Report of Financial Loss of Accountability or Funds

“The mission is to combat the needless waste of human and material resources…We hold those entrusted with leadership to be accountable and responsible for the resources entrusted to them. They must demonstrate fiduciary stewardship. We support leadership that has the courage to put in place a comprehensive strategy to be responsible and accountable for the resources entrusted to them. We believe that good values, strong character, and responsibility are inconsistent with fraud, waste of resources and mismanagement.” —Imam W. Deen Mohammed (RA)

Attention Accountable Financial Custodian: As-Salaam-Alaikum.

Use this form to report to the Board of Directors an incidence of loss of financial accountability of funds under your custody.

All loss of accountability and/or funds are to be reported to the Board of Directors immediately upon knowledge of such incident, but not later than 24 hours of your knowledge of an incident. Report the loss also to the Financial Director and Custodian of the Check Register unless both are members of the Board of Directors.

Please complete all required sections and provide by email to info@cwsc.us any required documentation.

If you have questions completing this form, email info@cwsc.us or call (910) 317-0297.

First and Last Name(required)

Your Email(required)

Phone(required)

Enter Total $ Dollar Amount of Loss (Do not subtract any bank reversals of the loss)(required)

Date of Loss of Funds (enter initial date if several dates apply)(required)

Date you became aware of funds loss(required)

Enter other type of loss if applicable

Give all facts and describe in detail to the best of your knowledge how loss occurred(required)

Total Expense Amount ($)(required)

(required)

If yes, enter Police Report No. and name of officer along with name, address, and telephone number of law enforcement authority or department and provide a copy of report via email to info@cwsc.us for CWSC and Board Records. All fraud incidents must be reported to the police by the accountable custodian.(required)

Enter any additional or explanatory comments here

Date Today(required)

Thank you for completing this form. For any reports made to bank or law enforcement agencies, please provide any updates to the Board. The Board may also request additional information to maintain its accountability. To submit ideas on how to improve this form or procedures, send mail to info@cwsc.us.

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Report of Financial Loss of Accountability or Funds

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Report of Financial Loss of Accountability or Funds

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