Mark up file National Independent

OMB APPROVEDPENDING OMB APPROVAL

No. 3206-0131

Combined Federal Campaign

2006 2007 Application Instructions for

National/International Unaffiliated Independent Organizations And Federation Members of Federations

Background

Enclosed is the model application for useparticipation by national/international unaffiliated independent organizations to apply to participate in the Combined Federal Campaign (CFC) and for use by federation members to submit to the federations to which they belong. The following instructions and form are intended to assist charitable organizations in applying for participation in the CFC. All aspects of the CFC, including eligibility for partici­pation, are strictly governed by Federal regulation. Copies of current CFC regulations are available in PDF and Word formats on our website at www.opm.gov/cfc. Additional copies of the application can also be downloaded from the website. The Office of Personnel Management (OPM) encourages organizations to apply early.

The application deadline for unaffiliated independent organizations and federations seeking national eligibil­ity is 5:00 p.m. Eastern Standard Time, TuesdayWednesday, January 31, 20062007, but applications may be sent to OPM’s Office of CFC Operations as early as ThursdayFriday, December 1, 20052006. A timely application must be received by the deadline at the following address:

Office of Personnel Management

Office of CFC Operations

Room 5450

1900 E Street, NW

Washington, DC 20415

Federation members must submit their applications to the federation. Copies of these applications should not be sent to OPM.

All required documents and attachments must be complete and submitted before the application deadline. Applicants whose applications do not contain required documents or who submit incomplete or out-of-date documents will not be

permitted to correct their applications during the

appeals process. Organizations that apply for national/international eligibility and are found in-eligible have only one opportunity to appeal to the Director of OPM. The Director's decision is final for administrative purposes. Therefore, appellants should ensure that their appeals are complete and

responsive to the actual reasons for the original denial decision.

OPM suggests that national/international organizations use the model application provided when applying to the CFC. Although not required, submission of this form will expedite the processing of individual applications. OPM will not accept applications with modifications to any of the certification statements.

In order to determine whether an organization may participate in the campaign, OPM may request evidence of corrective action regarding any prior violation of regulation or directive, sanction, or penalty, as appropriate. OPM will decide whether the organization has demonstrated, to OPM’s satisfaction, that the organization has taken appropriate corrective action. Failure to demonstrate satisfactory corrective action or to respond to OPM’s request for information within 10 business days of the date of the request may result in a determination that the organization will not be included in the Charity List.

FAXES OR ELECTRONIC SUBMISSIONS OF APPLICATIONS ARE NOT ACCEPTED

DEFINITIONS

Organization Legal name of the applicant org-anization. If the name of the applicant organization differs from the name that appears on the IRS determination letter, the IRS Form 990, or audited financial statements, or annual report, documentation from the IRS or state government authorizing use of thisa name change must accompany the application. The Federal Tax ID NumberEIN must be included.

Employer Identification Number (EIN) The nine-digit EIN that appears on the IRS determination letter and the IRS Form 990 submitted with the application.

4 Digit CFC No.Number The number assigned to the organization in the previous year's campaign, if applicable. Organizations that did not participate in the 2006 CFC should leave this field blank. NOTE: All participating charities will be assigned a new five-digit code for the 2007 campaign.

Mailing Address A physical mailing address must be provided – Post Office Box addresses will not be accepted.

Telephone Organization’s telephone number.

C

Contact Person The individual to whom OPM will direct communications regarding the application. This may be any individual in the organization.

Contact Address Contact Person’s physical

mailing address if different than the organization's address. Post Office Boxes may not be used. Participation decision letters will be sent to this address.

Contact Telephone Contact person’s telephone number, if different than the organization’s tele-phone number.

Fax Contact person’s fax number.

Contact E-Mail The contact person’s electronic mail address.

Website Address List the complete Internet address of the applicant organization (no e-mail addresses). This information is required, if the organization has an Internet address.

Certifying Official The certifying official is the individual who has the authority to affirm that all state­ments in the application are accurate.

INSTRUCTIONS

For details regarding CFC eligibility requirements for national/international independent organ-izations and federations members, refer to CFC Guidance Memorandum Memoranda 2004-10 on the CFC website at www.opm.gov/cfc.

