Corrective Action Plans

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Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the ...
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been updated along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the ...
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been updated along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the ...
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been updated along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanat...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been created along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
The financial statements shall be submitted to HUD once finalized.
The financial statements shall be submitted to HUD once finalized.
Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Cont...
Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Control over Compliance Criteria and Condition: According to Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), section 200.430, charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that the system for establishing the estimates produces reasonable approximations of the activity actually performed; significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges based on budget estimates. Proof of these employees' approved compensation and job title is required to ensure their roles are allowable under the grant. Timesheets provided to support payroll charges did not accurately support the payroll expenses charged to the grants. Also, approval of the timesheets was not evident by the documentation provided. Finally, documentation supporting approval of each employee’s compensation was not maintained and provided to support the accuracy of employee compensation. Cause: During 2024, CVC’s management team underwent significant turnover, including the top finance officer, who represents the entire accounting department, as well as the HR director. Documentation was not maintained or could not be located to support payroll expenses allocated to the federal program. Effect and Context: When adequate support is not obtained and used to support the amount charged to the federal program, there is a risk that unsupported or inaccurate costs are being charged to the federal program. Questioned Costs: Payroll costs charged to the awards total $2,570,558. Recommendation: We recommend proper control activities should be implemented to allow for a consistent, accurate, and allowable method to support distribution of personnel charges to federal programs. Documentation should be properly maintained in the organization’s records. Views of responsible officials and planned corrective actions: CVC management will implement a process to perform timely review of salary expenses charged to federal awards, and retain records by pay period, and any pay rate and title changes, as support for expenditures charged to federal awards. Name of Contact Person: Gil Catbagan, Director of Finance Proposed Completion Date: December 31, 2025
View Audit 368632 Questioned Costs: $1
Contact Person Brenna Ohman, Finance Director Corrective Action Plan Management acknowledges that due to limited personnel there is not always proper segregation of duties. Starting in October 2025, Management will begin having another review and approve grant reimbursement requests and grant report...
Contact Person Brenna Ohman, Finance Director Corrective Action Plan Management acknowledges that due to limited personnel there is not always proper segregation of duties. Starting in October 2025, Management will begin having another review and approve grant reimbursement requests and grant reporting prior to submission. Completion Date Rural Development Finance Corporation will implement the plan in 2025.
The Rensselaer Housing Authority (RHA) has already implemented a check list to ensure tenant files are organized and reviewed by another employee and signed off as completed. Planned implementation Date of Corrective Action: Already in effect Person Responsible for Corrective Action:: Stacey Sabiani...
The Rensselaer Housing Authority (RHA) has already implemented a check list to ensure tenant files are organized and reviewed by another employee and signed off as completed. Planned implementation Date of Corrective Action: Already in effect Person Responsible for Corrective Action:: Stacey Sabiani, Executive Director
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. This revised process will be put in place on October 1, 2025.
View Audit 368617 Questioned Costs: $1
Finding 2024-004 Significant Deficiency in Controls over Compliance and Noncompliance - Reporting Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition - A total of $910,157 of costs was passed through to se...
Finding 2024-004 Significant Deficiency in Controls over Compliance and Noncompliance - Reporting Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition - A total of $910,157 of costs was passed through to selected sub recipients during the year and the subawards were not reported in the FSRS. Corrective Action Plan – Henry Ford Health agrees with this finding and has created a workgroup to ensure that current information on FSRS is accurate and to also to clarify responsibility for ongoing reporting and review of subrecipient disclosure requirements to ensure timeliness and accuracy. Anticipated Completion Date – December 31, 2025. Contact Person – J. Douglas Clark, Senior Vice President and Chief Accounting Officer.
Finding 2024-003 Material Weakness in Controls over Compliance and Material Noncompliance – Cash Management Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – There were four drawdowns made in relation ...
Finding 2024-003 Material Weakness in Controls over Compliance and Material Noncompliance – Cash Management Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – There were four drawdowns made in relation to the fiscal year 2024 expenses for the grant. For two out of the four drawdowns, management erroneously drew down in excess of the expenses incurred. Corrective Action Plan – Henry Ford Health agrees with this finding. As of August 31, 2025, the grant is in a net receivable position, so no adjustment is required. An additional level of review is being added to the drawdown process to improve the control environment and reduce the associated risk of error. Anticipated Completion Date – December 31, 2025. Contact Person – J. Douglas Clark, Senior Vice President and Chief Accounting Officer.
