Corrective Action Plans

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Special Test and Provisions-Monthly Board Financial Reporting and Budgetary Comparisons. Auditor’s Recommendation: We recommend that management establish formal procedures requiring the preparation and review of monthly budget-to-actual financial reports and ensure that accurate financial statements...
Special Test and Provisions-Monthly Board Financial Reporting and Budgetary Comparisons. Auditor’s Recommendation: We recommend that management establish formal procedures requiring the preparation and review of monthly budget-to-actual financial reports and ensure that accurate financial statements are presented to the Board of Directors on a regular basis. Documentation of financial reports presented, discussions held, and actions taken should be maintained in meeting records to demonstrate compliance with Head Start governance and financial oversight requirements. Organization’s Response: Management acknowledges the finding related to governance reporting requirements not being consistently presented to the Board during fiscal year 2025 in report form. The Board had more robust discussions regarding financial statements, concentrated around the time of drawdowns and the use of funds. Effective 2026, management will implement a structured monthly reporting process to ensure the Board and Finance Committee receive timely financial statements, budget-to-actual reports, grant expenditure reports, and other required compliance updates. Board meeting agendas will include financial oversight as a standing item, and meeting minutes document the Board’s review and acceptance. The Finance Director and CEO are responsible for monitoring compliance with this process to ensure the condition does not recur.
Special Test and Provisions-Monthly Board Financial Reporting and Budgetary Comparisons. Auditor’s Recommendation: We recommend that management establish formal procedures requiring the preparation and review of monthly budget-to-actual financial reports and ensure that accurate financial statements...
Special Test and Provisions-Monthly Board Financial Reporting and Budgetary Comparisons. Auditor’s Recommendation: We recommend that management establish formal procedures requiring the preparation and review of monthly budget-to-actual financial reports and ensure that accurate financial statements are presented to the Board of Directors on a regular basis. Documentation of financial reports presented, discussions held, and actions taken should be maintained in meeting records to demonstrate compliance with Head Start governance and financial oversight requirements. Organization’s Response: Management acknowledges the finding related to governance reporting requirements not being consistently presented to the Board during fiscal year 2025 in report form. The Board had more robust discussions regarding financial statements, concentrated around the time of drawdowns and the use of funds. Effective 2026, management will implement a structured monthly reporting process to ensure the Board and Finance Committee receive timely financial statements, budget-to-actual reports, grant expenditure reports, and other required compliance updates. Board meeting agendas will include financial oversight as a standing item, and meeting minutes document the Board’s review and acceptance. The Finance Director and CEO are responsible for monitoring compliance with this process to ensure the condition does not recur.
ELIGIBILITY VERIFICATIONS – GRANTS TO STATES FOR MEDICAID PROGRAM Recommendation: It is recommended that the County increase review over casefiles and ensure verifications are sent out when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Ac...
ELIGIBILITY VERIFICATIONS – GRANTS TO STATES FOR MEDICAID PROGRAM Recommendation: It is recommended that the County increase review over casefiles and ensure verifications are sent out when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will remind staff to perform reviews and to ensure that verifications are sent out when necessary. Name of the contact person responsible for corrective action plan: Kayla Matter, HHS Deputy Director Planned completion date for corrective action plan: December 31, 2026
Staff will closely monitor all expenditures for a grant paid in future fiscal years and will record them properly on the Statement of Expenditures of Federal Awards
Staff will closely monitor all expenditures for a grant paid in future fiscal years and will record them properly on the Statement of Expenditures of Federal Awards
Staff that oversaw keeping the documentation for the grants was on vacation. In the future documentation will be kept by the departments awarded the grants.
Staff that oversaw keeping the documentation for the grants was on vacation. In the future documentation will be kept by the departments awarded the grants.
Finding 1221287 (2025-004)
Material Weakness 2025
Eligibility Determination Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesot...
Eligibility Determination Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5MAP and 2505MN5ADM Compliance Requirement Affected: Eligibility Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the County implement procedures to ensure the citizenship, asset, and income verification documentation in the casefiles be retained and that it matches the METS eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review procedures and show staff proper documentation and entry into METS and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Loni Swenson, Finance Director Planned completion date for corrective action plan: December 31, 2026
We have implemented a plan for proper training to make sure everyone is aware of HUD rules regarding family eligibility. We will complete a quarterly audit of randomly selected files to ensure we are adhering to HUD rules. We will ensure staff monitors eligibility for each resident within the requir...
We have implemented a plan for proper training to make sure everyone is aware of HUD rules regarding family eligibility. We will complete a quarterly audit of randomly selected files to ensure we are adhering to HUD rules. We will ensure staff monitors eligibility for each resident within the required time frame.
