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| Representation Regarding Independence and Other Matters |
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| The purpose of this form is to affirm your compliance with the Firm’s policies regarding independence. All personnel are required to complete this form upon employment with the Firm and on an annual basis. A listing of our clients, as to which independence rules apply, is available for your review. |
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| Our auditor’s reports and accountant’s letters from unaudited statements normally cover two years. The questions listed below relate to activities and relationships existing during the past two calendar years and through the present date. |
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| If your answer to any of the questions is yes, please provide all pertinent facts and details at the bottom of this document. Please fill in your name, date and return the form via e-mail. |
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| The term “YOU”, as used in the questions, refers to (1) yourself; (2) your spouse, children, brothers and sisters, parents, parents-in-law, grandparents and their respective spouses; and (3) any third person or entity in which you have a financial interest, e.g., a trust or estate, mutual fund, investment club, real estate, partnership, etc. of which you have knowledge. |
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| Please answer “no” or “yes” to the following questions: |
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ANSWER |
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| 1. Do you have any direct or indirect financial interest in a client? Financial interest includes ownership in, commitment to acquire loans to, and loans from any client (including home mortgages or other secured or non-secured loans) except as grandfathered or permitted. |
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| 2. Are you related to an officer, director, stockholder or employee of any client for which we provide attest or compilation services? If so, please indicate (a) the relationship, (b) whether you live in the same household and are supported by the relative, and (c) your position in the office. |
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| 3. Do you have any type of direct or material indirect financial interest in, claim against, or official position with any client? |
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| 4. Do you have any loans from financial institution clients? If so, indicate the outstanding amount and terms of the loan, whether it was made under normal lending conditions, the nature and value of the collateral and how that value was determined, and the date the loan was obtained or renegotiated. (Refer to AICPA Professional Standards, Interpretation 101-5). |
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| 5. Since your last independence questionnaire, have you engaged in any financial transactions with any client at terms more favorable than the client ordinarily allows to its customers? (This includes items to or from the client, such as: rentals, services rendered, indebtedness, gifts, repetitive entertainment. Exclude items aggregating less than $100 to or from any client). |
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| 6. Do you serve as director, officer, administrator, executor, trustee or personal representative for any entity (1) for which [Firm Name] provides attest or compilation services or (2) which has a financial interest in a client for which [Firm Name] provides attest or compilation services? |
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| 7. Do you have any financial interest in any entity or venture, which either (1) has an investment or financial interest in a client or (2) in which any client or any of its officers, directors or principal stockholders has a financial interest or investment? (Disregard publicly held companies, which are not clients of ours.) |
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| 8. Have you had any joint closely A45held business investments (including real estate, vacation home, etc.) with a client or parties associated with a client? |
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| 9. Have you been connected with a client of our Firm as a promoter, underwriter, voting trustee, director, officer, or in any capacity equivalent to that of a member of management or as an employee or as a trustee for any pension or profit-sharing plan? |
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| 10. Has your spouse or minor child been employed by a client? |
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| 11.Have you developed any bias, including those induced by political or social convictions that result from employment in or loyalty to, a particular group, organization, or level of government, or developed any preconceived ideas toward individuals, groups, organizations, or objectives of a particular program that could bias my work? |
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| Other Matters |
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| 12. Since your last independence questionnaire, have you: |
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| a. Made personal use in any way, including unauthorized disclosure to anyone outside the firm, of any information relating to or concerning any client? |
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| b. Received any compensation in the form of cash or other things of material value from any client which was not turned over to the Firm? |
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| 13. Do you: |
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| a. Receive any compensation for bookkeeping work, accounting, auditing, tax or any other work pertaining to the accounting profession, which is not turned over to the Firm? |
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| b. Serve as a director, officer, administrator, executor, trustee, or personal representative for any corporation, organization, estate or trust which is (1) not a client or (2) a client for whom the Firm provides services other than attest or compilation and is therefore not reported under question 6 above? If so, please indicate whether the entity is publicly held, closely held, or not-for-profit. |
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| c. Serve as promoter, underwriter, employee, officer or fiduciary for any non-client corporation or organization? |
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| 14. Do you have any financial interest, direct or indirect, in any non-client where the holding of such interest requires more time and/or activity than is ordinarily involved for any passive investor? |
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| If any situations involving independence issues evolve as relates to current clients or clients obtained subsequent to the date this document is signed, I will notify the Firm’s President. |
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| IF ANY QUESTIONS ARE ANSWERED “YES”, PLEASE EXPLAIN YOUR ANSWERS BELOW: |
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| COMMENTS BY REVIEWER |
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| Describe conclusions as to the effect on the Firm’s independence of items listed above and any actions taken to ensure independence. In the case of a client relationship, indicate the service(s) we perform for that client and the type of report we issue, if any. State whether a lack of independence is indicated in the report. |
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| Independence Matters: |
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| Other Matters: |
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