
ENTITY ANNUAL REPORT STATE BOARD OF ACCOUNTS
302 WEST WASHINGTON STREET
Form E-1 (2-07) ROOM E418
Prescribed by State Board of Accounts INDIANAPOLIS, INDIANA 46204-2765
Note: The Entity Annual Report (Form E-1) is used to determine Telephone: (317) 232-2513
the audit requirements placed on your entity by IC 5-11-1-9 Fax: (317) 232-4711
File report within thirty (30) days of the close of your entity's Web Site: www.in.gov/sboa
fiscal year end. Instructions for completing Form E-1 are
included in the attached memorandum Page 1 of 2
OFFICE USE ONLY
S
BA NO: _____________
Entity's Fiscal Year End
______ ______ ______
Month Day Year
Audit Determination:
____________ Complete
____________ Waived
Legal Name: Federal ID No:
D/B/A: Business Phone No: ( )
Street Address:
City: County: State: Zip Code:
Name of Operating Officer: Title:
TYPE OF ORGANIZATION
LEGAL STATUS
_________ Corporation _________ Association
_________ Partnership _________ Individual
_________ For Profit
_________ Not-For-Profit
FINANCIAL INFORMATION
1. Government funds received during year (Detailed on Page 2) $__________________
2. Government funds disbursed during year $__________________
3. Entity's total disbursements (or expenditures) for the year $__________________
4. Percent of government funds disbursed to entity's total
disbursements (or expenditures) (Line 2 / 3) _________________ %
This information is reported on the ___________ cash basis ___________ accrual basis.
Is this the initial Form E-1 filing for the entity? Yes __________ No __________
CERTIFICATION: This is to certify that the data contained in this report is accurate to the best of my
knowledge and belief.
Signature:________________________________ Title __________________________
Printed Name: ____________________________ Date Signed: ___________________