FINANCIAL DISCLOSURE

COMMUNICATION QUESTIONNAIRE
Name:
Period:
Area of Responsibility:
The corporate financial reporting department and the presentation and disclosure committee request your
assistance in helping to ensure we are aware of all material transactions, contracts, events or other items
which might require disclosure in our SEC filings. This effort is also is in support of the certification and
disclosure requirements mandated under the Sarbanes-Oxley Act (the Act). Therefore, as with the
control questionnaire, prompt completion of this form is critical due to the short timeframe under which we
are working to comply with this Act. The questions below are designed to facilitate communication of
items you are aware of that should be considered for disclosure. This form does not include all possible
disclosure items, but it does include the primary types of items that should be considered. If you are
aware of anything you feel should be considered in the process of drafting the financial statements and
Form 10Q that is not covered by this form, please also communicate this information through this form.
For any areas where you answer "Yes," please provide a thorough explanation and, if necessary, add a
page to this file or refer to and attach or forward any supporting documentation that might be necessary
for the financial reporting department to consider.
In considering whether an item is material enough for inclusion on this form, unless otherwise noted in the
item, limit affirmative responses to individual events or transactions of $X or more, or an aggregate of
non-recurring transactions of $X or more. Responses should be limited to transactions or events during
the reporting period shown at the top of this form. Note that this process is raising issues not currently
disclosed. If you know it is currently in the SEC filings, there is no need to include it here.
Please note that this tool is designed to foster a more formalized means of communicating significant
transactions or other matters that should be considered for disclosure in the company's financial
statements. To maximize the benefit of this tool, please carefully consider all activity during the period and
ensure that all matters meeting the criteria within this form are communicated. Please send the completed
form and any necessary supporting information you feel corporate financial reporting and the presentation
and disclosure committee need to understand and evaluate respective matters to (Email) by end of
business on (Date). If supporting information is not in electronic form, fax it to headquarters at (Fax
Number).

Source: www.knowledgeleader.com

Quarterly Disclosures

YES or
NO?

If YES, please
explain.

Are you aware of any of the following?

Accounting Policies and Procedures
Any changes in accounting policies?
Any changes in the application of accounting policies?
Any changes in methods used to prepare significant
management estimates?
Any correction of errors?
Any prior period adjustments or reclassifications?
New Contracts/Agreements
Any new contracts during the quarter related to any of the
following (if so, attach a copy unless already communicated
through appropriate channels):

Maintenance?

Leases (other than fleet)?

Property, plant and equipment?

Debt agreements?

Bank accounts?

Purchase commitments or contractual minimums?

Acquisition or sale of assets?

Joint venture or special purpose entities agreements?

Key employee contracts?

Research & development arrangements?

Other Disclosure Items

Any one-time, non-recurring or unusual transactions?

Any adjustments not of a normal, recurring nature?
Any significant adjustments to any prepaid account or
accrued liabilities?

Source: www.knowledgeleader.com

Quarterly Disclosures

YES or
NO?

If YES, please
explain.

Any related-party transactions and/or outstanding balances?

Any significant loans to officers, directors or other employees
of the company?
Any competition threats to your business?
Any new products or services?
Any contact from a government or tax authority for any
reason?
Any unpaid taxes or tax assessments not recorded in the
financial statements?
Any threatened, pending or actual litigation or unasserted
claims?
Any settlement of litigation?
Any significant changes to the business plan and/or
forecast?
Any bad debt losses or charges to the reserve for bad debts
(other than typical bad debt calculation in accordance with
company policy)?
Any significant uncollectible receivables that should be
reserved in addition to the general bad debt allowance?
Any advertising costs incurred that are captured in an
account outside of the advertising expense account?
Any debt covenant violations?
Any restrictions or liens on any assets, including political,
economic or currency restrictions?
Any impaired or unused assets on the books?
Any contingent liabilities?

Source: www.knowledgeleader.com

Quarterly Disclosures

YES or
NO?

If YES, please
explain.

Any off-balance sheet assets/liabilities?

Any plans to abandon or sell assets, outside of the ordinary
course of business, with or without recourse?
Any changes in the federal, state or local laws that will affect
the business?
Any unrecorded assets or liabilities?
Any plans to close a site?
Any concentrations of customers, services, available
resources or geographic concentrations that make the
company vulnerable to risk or loss?
Any changes in the classification of assets and liabilities that
could affect comparability to prior years?
Any changes in control of an unconsolidated subsidiary, a
majority-owned subsidiary or equity method investee?
Any guarantees of a third-party's debt?
Any barter transactions?
Any illegal acts committed by the company or by a member
of management in representing the company? (Report all
instances, even if under the materiality level established
above.)
Any customer-refundable fee arrangements?
Any amounts not recorded in the appropriate legal entity?
Any amounts not recorded in the appropriate business
segment?
Any amounts not recorded in accordance with U.S. generally
accepted accounting principles (GAAP)?

Source: www.knowledgeleader.com

Quarterly Disclosures

YES or
NO?

If YES, please
explain.

Any amounts netted against revenue? (Exclude normal items

such as discounts.)
Any loss of a significant customer? (Please list name[s] and
estimated lost revenue.)
Any significant new customer sales contracts during the
quarter? (Please list name[s] and estimated revenue.)
Any other information not already mentioned that may be
subject to disclosure and which should be communicated to
corporate financial management for their consideration?
Internal Controls and Fraud
Are you aware of any significant deficiencies in internal
controls or information systems that have not already been
communicated which may subject the company to an
increased risk of material loss or may prevent the accurate
reporting of financial data?
Are you aware of any fraud or other improper activity
committed by any member of management with significant
responsibility over the internal controls or financial reporting
of the company? (Report all instances, even if under the
materiality level established above.)
Are you aware of any instances in which a member of
management has attempted to influence accounting entries
or the establishment of estimates in an improper way?
(Report all instances, even if under the materiality level
established above.)
Are you aware of any breakdowns, problems or inadequacies
in the information systems that could lead to a material error
in summarizing and reporting financial data?

Source: www.knowledgeleader.com