In order to keep cash as accurate as possible, we will work to clear interfund as often as possible. With upcoming development revenue that we will see come in over the next 1-2 years on the non profit side, we will work to prioritize returning funds to the Public Housing Operating Funds. To prevent...
In order to keep cash as accurate as possible, we will work to clear interfund as often as possible. With upcoming development revenue that we will see come in over the next 1-2 years on the non profit side, we will work to prioritize returning funds to the Public Housing Operating Funds. To prevent co-mingling of cash, we will begin a plan to break apart the funds for each program - Spencer, COCC, 3rd and 11th. Each quarter, we access payroll allocations to better reflect employees’ use of time and actual costs incurred by program and by LITC property. Public Housing and COCC training is planned that all finance staff will attend to make sure proper HUD procedures, rules, and guidelines are followed. The plan is to reduce the receivable down to $-0- as soon as possible and within 5 years.
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. The new policy was approved by the board of Directors in December 2025. The new process is being implemented in 2026. Internal audit began monthly audits and corrective training in February 2026 with target goal by Q3 2026.
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened controls to ensure that all Head Start/ Early Head Start charges are adequately documented, properly approved, and reviewed for compliance with allowable cost requirements. The Organization has implemented...
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened controls to ensure that all Head Start/ Early Head Start charges are adequately documented, properly approved, and reviewed for compliance with allowable cost requirements. The Organization has implemented processes requiring documented approval for Head Start/Early Head Start charges. Required support includes invoices or payroll documentation, allocation support when applicable, evidence of allowability, and documented supervisory approval. Finance will verify that required support is complete before costs are charged to the program. Periodic internal monitoring procedures are currently being performed to review Head Start/ Early Head Start expenditures for documentation sufficiency, evidence of approval, and compliance with allowable cost principles. Any deficiencies identified will be corrected timely, and recurring issues will be addressed through staff training or process improvements. Management will review the questioned costs identified in the audit and determine the appropriate corrective action, including obtaining additional supporting documentation or reclassifying costs, as needed. Responsible Party: Chief Financial Officer, with support from the Finance Team and Head Start Program Leadership. Anticipated Completion Date: Updated processes have been implemented and are currently in operation to mitigate the risk of future findings. Monitoring Plan: Management will perform quarterly reviews of Head Start/ Early Head Start expenditures. Results will be reviewed with the CFO and Program Leadership, and any corrective actions will be documented and tracked through resolution.
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened its grant accounting, financial close and reporting controls to ensure that grant revenue, receivables, expenses, refundable advances and SEFA amounts are recorded accurately and in the appropriate reporti...
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened its grant accounting, financial close and reporting controls to ensure that grant revenue, receivables, expenses, refundable advances and SEFA amounts are recorded accurately and in the appropriate reporting period. During fiscal year 2025, the Finance department experienced significant personnel changes. New management performed a transaction review to determine whether transactions were properly allocated and recorded. During this review, several transactions totaling $741,113 were identified as having been allocated to the incorrect fiscal period. In addition, the $357,774 liability resulted from an adjustment made by a contractor in March 2025 that incorrectly allocated CACFP revenues and related expenses to fiscal year 2024. Responsible Party: Chief Financial Officer, with support from the Finance Team. Anticipated Completion Date: Updated processes have been implemented and are currently in operation to mitigate the risk of future findings. Monitoring Plan: Management will perform monthly reviews of grant reconciliations, cost transfers, and significant grant-related journal entries to ensure transactions are recorded accurately, supported by appropriate documentation, and recognized in the proper reporting period.
Corrective Action Plan – Single Audit Finding Entity Name: Brocton Housing Development Company, Inc. Audit Period: For the year Ended September 30, 2025 Finding Reference Number: 14.157 Federal Program: Supportive Housing for the Elderly (Section 202) 1. Audit Finding Summary Describe the audit find...
