1

Date

[## MON YEAR]

2

Security Cooperation Customer Code/IA/ Case Designator(s)

[XX-X-XXX]

3

Issue of Concern:
Dates
Systems
Dollar Amounts

[detailed description of issue of concern with supporting documentation (e.g., why problem disbursement cannot be reconciled, dates and system(s) where records are no longer available, current value of problem disbursements, and other applicable information)]

4

Reconciliation Attempt

[description of attempt to reconcile the Problem Disbursements shown in among relevant systems (e.g. General Ledger and Accounting, etc.)]

5

Proposed Solution

[(e.g., proposed next steps, estimated reconciliation date, amounts needed to reconcile, etc.)]

6

Signed Attestation

[Attestation does the following:

1. Attest that information in MFR is accurate;
2. Attest that actions with IA’s responsible records officer and/or designees were taken to request needed documentation from key functional areas including:
   1. IT management,
   2. Data management,
   3. Cybersecurity,
   4. Information security,
   5. Acquisitions,
   6. Budget formulation and execution
   7. Contractor-maintained contract records (FAR, Part 4, Subpart 4.7.)]

See DoW Records Management Program, DoW Instruction 5015.02

Letter is signed by Military Department Assistant Secretary for Financial Management and Comptroller (FM&C), Defense Agency Comptroller, or other IA delegated funds control official (General Schedule-15 level/equivalent or higher)]

7

IA point of contact (POC)

[Name, email, phone number]