New Jersey Department of Health

Financial Services

Grants Management and Review

P.O. Box 360

Trenton, NJ 08625-0360	NOTIFICATION OF

LICENSED PUBLIC ACCOUNTANT

– SEE INSTRUCTIONS –
PROVIDER AGENCY NAME

AGENCY FISCAL YEAR

ADDRESS

ZIP CODE

NAME OF CONTACT INDIVIDUAL

TITLE

TELEPHONE NUMBER

CHARITIES REGISTRATION NUMBER

FEDERAL ID NUMBER

FISCAL YEAR OF LAST TAX RETURN FILED

/ IRS FORM NO.
I. FUNDING FROM STATE OF NEW JERSEY

(Use Additional Sheet If Necessary)
Department	Contract or Grant No.	Catalog of Federal Domestic Assistance No./

Funding Authorization No.	Period of Award	Amount of

Contract or Grant
II. DIRECT FUNDING FROM THE FEDERAL GOVERNMENT

(Use Additional Sheet If Necessary)
Federal Agency	Contract or Grant No.	Catalog of Federal

Domestic Assistance No.	Period of Award	Amount of Award
III. LICENSED PUBLIC ACCOUNTANT
CURRENTLY LICENSED TO PRACTICE IN NEW JERSEY?

YES	NO	IF YES, N. J. LICENSE NO.:	EXPIRATION DATE:
FIRM NAME

TELEPHONE NUMBER

ADDRESS

ZIP CODE

NAME OF CONTACT INDIVIDUAL

TITLE

ANTICIPATED AUDIT COMPLETION DATE

CERTIFICATION – SIGNATURE

TITLE

DATE OF LATEST QUALITY CONTROL REVIEW

IV. FOR DEPARTMENT USE ONLY
DATE RECEIVED

DATE VERIFIED

AUDIT CONTROL NUMBER

REMARKS
FS-27

AUG 12	DISTRIBUTION: Original - Forward to Above Address

FS-27, Notification of Licensed Public Accountant

FS-27, Notification of Licensed Public Accountant, financial services, grants management

EWhite

2003-01-30

NJDOH