Fill and Sign the Analysis of Improper Payment Form

ANALYSIS OF IMPROPER PAYMENT/ INTERNAL CONTROL STATEMENT CO-790S STATE OF CONNECTICUT OFFICE OF THE STATE COMPTROLLER ACCOUNTS PAYABLE DIVISION 55 ELM STREET HARTFORD, CT 06106-1775 1. BUSINESS UNIT 2. AGENCY NAME 3. STREET ADDRESS 4. CITY, STATE, ZIP5. VENDOR ID 6. FEIN/SSN 7. PAYEE NAME 8. PMT REFERENCE NO. 9. PAYMENT AMOUNT 10. PAYMENT DATE11A. VOUCHER ID 12A. VOUCHER AMOUNT 11B. VOUCHER ID 12B. VOUCHER AMOUNT 11C. VOUCHER ID 12C. VOUCHER AMOUNT 11D. VOUCHER ID 12D. VOUCHER AMOUNT 13A. VOUCHER ID 14A. VOUCHER AMOUNT 13B. VOUCHER ID 14B. VOUCHER AMOUNT 13C. VOUCHER ID 14C. VOUCHER AMOUNT 15. PMT REFERENCE NO. 16. PAYMENT AMOUNTIF THIS FORM IS BEING COMPLETED BECAUSE OF A DUPLICATE PAYMENT, PROVIDE \ THE VOUCHER ID(S) AND PAYMENT REFERENCE NUMBER OF THE DUPLICATED PAYME\ NT 17. HAVE YOU ESTABLISHED PROCEDURES TO ELIMINATE INCORRECT PAYMENTS, OVE\ RPAYMENTS, DUPLICATE PAYMENTS? YESNO18. WILL YOU REQUIRE ASSISTANCE IN ESTABLISHING PROCEDURES FOR EFFECTIVE\ INTERNAL CONTROL FROM THE OSC - ADMINISTRATIVE SERVICES UNIT? YESNOSECTION A: PLEASE EXPLAIN THE PROCEDURES THAT LED TO THE ISSUANCE OF THE INCORRECT \ PAYMENT. PLEASE PROVIDE AN ANALYSIS, RATHER THAN A NARRATIVE. PURPOSE OF THIS FORM: This form must be used to explain overpayments, duplicate payments, inco\ rrect payment amounts, incorrect vendor payments or any other type of im\ proper payment that has transpired. Agency internal controls must be thoroughly\ reviewed and revised if necessary to prevent improper payments from rec\ urring. GENERAL INSTRUCTIONS 1. Complete Sections A, B, and C, above, in detail. 2. The completed form must be signed by the Agency Head or Deputy only. The form will be rejected if this instruction is not followed. 3. Attach the properly signed, completed original to the CO-790 and \ submit the documents to the Accounts Payable Division, Office of the Sta\ te Comptroller. 4. If a CO-790 is not needed, send the completed form to the Account\ s Payable Division, Office of the State Comptroller, ATTN: Special Proce\ ssing Section.NAME OF CONTACT PERSON TITLE E-MAIL ADDRESSTELEPHONE NUMBERAUTHORIZED SIGNATURE NAME OF AUTHORIZED SIGNATORTITLEDATESECTION B: DESCRIBE IN DETAIL THE INTERNAL ACCOUNTING CONTROLS IN PLACE, PRIOR TO T\ HIS INCIDENT, FOR THIS TYPE OF TRANSACTIONS. SECTION C: DESCRIBE IN DETAIL ANY REVISION TO EXISTING CONTROLS AND/OR IMPLEMENTATI\ ON OF NEW CONTROLS TO PRECLUDE A RECURRENCE OF SUCH INCIDENTS.NOTE: IF YOU ANSWERED "YES", A COPY OF THIS FORM WILL BE FORWARDED TO TH\ E ADMINISTRATIVE SERVICES UNIT, AND A REPRESENTATIVE WILL GET IN TOUCH WITH THE CONTACT PERSON LISTED BELOW. REV 06/19