Applicants must check the box next to each certification statement to demonstrate agreement to comply with the statement and to certify that it meets the requirement. Failure to provide a check mark for each of the statements will be considered as a refusal to certify and will result in the denial of the application.

Item 1

Check the one appropriate box. Include Attach-ment A. CFC eligibility requirements mandate that a Nnational/Iinternational organization demon-strate that it provided services in at least 15 different states or one foreign country over the three year period immediately preceding the start of the campaign’s application year. A schedule listing a detailed description of the services in each state (minimum 15) or foreign country (minimum 1), including the year of service, must be included with the application. The schedule must make a clear showing of national and/or international presence. Simply providing a list of states or countries where an organization conducts or provides real services, benefits or program activities is not sufficient. An organization must provide a detailed description of the ser­vices and activities it provided, and the year in which those services were provided, in each state or foreign country. The schedule must also include human health and welfare services that were provided in calendar year 2006 (see Certification #3).

This requirement cannot be met on the sole basis of services provided through an “800” telephone number or by disseminating information and publications via the U.S. Postal Service, the Internet, or a combination thereof. Broad descriptions of services and identical repetitive narratives will not be accepted at the sole discretion of OPM if they do not allow OPM to adequately determine that real services were provided or to accurately determine the individuals or entities who benefited. Providing listings of affiliated groups does not sufficiently demonstrate provision of real services by the applicant. Location of residence of organization members or location of residence of visitors to a facility does not substantiate provision of services in the location of residence. However, organizations that issue student scholarships or fellowships must indicate the state in which the recipient resides, not the state of the school or place of fellowship. Mere dissemination of information does not demonstrate provision of real services.

While it is not expected that an organization maintain an office in each state or foreign country, a clear showing must be made of the actual services, benefits, assistance or activities provided in each state or foreign country. De minimis services, benefits, assistance, or other program activities in any state or foreign country will not be accepted as a basis for qualification as a national or international organization.

Simply providing a list of states or countries where an organization conducts or provides real services, benefits or program activities is not sufficient. An organization must provide a detailed description of the ser­vices and activities it provided, and the year in which those services were provided, in each state or foreign country. For further information, please see CFC Memorandum 2004-10.

Item 2

Include as Attachment B a copy of the organization’s most recent IRS determination letter. If the name of the applicant organization differs on the IRS determination letter, the IRS Form 990, or audited financial statements, or annual report, documentation from the IRS or state government authorizing this name change must accompany the application.

Interim 501(c)(3) letters with expira­tion dates before December 31 of the year preceding the campaign year for which the organization is applying will be accepted only with proof of application to the IRS for permanent 501(c)(3) status.

National/international organizations that are part of an IRS group exemption must provide a copy of the IRS letter granting the group exemption, as well as the list of subordinates that are covered by the group exemption. The EIN on the applicant’s Form 990 must match the EIN on the IRS determination letter.

Bona-fide chapters or affiliates of a national organization that do not have an IRS deter-mination letter for the local organization must provide a certification signed by either the Chief Executive Officer (CEO) or CEO equivalent of the national organization stating that the local charitable organization operates as a bona-fide chapter or affiliate in good standing of the national organization and it is covered by the national organization’s 501(c)(3) tax-exemption. A copy of the national organization’s 501(c)(3) letter must accompany the CEO’s certification.

Private foundations and units of government are not eligible to participate in the CFC.

Each applicant’s 501(c)(3) status will be verified with the IRS. Applicants whose current 501(c)(3) status cannot be confirmed by the IRS will be denied participation. OPM encourages organizations to request current letters from the IRS confirming the group’s tax-exempt status. This request can be made by contacting the IRS at (877) 829-5500.

Item 3

Self-explanatory. Human health and welfare services provided in calendar year 2006 must be reflected in Attachment A.