Corrective Action Plan – Single Audit Finding Entity Name: Brocton Housing Development Company, Inc. Audit Period: For the year Ended September 30, 2025 Finding Reference Number: 14.157 Federal Program: Supportive Housing for the Elderly (Section 202) 1. Audit Finding Summary Describe the audit finding and the specific noncompliance identified by the auditor. In accordance with 24 CFR 891.400(e), a separate interest-bearing project fund account shall be maintained in a depository or depositories which are members of the Federal Deposit Insurance Corporation or National Credit Union Share Insurance Fund and all tenant payments, charges, income and revenues arising from project operation or ownership shall be deposited to this account. 2. Root Cause Explain the underlying reasons for the finding, such as process gaps, training issues, or lack of controls. Subsequent to the initial rental assistance contract, changes to HUD regulations resulted in the requirement that the project fund account be an interest-bearing account. This change was an oversight by the Company's management. 3. Corrective Actions Action Item: Use an interest-bearing account for project funds Responsible Person: Chief Financial Officer Completion Date: TBD Status: In process 4. Monitoring Plan Describe how the implementation of corrective actions will be monitored and evaluated. Management inquired with the bank and deemed the cost outweighs the benefit due to the fees charged for an interest bearing account exceeding the interest that would be earned. 5. Contact Information Name: Aaron Hejmowski Title: Chief Financial Officer Phone: 716-884-7791 Email: ahejmowski@belmonthousingwny.org
The Authority will submit its SEMAP certification to HUD within sixty days of its fiscal year-end. Ms. LaTonya Coley-McKenley, Executive Director, has assumed the responsibility of executing this corrective action by November 29, 2026.
The Authority will submit its SEMAP certification to HUD within sixty days of its fiscal year-end. Ms. LaTonya Coley-McKenley, Executive Director, has assumed the responsibility of executing this corrective action by November 29, 2026.
The Authority will catalog and maintain all required tenant file documents in accordance with federal requirements and the Authority’s internal policies. Ms. LaTonya Coley-McKenley, Executive Director, has assumed the responsibility of executing this corrective action by August 1, 2026.
The Authority will catalog and maintain all required tenant file documents in accordance with federal requirements and the Authority’s internal policies. Ms. LaTonya Coley-McKenley, Executive Director, has assumed the responsibility of executing this corrective action by August 1, 2026.
Assistance Listing 14.239 – HOME Investment Partnership Program Material Weakness in Internal Control over Compliance; Material Noncompliance – Eligibility Background of Occurrence: For the year under audit, not all tenant income re-certifications were found in paper or digital form in the company f...
Assistance Listing 14.239 – HOME Investment Partnership Program Material Weakness in Internal Control over Compliance; Material Noncompliance – Eligibility Background of Occurrence: For the year under audit, not all tenant income re-certifications were found in paper or digital form in the company files after the termination of the former property manager in February, 2026. Planned Corrective Action: To address this issue prospectively, WCCAC has implemented an internal system to ensure re-certifications are completed timely, with three levels of accountability as outlined in the new Homes Program Internal Control Compliance Memo (see attached) Under Paragraph “Control Activities” it outlines new corrective action procedures to ensure compliance. Anticipated Completion Date: April, 2026 – This corrective action has been incorporated immediately into our internal processes. Name and Title of Contact Person Responsible for Corrective Action: Timothy Fisher, Chief Executive Officer
Assistance Listing 14.239 – HOME Investment Partnership Program Material Weakness in Internal Control over Compliance; Material Noncompliance – Special Tests and Provisions – Housing Quality Standards Background of Occurrence: For the year under audit, the historically maintained consolidated inspec...
Assistance Listing 14.239 – HOME Investment Partnership Program Material Weakness in Internal Control over Compliance; Material Noncompliance – Special Tests and Provisions – Housing Quality Standards Background of Occurrence: For the year under audit, the historically maintained consolidated inspection log that was used to track unit inspections and other supporting documentation was not found in paper or digital form in the company files after the termination of the former property manager in February, 2026. Planned Corrective Action: A new inspection log has been created and fully implemented into the processes to document each unit, the date of inspection, and the condition or quality of the unit. This log is now maintained as part of standard operating procedures and will support timely retrieval of inspection records going forward. We have updated our internal control document related to the Home Investment Partnership with new property staff and review procedures. (see attached) Anticipated Completion Date: April, 2026 – This corrective action has been incorporated immediately into our internal processes. Name and Title of Contact Person Responsible for Corrective Action: Timothy Fisher, Chief Executive Officer
Due to inadequate monitoring of grant deadlines and project implementation timelines, the Organization did not obligate certain federal funds before the expiration of the award period. As a result, a portion of the awarded funds remained unused and was no longer available for program activities. The...
