically valid. Known Questioned Costs: • Mainstream Vouchers $19,830 • Section 8 Housing Choice Vouchers Program $1,875 Cause: There is a significant deficiency in compliance for the eligibility type of compliance related to the maintenance of tenant files in the Section 8 Housing Choice Vouchers Program. There is a material weakness in compliance for the eligibility type of compliance related to the maintenance of tenant files in the Mainstream Vouchers Program. The Authority has not properly maintained tenant files in compliance with program requirements following the expiration of HUD waivers. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. The Mainstream Vouchers Program is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement a corrective action plan that will assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. Following the expiration of the COVID-19 HUD regulatory waivers, the Authority experienced a large backlog of reexaminations along with higher than usual rates of staff turnover and other staff capacity challenges related to the pandemic. Authority management developed and implemented a plan to rapidly work through the backlog, and has made significant progress to bring the program into compliance. The audit resulted in one missing consent form (HUD 9886), and one re-examination (HUD 50058), which is noted as missing. While the consent form had expired and a new consent form was required during the audit period, the income information collected for the household was collected while the consent form was still valid. With regards to the re-examination noted as missing, this re-examination was performed late, having been completed just six days after the end of the audit period. The re-examination was initiated on time, and the delay in completing the re-examination was caused by the program participant’s delay in providing the required documents. Additionally, the Authority has been selected for participation in the Moving to Work program ('MTW'). Alternative re-examination schedules, including biennial re-examinations, are an approved MTW activity allowable through the MTW Operations Notice. The Authority has received HUD approval of a waiver that allows the use of an alternate re-examination schedule effective July 1, 2023. This re-examination schedule is in effect currently and will be in effect for the entire duration of the subsequent audit period. Based on the transition to biennial and triennial re-examinations, the Authority has already come into compliance with timely recertifications. Further, the Authority management is in the process of implementing enhanced Quality Control procedures, with staff to conduct ongoing internal audits over the course of the year. If the U.S. Department of Housing and Urban Development has any questions regarding this plan, please call Aaron Pomeroy, Finance Director at 831-454-5908.
View Audit 294774 Questioned Costs: $1
Recommendation: We recommend the University review its policies and procedures for the filing of the HEERF to ensure that there is sufficient time in the process to meet the due date in accordance with the stated criteria. The evidence of submission should include the original supporting documentati...
Recommendation: We recommend the University review its policies and procedures for the filing of the HEERF to ensure that there is sufficient time in the process to meet the due date in accordance with the stated criteria. The evidence of submission should include the original supporting documentation for the information published. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will review its policies and procedures for the filing of HEERF required reports to ensure that that there is sufficient time in the process to meet the due date in accordance with the stated criteria. Name(s) of the contact person(s) responsible for corrective action: Michael Moos, Controller Planned completion date for corrective action plan: Completed in January 2024
Recommendation: We recommend that the University review its processes and internal controls to includes a review of all manual adjustment made within NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The err...
Recommendation: We recommend that the University review its processes and internal controls to includes a review of all manual adjustment made within NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The error was made while making manual corrections to prior year posting. The University formally document a policy and procedure that will require the review all manual edits made to NSLDS. Name(s) of the contact person(s) responsible for corrective action: Mark Quistorf and Registrar’s office. Planned completion date for corrective action plan: March 31, 2024
Recommendation: We recommend that the University work to formally document the policy establishing systems of internal control over compliance that includes proper segregation of duties. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken i...
Recommendation: We recommend that the University work to formally document the policy establishing systems of internal control over compliance that includes proper segregation of duties. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will formally document the policy establishing systems of internal control over compliance that includes proper segregation of duties specific to use of the G5 system. Name(s) of the contact person(s) responsible for corrective action: Michael Moos and Mark Quistorf Planned completion date for corrective action plan: March 31, 2024
Recommendation: We recommend that the University work to formally document the policy as a part of the University's 'Information Security Plan' as included in the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in respo...
Recommendation: We recommend that the University work to formally document the policy as a part of the University's 'Information Security Plan' as included in the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University engaged a consultant in FY 2022-23 to conduct a cyber security review and assist the University in establishing policies to ensure compliance with 16 CFR 314©(1) through (8). The unintentional omission of a policy specific to applications resulted because the University does not have applications developed by the institution. The University will develop a policy specific to institution developed applications. Additionally, the University will conduct an annual review with the assistance of our security consult to ensure ongoing compliance.