Item 4

Self-explanatory

Item 54

The certifying official must verify certify that the organization accounts for its funds on an accrual basis in accordance with Generally Accepted Accounting Principles and has an audit of its fiscal operations completed by an independent certified public accountant in accordance with Generally Accepted Auditing Standards (GAAS). uses the accrual method of accounting. No other basis of accounting is acceptable under Generally Accepted Accounting Principles (GAAP). The cash basis, modified cash basis, and modified accrual basis, and any other methods basis are not acceptable methods of accounting under GAAP. Use of these other accounting methods will result in a denial.

Include as Attachment C a copy of the organi-zation's audited annual financial statements. The audited financial statements and IRS Form 990 must be prepared using the accrual method of accounting and cover the same fiscal period that ended not more than 18 months prior to January 2007 (i.e. ending on or after June 30, 2005).

Item 65

Check the appropriate box. Include as Attachment D a copy of the complete, signed IRS Form 990 for a period ended not more than 18 months prior to January 2007. The IRS Form 990 must include a signature in the block marked “Signature of officer”; the preparer’s signature alone is not sufficient.

A complete IRS Form 990 is required, including all supplemental state­ments and Schedule A, if applicable, to be eligible for the CFC. If the IRS does not require the organization to file the Form 990 it must complete and submit a pro forma IRS Form 990 page 1 and Part V only. IRS Forms 990EZ, 990PF, and comparable forms will not be accepted. However, smaller organizations that file Form 990EZ may submit it with page 1 and Part V of the Form 990 attached in lieu of a complete IRS Form 990.

The audited financial statements and IRS Form 990 must be prepared using the accrual method of accounting and cover the same fiscal period ended not more than 18 months prior to January 2007 (i.e. ending on or after June 30, 2005).Include as Attachment C a copy of the organization's annual audited financial statements. Combined and consolidated financial statements are not accepted unless the applicant’s financial information is reflected in a separate audited combining or consolidating schedule. The financial statements must cover the fiscal period ending not more than 18 months prior to the January of the campaign year to which the organization is applying. The IRS Form 990 and audited financial statements must cover the same fiscal period and be prepared using the accrual basis of accounting. If reve­nue and expenses on the two documents differ, these amounts must be reconciled either on the IRS Form 990, Parts IV-A and IV-B, or by the certified public accountant who completed the audit in an accompanying signed statement. For further information, please see CFC Memorandum 2004-10.

Item 7

Include as Attachment D a copy of the most recently completed, signed IRS Form 990, including a signature on page 6 in the block marked “Signature of officer.” The preparer’s signature alone is not sufficient. A complete form, including all supplemental state­ments and schedules, if applicable, is required to be eligible for the CFC even if the Internal Revenue Service does not require your organization to file the Form 990. IRS Forms 990EZ, 990PF, and comparable forms will not be accepted. However, smaller organizations that file Form 990EZ may submit it with pages 1 & 2 of the Form 990 attached. The IRS Form 990 and audited financial statements must cover the same fiscal period and be prepared using the accrual basis of accounting. If revenue and expenses on the two documents differ, these amounts must be recon­ciled either on the IRS Form 990, Parts IV-A and IV-B or by the accounting firm that completed the audit in an accompanying signed statement.

IMPORTANT NOTES:

OPM prefers that applicants reconcile their revenues and expenses using page 4 of the IRS Form 990. The IRS Form 990 MUST be signed on page 6 in the block marked “Signature of officer.” For additional guidance about re-conciling audited financial statements and IRS Forms 990, please refer to CFC Memorandum 2004-10.

Item 86

Calculate and enter the organization’s Check the one appropriate box. The annual per­centage for administrative and fundraising expenses. The percentage is computed only from the IRS Form 990 by adding the amount spent onreported as "management and general" (line 14) to "fundraising" (line 15) and then dividing the resulting total by "total revenue" (line 12). No other method may be used to calculate this percentage. If the annual per-centage for adminis­trative and fundraising expenses is greater than 25.04%, include as Attachment E an explanation of the organization's management, general and fund-raising expenses and a formal plan to reduce expenses to 25% or less. Failure to separately submit an acceptable justification and plan for reducing expenses may result in a denial. (All percentages must be to the tenth of a percent. For example, 10.0% or 15.5%.)