Due to inadequate monitoring of grant deadlines and project implementation timelines, the Organization did not obligate certain federal funds before the expiration of the award period. As a result, a portion of the awarded funds remained unused and was no longer available for program activities. The Organization will implement enhanced grant management procedures to ensure that federal funds are obligated and utilized within the approved period of availability. Corrective actions include: 1. Maintaining a centralized grant tracking system that identifies award periods, obligation deadlines, expenditure deadlines, and closeout requirements. 2. Requiring quarterly reviews of grant balances and project progress by program and finance personnel. 3. Establishing written procedures for monitoring unobligated balances and addressing delays in project implementation. Providing training to program managers and fiscal staff regarding federal grant requirements, including obligation and period-of-performance requirements. Requiring management review of all federal awards at least 90 days prior to expiration to identify and address any risk of unexpended or unobligated funds. Anticipated Completion Date: Immediately
Due to inadequate monitoring of grant deadlines and project implementation timelines, the Organization did not obligate certain federal funds before the expiration of the award period. As a result, a portion of the awarded funds remained unused and was no longer available for program activities. The...
Due to inadequate monitoring of grant deadlines and project implementation timelines, the Organization did not obligate certain federal funds before the expiration of the award period. As a result, a portion of the awarded funds remained unused and was no longer available for program activities. The Organization will implement enhanced grant management procedures to ensure that federal funds are obligated and utilized within the approved period of availability. Corrective actions include: 1. Maintaining a centralized grant tracking system that identifies award periods, obligation deadlines, expenditure deadlines, and closeout requirements. 2. Requiring quarterly reviews of grant balances and project progress by program and finance personnel. 3. Establishing written procedures for monitoring unobligated balances and addressing delays in project implementation. Providing training to program managers and fiscal staff regarding federal grant requirements, including obligation and period-of-performance requirements. Requiring management review of all federal awards at least 90 days prior to expiration to identify and address any risk of unexpended or unobligated funds. Anticipated Completion Date: Immediately
Views of Responsible Officials and Planned Corrective Action: Management is aware of this matter and acknowledges the need to strengthen controls over the timely reconciliation and review of aged accounts payable related to federal awards. Management has implemented, or will implement, enhanced proc...
Views of Responsible Officials and Planned Corrective Action: Management is aware of this matter and acknowledges the need to strengthen controls over the timely reconciliation and review of aged accounts payable related to federal awards. Management has implemented, or will implement, enhanced procedures designed to prevent similar issues in future reporting periods, including: (1) formalizing written policies requiring monthly accounts payable reconciliations; (2) adding a review control focused specifically on items outstanding more than 90 days, including documented investigation and resolution; and (3) training accounting personnel on these procedures and related documentation requirements. Management believes these corrective actions will improve the timely identification, review, and resolution of aged accounts payable balances in future reporting periods.
Finding Number: 2025-001 Anticipated Completion Date: 6/30/26 Responsible Contact Person: Bradley L McCain, CFO Planned Corrective Action: Management agrees with the finding. The Association's annual Federal Financial Report (FFR) was submitted 22 days after the required due date, and the semi-annua...
Finding Number: 2025-001 Anticipated Completion Date: 6/30/26 Responsible Contact Person: Bradley L McCain, CFO Planned Corrective Action: Management agrees with the finding. The Association's annual Federal Financial Report (FFR) was submitted 22 days after the required due date, and the semi-annual FFR was submitted 65 days after the required due date. The delays resulted from staffing disruptions, including employee turnover and an extended employee leave under the Family and Medical Leave Act (FMLA), which impacted the Association's ability to complete and submit required reports within the prescribed deadlines. To address this issue, the Association has strengthened its internal controls over Federal reporting by establishing a formal reporting calendar that identifies all required Federal reports, due dates, responsible individuals, and internal review deadlines. The Director of Grant Compliance is responsible for preparing and submitting Federal financial reports, while the Executive Director of Data and Grants Administration performs a final review to ensure completeness, accuracy, and timely submission. Management has also implemented cross-training and documented reporting procedures to reduce the risk of future delays caused by staff absences or turnover. Internal due dates have been established in advance of Federal deadlines to allow sufficient time for review and submission. The effectiveness of these corrective actions has already been demonstrated, as the subsequent semi-annual Federal Financial Report was submitted by the required deadline. Compliance with Federal reporting deadlines will be monitored on an ongoing basis.
Views of Responsible Officials: Management respectfully acknowledges the auditors’ observation regarding the reconciliation of the fixed asset schedule to the BarCloud inventory management system. However, management disagrees with the classification of this matter as a Significant Deficiency and wi...