View Audit 368602 Questioned Costs: $1
Finding 2024-002 Material Weakness in Controls over Compliance and Material Noncompliance – Allowable Costs Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – Payroll expenses for one employee were inad...
Finding 2024-002 Material Weakness in Controls over Compliance and Material Noncompliance – Allowable Costs Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – Payroll expenses for one employee were inadvertently recorded twice for the fiscal year, resulting in an overstatement of personnel costs charged to the federal award. Further, indirect costs were charged in excess of the budgeted and approved amount under the grant agreement. Corrective Action Plan – Henry Ford Health agrees with this finding. The payroll expense was corrected in the Schedule of Expenditures of Federal Awards and will be corrected in September 30, 2025, Federal Financial Report. Prospectively the payroll for the employee in question will be processed through our automated payroll time and effort process, rather than through manual journal entries, thus reducing the risk of error. Additionally, set up and review procedures have been enhanced to improve the controls related to recovery of indirect costs. Anticipated Completion Date – December 31, 2025. Contact Person – J. Douglas Clark, Senior Vice President and Chief Accounting Officer.
View Audit 368602 Questioned Costs: $1
The Board of Education has acknowledged the finding and has agreed to the finding. We have reviewed the affected payroll records and confirmed the underpayment. We have issued a check to pay the difference owed to the employee. At fiscal year end, we will implement a more detailed review process to ...
The Board of Education has acknowledged the finding and has agreed to the finding. We have reviewed the affected payroll records and confirmed the underpayment. We have issued a check to pay the difference owed to the employee. At fiscal year end, we will implement a more detailed review process to ensure all employees' salary schedules are updated when we process the system-wide update. We will have an additional person to review and sign the new salary schedules before the first payroll is processed in the new fiscal year.
The Board of Education has acknowledged the finding and has agreed to the finding. We have reviewed the affected payroll records and confirmed the underpayment. We have issued a check to pay the difference owed to the employee. At fiscal year end, we will implement a more detailed review process to ...
The Board of Education has acknowledged the finding and has agreed to the finding. We have reviewed the affected payroll records and confirmed the underpayment. We have issued a check to pay the difference owed to the employee. At fiscal year end, we will implement a more detailed review process to ensure all employees' salary schedules are updated when we process the system-wide update. We will have an additional person to review and sign the new salary schedules before the first payroll is processed in the new fiscal year.
Finding 2024-003 – Subrecipient Cash ManagementAssistance Listing No.: MultipleThe Office of Sponsored Programs ( OSP) will address the recommendation and review its current processes, policies, and procedures to minimize the time between invoice receipt and the transfer of federal funds to the subr...
Finding 2024-003 – Subrecipient Cash ManagementAssistance Listing No.: MultipleThe Office of Sponsored Programs ( OSP) will address the recommendation and review its current processes, policies, and procedures to minimize the time between invoice receipt and the transfer of federal funds to the subrecipient. This includes implementation of the following preventative controls to ensure that payments are made within the required timeline: a. Active communications with Principal Investigators of subawards on invoice approval timeline at award initiation and creation of procedures for documenting and advising OSP of invoices requiring correction and /or modification. b. Work with Post Award Staff to ensure that adequate documentation is created and maintained related to the follow-up that occurs when issues are being investigated and resolved that cause a delay in invoice processing.c. Development and utilization of a report for internal reporting and tracking of pending sub-invoices payments approaching the 30-day deadline. d. Implementation of the Invoice Receipt Date as a required field for subaward invoicing in Workday rather than the optional field it is at present. Responsible Official: Cate Ekstrom, Director of Research
Finding 2024-001 – ReportingAssistance Listing No.: 93.391, COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis Assistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for InfectiousDiseases...
Finding 2024-001 – ReportingAssistance Listing No.: 93.391, COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis Assistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for InfectiousDiseasesManagement will distribute the updated SEFA reporting policy and procedure, outlining the required reporting requirements and timelines. A SEFA preparation checklist will be implemented to ensure that all submissions are accurate and complete. At the end of the year, Finance and Grants Management will collaborate to review all grant activities to ensure proper inclusion in the SEFA.Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health
Finding 2024-002 – Subrecipient MonitoringAssistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC)Management will implement the established Research procedures for subrecipient risk assessments in accordance with Uniform Guidance Section 200.332(b)....
