<p> Township/Road District Motor Fuel Tax Internal Control Survey</p><p>MFT Audit Number: Purpose: To assist in determining the reliability of program monitoring, financial reporting, and compliance with laws, regulations and policies in regards to the Local Public Agency’s administration and use of Motor Fuel Tax funds.</p><p>County: Completed By: Date Completed:</p><p>Type of Government: Township Road District County Unit Road District</p><p>Entity Name:</p><p>Self-Assessment of Internal Controls</p><p>General: The following questions relate to the N/A No Yes Comments internal accounting 1. Does the County have an Agreement 2.of UnderstandingDoes the Township/Road District receive a 3. Are MFT funds used for payment of principal and/or </p><p>Receiving N/A No Yes Comments 4. Is there a process in place in which the 5. Does the Township/Road 6.DistrictAre havematerials a 7.inspectedAre quantities and and descriptions of materials and </p><p>Printed 4/5/2018 Page 1 of 4 BIC MFT 3005TWN/RD (Rev. 05/11/16) Formerly OCQR MFT 3005TWN/RD 8. Is a logbook or permanent copy of the receiving ticket Payroll N/A No Yes Comments 9. Are MFT funds being used for payroll 10.expenses?Are claims If no, for hourly wage 11.employeesAre MFT for payroll MFT expenses disbursed by pay period? If no, </p><p>Equipment Ownership N/A No Yes Comments Expense 12. Are MFT funds being used for equipment usage expenses? If 13. Areno, pleaseclaims forgo to #15. equipment usage for MFT work documented by date, 14. Are equipment expenses disbursed by pay period? If no, </p><p>Materials & Inventory N/A No Yes Comments 15. Are there detailed records showing the asset values of 16. Are detailed inventory 17.records Are detailedperiodically inventory 18.recordsAre periodicallydifferences between book 19. Arerecords there and procedures physical governing the use of </p><p>Retention of Records N/A No Yes Comments 20. Are employees responsible for MFT program and financial 21. Have policies and procedures been developed and 22. Are MFT documents retained in Printed 4/5/2018 Page 2 of 4 BIC MFT 3005TWN/RD (Rev. 05/11/16) Formerly OCQR MFT 3005TWN/RD 23. Do employees ensure all work-related electronic data is </p><p>Printed 4/5/2018 Page 3 of 4 BIC MFT 3005TWN/RD (Rev. 05/11/16) Formerly OCQR MFT 3005TWN/RD Additional Response Information (ARI) Section 2. List interest details:</p><p>3. List bond issue details:</p><p>4. Explain the process:</p><p>11. Payroll disbursement details: 12. List account(s)/fund(s):</p><p>14. List details regarding equipment expense disbursements:</p><p>Printed 4/5/2018 Page 4 of 4 BIC MFT 3005TWN/RD (Rev. 05/11/16) Formerly OCQR MFT 3005TWN/RD</p>