Item 7

Self-explanatory

Item 98

Include as Attachment F a complete listing of the organization’s board of directors and the beginning and end dates of each individual’s term of office (e.g. John Smith, 2004-2007). Attachment F must also list the board’s meeting dates and locations for the previous year. Self-explanatory

Item 9

Self-explanatory

Item 10

Self-explanatory

Item 11

Self-explanatory

Item 12

Self-explanatory

Item 13

Fill in name of state or entity.

Item 14

Organizations receiving over 80% of revenue from government sources are not eligible to par­ticipate in the CFC. Certify only if revenue from govern-ment sources, line 1c on IRS Form 990, is 80% or less of line 12 on the IRS Form 990. (Divide line 1c by line 12.) Medicare and Medicaid funds are not included as revenue from a government source.

Item 15

Include as Attachment G a copy of the organi­zation's most recently completed annual report. (The annual report must cover the fiscal year ending not more than 18 months prior to January of the campaign year to which the organization is applying or the preceding calendar year. It must contain a full descrip­tion of the organization’s activities and supporting services during the year covered by the report and identify its directors and chief administrative personnel.)

Reproductions of annual reports that are available on an organization's website are acceptable. The annual report must be clearly marked as such on the website and must include all of the criteria outlined in the CFC regulations (describe the organization's activities and identify the board of directors and chief administrative personnel). OPM will not accept miscellaneous pages from the organization's website that provide this information in lieu of an annual report document. A printed copy of the report must be included in the CFC application.

Item 10

Self-explanatory

Item 1611

Each federation and unaffiliated independent organization applying to participate in the CFC must, as a condition of participation, certify that it is in compliance with all statutes, Executive Orders, and regulations restricting or prohibiting U.S. persons from engaging in transactions and dealings with countries, entities, and individuals subject to economic sanctions administered by the U.S. Department of the Treasury’s Office of Foreign Assets Control (OFAC).  The programs administered by OFAC restrict or prohibit U.S. persons from engaging in transactions and dealings with targeted countries, entities, and individuals.  OFAC publishes a list of Specially Designated Nationals and Blocked Persons (SDN List).  The persons on the SDN List are subject to economic sanctions.  The SDN List and additional information relating to the economic sanctions programs that OFAC administers are available at http://www.treas.gov/ofac.  A link to the SDN List is available on the CFC website (www.opm.gov/cfc). For further information, please see CFC Memo 2005-13.

IF THE ORGANIZATION IS ADMITTED

If the organization is deemed eligible by OPM, it will receive an email, sent to the contact person’s email address, followed by a hard copy in the U.S. mail, providing information on the organization’s assigned five-digit CFC number.

Organization’s Program Description and Taxonomy Codes

The organization will also be given a Personal Identification Number and be directed to a secure website to register and verify the organization’s information on file with OPM. IF THE ORGANIZATION IS ADMITTED

If the organization is deemed eligible by OPM, it will receive an email, sent to the contact person’s email address, followed by a hard copy in the U.S. mail, providing information on the organization’s assigned four-digit CFC number. The organization will also be given a Personal Identification Number and be directed to a secure website to register and verify the organization’s information on file with OPM. All approved organizations, regardless of past participation, must register each year. During the registration process applicants will be asked to: verify contact inform-ation on file with OPM and enter the 25-word statement that will appear in the CFC brochure.; submit an address where paper checks should be sent, and; submit Electronic Funds Transfer (EFT) information if it wishes to receive funds electronically.

In addition, the organization will be asked to self-identify up to three program categories, in priority order, which most closely identifies identify the type of mission, services, and activities provided. The corresponding letters will be printed with your organization’s listing in the CFC brochure to assist donors in identifying charities by type of service provided. Categories are derived from the National Taxonomy of Exempt Entities (NTEE) classification system developed by the National Center for Charitable Statistics. The 26 categories are:

