CMHPSM Audit Waiver Request Form

CMHPSM Audit Waiver Request Form
Contractor Name:
Request Date

MonthDayYear
Requestor Full Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Fiscal year is based on your organization's stated fiscal year. Audits are due 90 days after your organizations fiscal year closes.
- January 1 - December 31 Fiscal Year Audits are due on March 31.
- July 1 - June 30 Fiscal Year Audits are due on September 30.
- October 1 - September 30 Fiscal Year Audits are due on December 31.
Audit waivers must be submitted within quarter three of your organizations fiscal year. If an audit waiver is approved by the CMHPSM, the financial compilation and any other financial information must be submitted within 90 days of the close of your organization's fiscal year.

Please see the CMHPSM Financial Audits of Contractors Policy for more details. www.cmhpsm.org/policies
Fiscal Year
Select:*

CONTRACTOR provides services to six or fewer PIHP consumers annually.CONTRACTOR receives $50,000 or less annually as reimbursement for PIHP consumer services.CONTRACTOR employs less than 15 full time equivalent employees.CONTRACTOR is requesting an audit exemption determination from the CMHPSM CFO.
The CMHPSM does not guarantee a waiver will be granted, even if one or more of the following conditions were met. Waivers are at the sole discretion of the CMHPSM, and must be requested on an annual basis. An approved waiver from a previous fiscal year does not guarantee approval for a subsequent fiscal year.
Contractor Comments:
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CMHPSM Password:
Reviewed by:

First NameLast Name
Date:

MonthDayYear
Request for Audit Waiver:

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CMHPSM Comments:
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