Views of Responsible Officials: Management respectfully acknowledges the auditors’ observation regarding the reconciliation of the fixed asset schedule to the BarCloud inventory management system. However, management disagrees with the classification of this matter as a Significant Deficiency and wishes to provide the following context for the record. Throughout the close of fiscal year 2025, management dedicated substantial time and resources to a comprehensive review and reconciliation of the Organization’s fixed asset records. This was a deliberate, proactive initiative undertaken by the finance and accounting team to identify and resolve historical discrepancies between the accounting system and BarCloud, enhance the quality and completeness of asset-level records, and establish a stronger foundation for ongoing compliance with 2 CFR 200.313(d). The discrepancies noted by the auditors were, in large part, the very items identified and addressed through this reconciliation effort—not indicators of a systemic or ongoing control failure.As part of this undertaking, management initiated a comprehensive effort to migrate all equipment records from legacy, manual binder-based files maintained at field offices to a centralized online BarCloud system. This effort is now substantially complete. Because a number of these binders were maintained at MBN’s overseas bureaus, obtaining timely access to the physical records presented logistical challenges that required additional coordination and time to resolve. To support this work, MBN engaged local vendors in each country where equipment records were maintained to perform additional inventory review and reconciliation, as well as independent professionals to assess the fair market value of equipment identified for disposition and to perform the required data sanitization of IT equipment in accordance with 2 CFR 200. As a result of this work, the Organization now maintains materially clean and reconciled fixed asset records. The condition observed during audit testing reflects the state of records prior to the completion of management’s remediation efforts, not the current state of the Organization’s controls. Management believes that the effort expended to bring the records into alignment, and the improved control environment that now exists as a result, should be considered in the assessment of severity. Accordingly, management does not believe that the remaining matters, in the context of the substantial remediation completed, rise to the level of a Significant Deficiency. Management agrees with the auditors’ recommendation to continue formalizing procedures for ongoing reconciliation between the accounting records and BarCloud. Management is committed to establishing a common asset identification methodology, implementing a periodic reconciliation schedule, and maintaining supporting documentation to evidence the process going forward. We appreciate the auditors’ recognition of the significant undertaking completed during fiscal year 2025 and remain committed to maintaining full compliance with Federal equipment management requirements under 2 CFR 200.313(d) and 2 CFR 200.303.
Community Mental Health Services of Livingston County Single Audit Report: Corrective Action Plan Year ended September 30, 2025 Finding 2025-001- Suspension and Debarment Requirement: As required by 2 CFR 200.214, Non-Federal entities are subject to the non-procurement debarment and suspension regul...
Community Mental Health Services of Livingston County Single Audit Report: Corrective Action Plan Year ended September 30, 2025 Finding 2025-001- Suspension and Debarment Requirement: As required by 2 CFR 200.214, Non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. Condition: The vendor used for this grant was not checked for suspension and debarment prior to execution of the contract. Also, the contract did not include certification that vendor was not suspended or debarred. Questioned Cost: None. Recommendation: We recommend that the CMHSP update contract language to include certification that vendor is not suspended or debarred. Corrective Action Plan LCCMHA will address the concern raised by RPC and agrees with the above recommendation. The Accounting Manager and Associate Director of Finance and Contracts will work with the Contract Manager to modify existing contract language to include certification that vendors are not suspended or debarred. This change will be implemented for fiscal year 2027 commencing 10/01/26. Responsible Party: Jim Kubus, Accounting Manager Anticipated completion date: September 30, 2026
Finding Number: 2025-003 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. Anticipated Completion Date: On-going R...
Finding Number: 2025-003 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. Anticipated Completion Date: On-going Responsible Contact Person: Cynthia Diaz, Finance Administrator
Finding Number: 2025-002 Planned Corrective Action: We concur with the finding. We will continue to monitor our federal grant cash requirements and seek additional cash flow when governmental environment changes. The Finance Administrator will continue to monitor cash flow requirements to mitigate c...
Finding Number: 2025-002 Planned Corrective Action: We concur with the finding. We will continue to monitor our federal grant cash requirements and seek additional cash flow when governmental environment changes. The Finance Administrator will continue to monitor cash flow requirements to mitigate cash advances to ensure timely federal grant cash remittance policies are being followed. Anticipated Completion Date: On-going Responsible Contact Person: Cynthia Diaz, Finance Administrator
Finding Number: 2025-001 Planned Corrective Action: We concur with the finding. We will be meeting with the auditors and the Financial Eligibility staff to monitor the calculation of patient sliding scale levels and put in place additional monitoring checks to ensure correct application of discount ...
Finding Number: 2025-001 Planned Corrective Action: We concur with the finding. We will be meeting with the auditors and the Financial Eligibility staff to monitor the calculation of patient sliding scale levels and put in place additional monitoring checks to ensure correct application of discount to patients. The Finance Administrator will continue to monitor whether the monitoring policies are being followed. Anticipated Completion Date: On-going Responsible Contact Person: Cynthia Diaz, Finance Administrator
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