A Arts, Culture, and Humanities

B Educational Institutions & Related Activities

C Envir. Quality, Protection & Beautification

D Animal Related

E Health – General and Rehabilitative

F Mental Health, Crisis Intervention

G Disease, Disorders, Medicinal Disciplines

H Medical Research

I Crime, Legal Related

J Employment, Job Related

K Food, Agriculture, and Nutrition

L Housing, Shelter

M Public Safety, Disaster Preparedness & Relief

N Recreation, Sports, Leisure, Athletics

O Youth Development

P Human Services – Multipurpose and Other

Q International, Foreign Affairs, National Security

R Civil Rights, Social Action, Advocacy

S Community Improvement, Capacity Building

T Philanthropy, Voluntarism & Foundations

U Science & Technology Research Institutes,

Services

V Social Science Research Institutes, Services

W Public, Social Benefit: Multipurpose, Other

X Religion Related, Spiritual Development

Y Mutual/Membership Benefit Orgs., Other

Z Other

IF THE ORGANIZATION IS DENIED

If your organization’s application is denied, it will receive a certified letter stating the reason(s) for the denial. If the organization wishes to appeal the decision to the Director of OPM, it must do sothe appeal must be received by OPM within ten business days of the receipt of the letter. The appeal should be complete and respond to the reason(s) for the original denial decision.

REQUIRED ATTACHMENTS (failure to provide any of these documents may result in a denial)

• Attachment A – Schedule of services by year and state and/or foreign country (See Item 1)

• Attachment B – IRS determination letter (See Item 2)

• Attachment C – Audited financial statements (See Item 4)

• Attachment D – IRS Form 990 (See Item 5)

omb approved

No. 3206-0131

Combined Federal Campaign

2006 2007 Application for

National/International Unaffiliated Independent Organizations

and Federation Members of Federations

(Federation members must complete this application to be kept on file by their federation.

This is an annual requirement. The application may be requested by OPM.)

Organization:

Employer Identification Number (EIN): __ __ - __ __ __ __ __ __ __

4 Digit CFC Number (If a participant in the last year's CFC): ___ ___ ___ ___

Mailing Address:

(Post Office Box addresses are not accepted and may result in automatic disqualification.)

Telephone: ( )__________________________

Contact Person: ____________________________________________________________

Contact Address:

(Post Office Box addresses are not accepted and may result in automatic disqualification. If different from the above address -- All OPM correspondence will be sent to this address.)

Contact Telephone: ( )_________________ Fax: ( )_____________________

Contact E-Mail Address: _________________________________________________________

Website Address (required, if available): ______________________________________________

Certifying Official

I, ____________________________________, am the duly appointed representative

(Name)

of ____________________________________ authorized to certify and affirm all statements

(Organization)

enclosed in this application.

______________________________

(Signature)

______________________________

(Typed or Printed Name)

Date Completed ______________________ ______________________________

(Title)

IMPORTANT SELECTION OF NATIONAL/INTERNATIONAL OR NATIONAL:

The National List will be divided into aA national/international organization section may be listed in either the national/international part of the Charity List or the International part of the Charity List. and an international organization section. The organization will be listed in the appropriate section based on the response to Item #1.

1) Place a check in the one appropriate box:

National/International SectionPart

I certify that the organization named in this application provided or conducted real ser­vices, benefits, assistance, or program activities in 15 or more different states over the three-year period immediately preceding the start of the campaign application year. (Include as ATTACHMENT A, a schedule listing those states where the program activities have been provided over the last three (3) years and a detailed description of the activities, including the year in which those services were provided, in each state listed.

- OR -

International SectionPart

I certify that the organization named in this application provided or conducted real ser­vices, benefits, assistance, or program activities in a foreign country over the three-year period immediately preceding the start of the campaign application year. (Include as ATTACHMENT A, a schedule listing each country where program activities have been pro­vided over the last three (3) years and a detailed description of the program activities, including the year in which those services were provided in each country listed.)

2) I certify that the Internal Revenue Service (IRS) recognizes the organization named in this

applica­tion as one which is tax-exempt under 26 U.S.C. 501(c)(3) and to which contributions are tax deductible pursuant to 26 U.S.C. 170(c)(2) and the organization is classified as a public charity under 26 U.S.C. 509(a). (Include as ATTACHMENT B a copy of the most recent IRS deter­mination letter as ATTACHMENT B. See instructions for additional information.)