Finding 2024-002 – Subrecipient MonitoringAssistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC)Management will implement the established Research procedures for subrecipient risk assessments in accordance with Uniform Guidance Section 200.332(b). Update the Research subrecipient monitoring checklist and use the subrecipient forms. This approach will be applied to all new subrecipient relationships starting in 2025 and beyond. Additionally, management will collaborate with Endeavor Health's legal, finance, and compliance teams to assess current processes and make any necessary corrections to improve the review and documentation of results going forward.Responsible Officials: Ashlee Jean Roffe, Director of Nutrition and Community Health, Community CARE
Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...
Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Proposed Completion Date: January 1, 2026
Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and ...
Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that the five transactions tested that did not have documentation of appropriate approval occurred prior to August 2024, the remediation date of Finding 2023-002. Completion Date: Matter was remediated in August 2024
1. Maintained and refined the shared federal financial reporting calendar to ensure all relevant deadlines and submission dates are consistently tracked and communicated. 2. Expanded and updated reporting checklists to incorporate additional compliance requirements and ensure completeness and accura...
1. Maintained and refined the shared federal financial reporting calendar to ensure all relevant deadlines and submission dates are consistently tracked and communicated. 2. Expanded and updated reporting checklists to incorporate additional compliance requirements and ensure completeness and accuracy prior to submission. 3. Assigned dedicated staff oversight for federal financial reporting, with cross-training implemented to strengthen continuity and mitigate risk in the event of staff turnover. 4. Conducted periodic evaluations of the reporting process, incorporating feedback and lessons learned from prior submissions, monitoring visits, and audit findings to drive ongoing improvements. 5. Reviewed and updated internal financial policies and procedures to align with current federal reporting requirements and best practices, with updates formally documented and disseminated to staff.
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regardin...
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. Actions Taken FINDING 2024-004: Supportive Housing for the Elderly, Assistance Listing 14.157 CORRECTIVE ACTION COMPLETED: The Company opened a residual receipt account and plans to deposit $3,633. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Natalie Bastien, Vice President, RPM Living.
View Audit 368559 Questioned Costs: $1
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regardin...
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. Actions Taken FINDING 2024-003: Supportive Housing for the Elderly, Assistance Listing 14.157 CORRECTIVE ACTION COMPLETED: HUD approved the suspension of monthly deposits to the replacement reserve account for 2024 due to the account being overfunded in prior years. The Company has requested from HUD to approve a withdrawal of $14,400 to reimburse the property for deposits made during the approved suspension of payments. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Natalie Bastien, Vice President, RPM Living.
View Audit 368559 Questioned Costs: $1
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regardin...
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. Actions Taken FINDING 2024-002: Supportive Housing for the Elderly, Assistance Listing 14.157 CORRECTIVE ACTION COMPLETED: The property management company obtained property insurance effective March 2025. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Natalie Bastien, Vice President, RPM Living.
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regardin...
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. Actions Taken FINDING 2024-001: Supportive Housing for the Elderly, Assistance Listing 14.157 CORRECTIVE ACTION COMPLETED: An adjusting audit entry was made to reduce the property management fees. Management will monitor the expenses to ensure in compliance with the HUD approved Form 9839. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Natalie Bastien, Vice President, RPM Living.
View Audit 368559 Questioned Costs: $1
September 29, 2025. Dear Cognizant or Oversight Agency for Audit: Hands of Healing Residential Treatment Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Doeren Mayhew Assurance, 2600 ...
September 29, 2025. Dear Cognizant or Oversight Agency for Audit: Hands of Healing Residential Treatment Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Doeren Mayhew Assurance, 2600 North Loop West, Suite 600, Houston, TX 77092. The finding discussed below from the Schedule of Findings and Questioned Costs (the schedule) for the year ended December 31, 2024 is numbered consistently with the number assigned in the schedule. Federal Award Finding 2024-000. Corrective Action Plan: Management understands that annual federal financial reports (FFR) are required to be submitted no later than 90 days after the end of each budget period. In order to ensure compliance, Management will delegate responsibilities for completing all FFR reports to the new Chief Financial Officer (CFO). She will be responsible for reading the Notice of Awards and calendaring out all FFR due dates for timely completion. The CFO was hired in part to focus on activities such as these to ensure sustainable compliance in all areas related to federal grant awards. Contact Person Responsible for Corrective Action: Mr. Victor Weetly, Chief Executive Officer. Anticipated Completion Date: The corrective action plan will be completed by September 30, 2025. Respectfully submitted, Mr. Victor Weetly, President.
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