Management will establish more oversight on the deposits to replacement reserve account
Management will establish more oversight on the deposits to replacement reserve account
Since the late submissions in November 2022, DRNY has ensured that the SF425s were submitted in accordance with the due dates per the Grant Award notices (GANs). Further DRNY has now calendared within outlook all the grant reporting required for awards for the next year and created an excel tracking...
Since the late submissions in November 2022, DRNY has ensured that the SF425s were submitted in accordance with the due dates per the Grant Award notices (GANs). Further DRNY has now calendared within outlook all the grant reporting required for awards for the next year and created an excel tracking sheet of all the remaining reporting required for current grants. Both the Executive Director and the CFO have access to this excel tracking and the calendar invites. As new GANs are received, the CFO will calendar in the tracking document all reporting requirements and within outlook send out invites each calendar year and copy the Executive Director on those calendar invites. CFO will confirm to Executive Director as these reports are complete and document in the excel tracker. Danielle Myers, CFO, is responsible for the resolution of this corrective action plan by 3/1/2024.
Management notes the recommendation. Moving forward the Director of HR, Finance, & Operations will enter claims into Oracle, in accordance with CPS plan, and the accountant will review the claims and post to the accounting system. These transactions will be reviewed as a part of the month end reconc...
Management notes the recommendation. Moving forward the Director of HR, Finance, & Operations will enter claims into Oracle, in accordance with CPS plan, and the accountant will review the claims and post to the accounting system. These transactions will be reviewed as a part of the month end reconciliation process. Variances are discussed and documented in these meetings. Responsible Parties: Director of HR, Finance & Operations Accountant Principal Finance Committee Start date 9/23- will be monthly on-going
Finding Number: 2023-005 Inaccurate Reporting (Material Weakness) Planned Corrective Action: As reported in item number 2023-004, some expenses were not properly allocated to the grant. If some of the receipts cannot be accounted for, one could infer that the reports submitted were inaccurate. To c...
Finding Number: 2023-005 Inaccurate Reporting (Material Weakness) Planned Corrective Action: As reported in item number 2023-004, some expenses were not properly allocated to the grant. If some of the receipts cannot be accounted for, one could infer that the reports submitted were inaccurate. To correct this matter, the ED will ensure that all receipted are accounted for and accurately reported to all grant funders. Person Responsible for Corrective Action: Nicole Ferguson, Executive Director. Anticipated Date of Completion: Currently in progress
Planned Corrective Action: Due to the turnover in the ED position, there were some costs that were not allocated timely. The previous ED had intended to correct this by year end but her leaving resulted in it not being completed. The new ED, unfamiliar with the process, took a few months to understa...
Planned Corrective Action: Due to the turnover in the ED position, there were some costs that were not allocated timely. The previous ED had intended to correct this by year end but her leaving resulted in it not being completed. The new ED, unfamiliar with the process, took a few months to understand the process. Once the new ED understood the process and grant requirements, she was able to find expenses from prior months and allocate them to the appropriate grant. Unfortunately, this was not completed in the 30-day timeframe. For FY2024 and future allocations, the new ED allocates expenses each month and has trained other staff to manage these transactions in her absence, so no expense goes unreimbursed for more than 30 days. Person Responsible for Corrective Action: Nicole Ferguson, Executive Director. Anticipated Date of Completion: Completed.
Planned Corrective Action: Similar to item 2023-002, there were some expenses that were not adequately tied back to the grant that was sampled. MCS has already implemented a new process for FY2024 by tracking grant allocation and expenses in multiple locations, having each expense signed off by the ...
Planned Corrective Action: Similar to item 2023-002, there were some expenses that were not adequately tied back to the grant that was sampled. MCS has already implemented a new process for FY2024 by tracking grant allocation and expenses in multiple locations, having each expense signed off by the ED, and sent to the accountant for multiple layers of review and internal controls. Person Responsible for Corrective Action: Nicole Ferguson, Executive Director. Anticipated Date of Completion: Currently in progress
View Audit 294751 Questioned Costs: $1
Recommendation: We recommend the College review its reporting procedures surrounding their third party servicer to ensure reporting is accurate and complete. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Link t...
Recommendation: We recommend the College review its reporting procedures surrounding their third party servicer to ensure reporting is accurate and complete. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Link to third party servicer has been updated in the appropriate places. Instructions related to updating third party servicer information has been included in the Bursar desk manual. Name(s) of the contact person(s) responsible for corrective action: Michele Peterson Planned completion date for corrective action plan: 12/31/23
Recommendation: We recommend the College review and strengthen its procedures for notifying students of their Direct Loan disbursements within the required time frame and that documentation of the letters sent is maintained. Explanation of disagreement with audit finding: There is no disagreement w...
Recommendation: We recommend the College review and strengthen its procedures for notifying students of their Direct Loan disbursements within the required time frame and that documentation of the letters sent is maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Bursar desk manual has been updated to include information regarding the notice required Direct Loan disbursements. Additionally, statements have been updated to include appropriate messaging when loads are disburses. The statements are sent at the time the disbursements are made. Name(s) of the contact person(s) responsible for corrective action: Michele Peterson Planned completion date for corrective action plan: 12/31/23
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Section 8 Housing Choice Voucher Cluster Federal Assistance Listing Number: 14.871 Pass‐through: N/A Award No. and Year: CA065‐2023 Compliance Requirement: Utility Allowance Schedule Type of Finding: Instance of Non‐Co...
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Section 8 Housing Choice Voucher Cluster Federal Assistance Listing Number: 14.871 Pass‐through: N/A Award No. and Year: CA065‐2023 Compliance Requirement: Utility Allowance Schedule Type of Finding: Instance of Non‐Compliance and Material Weakness in Internal Control over Compliance Views of Responsible Officials: The Housing Authority fully complied with 24CFR 982.517(C)(1) of HUD regulations that states that "A PHA must review its schedule of utility allowances each year and must revise its allowance for a utility category if there has been a change of 10 percent or more in the utility rate since the last time the utility allowance schedule was revised. The PHA must maintain information supporting its annual review of utility allowances and any revisions made in its utility allowance schedule." Each year, the Housing Authority hires a consultant to analyze the Utility allowances for the Fairfield jurisdiction. Once that assessment is completed, Housing Authority staff and Management review it. The Housing Authority staff then meets with the Consultant to discuss any irregularities found or resolve questions emanating from its review. Once staff and Management are satisfied with the information, have clear documentation explaining the Consultant's conclusions, and memorialize any categories that have changed 10% or more, Management will finalize its review of the Utility Allowance Schedule. The Housing Authority will document Management’s approval of the utility allowance adjustments, if any. Responsible Individual(s): Tanya Tran, Housing Division Manager LaTanna Jones, Deputy Executive Director Anticipated Completion Date: June 1, 2024
Finding 375665 (2023-007)
Significant Deficiency 2023
Finding 2023‐007 Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Section 8 Housing Choice Voucher Cluster Federal Assistance Listing Number: 14.871 Pass‐through: N/A Award No. and Year: CA065‐2023 Compliance Requirement: Housing Quality Standards Inspection Type of ...
Finding 2023‐007 Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Section 8 Housing Choice Voucher Cluster Federal Assistance Listing Number: 14.871 Pass‐through: N/A Award No. and Year: CA065‐2023 Compliance Requirement: Housing Quality Standards Inspection Type of Finding: Instance of Non‐Compliance and Significant Deficiency in Internal Control over Compliance Views of Responsible Officials: We concur. The Housing Authority will ensure that HQS inspections are completed at least biennially for all units in the program. Each Housing Specialist maintains a tabulation of inspection deadlines for each unit; hence, 98% of the 60‐unit test group was completed on time. However, Management will more frequently monitor the inspection deadlines with the specialist to avoid even a 2% margin of error, as indicated in this audit assessment. Responsible Individual(s): Tanya Tran, Housing Division Manager Anticipated Completion Date: June 1, 2024
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Section 8 Housing Choice Voucher Cluster Federal Assistance Listing Number: 14.871 Pass‐through: N/A Award No. and Year: CA065‐2023 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Contr...
Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Section 8 Housing Choice Voucher Cluster Federal Assistance Listing Number: 14.871 Pass‐through: N/A Award No. and Year: CA065‐2023 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance Views of Responsible Officials: We concur. The Housing Authority addressed this issue when the City was informed in March 2023 there was not enough documentation prior to online grant reporting for the auditors to verify grant reports were reviewed prior to submission on other grants being audited. The Housing Authority has continuously maintained a check and balance approach for preparing and reviewing VMS reports before HUD submission. All reports are prepared by the Housing Authority and finance staff, then reviewed by either the Housing Authority Manager or the Deputy Executive Director before submission to HUD. The reviewer is now documenting their review prior to submitting the VMS reports. Responsible Individual(s): Tanya Tran, Housing Division Manager Anticipated Completion Date: June 30, 2023
Finding 375660 (2023-005)
Significant Deficiency 2023
Federal Agency: U.S. Department of Transportation Program/Cluster: Highway Planning and Construction Federal Assistance Listing Number: 20.205 Pass‐through: California Department of Transportation Award No. and Year: STPCML‐5132 (049) – 2022 and HSIPL‐5132 (52) ‐ 2022 Compliance Requirement: Special...
Federal Agency: U.S. Department of Transportation Program/Cluster: Highway Planning and Construction Federal Assistance Listing Number: 20.205 Pass‐through: California Department of Transportation Award No. and Year: STPCML‐5132 (049) – 2022 and HSIPL‐5132 (52) ‐ 2022 Compliance Requirement: Special Tests and Provisions – Wage Rate Requirements Type of Finding: Significant Deficiency in Internal Control over Compliance Views of Responsible Officials and Corrective Action Plan: The Public Works Department does review the certified payroll by management and files it within the project folder yet there was no documented sign off to verify when this review was completed. The City will add an additional step to document the verification of the review by management for future projects. Responsible Individual(s): Roger Dunham, Administration Division Manager Anticipated Completion Date: March 1, 2024
Federal Agency: U.S. Department of Homeland Security Program/Cluster: Staffing for Adequate Fire & Emergency Response Federal Assistance Listing Number: 97.083 Pass‐through: N/A Award No. and Year: EMW‐2020‐FF‐00816, 2020 Compliance Requirement: Reporting Type of Finding: Material Weakness in Intern...
Federal Agency: U.S. Department of Homeland Security Program/Cluster: Staffing for Adequate Fire & Emergency Response Federal Assistance Listing Number: 97.083 Pass‐through: N/A Award No. and Year: EMW‐2020‐FF‐00816, 2020 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance Views of Responsible Officials and Corrective Action Plan: The Fire Department has addressed this issue when the City was informed in March 2023 there was not enough documentation prior to online grant reporting for the auditors to verify grant reports were reviewed prior to submission on other grants being audited. The two (2) submissions in question were reviewed and verified by management but were not documented for the auditors to verify when the review was completed, prior to the City being notified in March 2023 to further document the review process. The City has implemented this recommendation. Responsible Individual(s): Taylor Armour, Administration Division Manager Anticipated Completion Date: June 30, 2023
With new leadership, we have implemented new procedures and processes to ensure program requirements are being met. All program transactions are being monitored, reviewed, and approved by the Executive Director and Fiscal Director to ensure compliance with the established guidelines. A monthly close...
With new leadership, we have implemented new procedures and processes to ensure program requirements are being met. All program transactions are being monitored, reviewed, and approved by the Executive Director and Fiscal Director to ensure compliance with the established guidelines. A monthly closeout process has been implemented to ensure that all the transactions are documented with supervisory review and approval. We have revised and adopted a new Financial Manual that was approved by our Board of Directors in October 2023.
Finding 2023-002: Section 202 Supportive Housing for the Elderly, Capital Advance and Project Rental Assistance Contract, ALN 14.157 Anticipated Completion Date: September 30, 2024 Recommendation: It was recommended management of Sessions Village 202 review their internal controls over the cash...
Finding 2023-002: Section 202 Supportive Housing for the Elderly, Capital Advance and Project Rental Assistance Contract, ALN 14.157 Anticipated Completion Date: September 30, 2024 Recommendation: It was recommended management of Sessions Village 202 review their internal controls over the cash disbursement process with the necessary individuals involved in the process to ensure the implementation of general ledger account coding on cash disbursements is consistently performed going forward. Action Taken: The Executive Director and A/P Clerk agreed upon using certain general ledger account codes consistently for similar purchases from the same vendor. In Sessions Village 202’s accounting system, these agreed upon general ledger account codes have been pre-set as a default for certain vendors. When invoices are received that should be appropriately coded to this default general ledger account code, errors of not documenting the general ledger account code on the invoice are periodically made. Sessions Village 202 will consistently perform the general ledger account coding internal control procedures on invoices going forward.
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