3) I certify that the organization named in this application either has no expenses connected with lobbying or attempting to influence voting or legislation at the local, State, or

Federal level or that such expenses are within the extent permitted for organizations recognized as tax-exempt under 26 U.S.C. 501(c)(3).

43) I certify that the organization named in this application is a human health and welfare organi-­ zation providing services, benefits, or assistance to, or conducting activities affecting human

health and welfare. The services, benefits, assistance, or program activities affecting human health and welfare provided in 2006 are reflected in ATTACHMENT A.

54) I certify that the organization named in the application accounts for its funds on an accrual basis in accordance with generally accepted accounting principles (GAAP) and . Note: The only acceptable basis of accounting under GAAP is the accrual method. Cash basis, modified cash basis and modified accrual basis are not acceptable methods of accounting under GAAP.has an audit of its fiscal operations completed annually by an independent certified public accountant in accordance with generally accepted auditing standards (GAAS). (Include as ATTACH-MENT C a copy of the organization's most recent audited financial statements for a fiscal period ending no later than 18 months prior to January 2007. )

6) I certify that the organization named in the application was audited in accordance with gener­ally accepted auditing standards (GAAS) by an independent certified public accountant in the immediately preceding year. Include a copy of the organization's most recently completed audited financial statements as ATTACHMENT C. See instructions for additional information.

75) Place a check in the one appropriate box:

Include as ATTACHMENT D a copy of the most recently completed IRS Form 990, including signature on page 6 in the box marked “Signature of officer.” The pre­parer’s signature alone is not sufficient. (NOTE: If the Internal Revenue Service does not require your organization to file the Form 990, you must still complete one in accor­dance with IRS regulations to be eligible for the CFCI certify that the organization named in this application prepares and submits to the IRS a complete copy of the organization’s IRS Form 990. (Include as ATTACHMENT D a copy of the complete IRS Form 990 for a period ending no later than 18 months prior to January 2007, including signatures in the box marked “Signature of Officer”. The preparer’s signature alone is not sufficient. IRS Forms 990EZ, 990PF, and comparable forms are not acceptable substitutes.)

- OR -

• I certify that the organization named in this application is not required to prepare and submit an IRS Form 990 to the IRS. (Include as ATTACHMENT D a pro forma IRS Form 990 page 1 and Part V only for a period ending no later than 18 months prior to January 2007. IRS Forms 990 EZ, 990PF, and comparable forms are not acceptable substitutes.) .)

86) Place a check in one appropriate box:

I certify that the administrative and fundraising rate for the organization named in this

application has spent 25% or less of its total support and revenue on administrative and fundraising expenses during the year covered by the submitted IRS Form 990. The actual percentage of administrative and fundraising expenses is ______%. __ __ . __%. This percentage has been computed from information on the IRS Form 990 submitted with this application by adding the amount spent on "management and general" (line 14) to "fundraising" (line 15) and divid­ing the resulting total by "total revenue" (line 12). No other method may be used to calculate this percentage. (All percentages must be listed to the tenth of a percent. For example, 10.0% or 15.5%.)

• OR –

I certify that the organization named in this application has spent in excess of 25% of its total support and revenue on administrative and fundraising expenses during the year covered by the submitted IRS Form 990. The actual percentage of management, general and fundraising expenses is _______ % and this percentage is reasonable under the circumstances. (All percentages must be listed to the tenth of a percent. For example, 10.0% or 15.5%.) Include as ATTACHMENT E an explanation of the organization's management, general, and fundraising expenses and a formal plan to reduce these expenses to 25% or less of its total support and revenues.

97) I certify that an active and responsible governing body, whose members have no material conflict of interest and a majority of which serve without compensation, directs the organization named in this application. Include as ATTACHMENT F a listing of the organization’s board of directors, beginning and end dates of each member’s term of office, and the board’s meeting dates and locations for the previous year.

108) I certify that the organization named in this application prohibits the sale or lease of CFC contributor lists.

9) I certify that the organization named in this application conducts publicity and promotional activities based upon its actual program and operations, and that these activities are truthful and non-deceptive, include all material facts, and make no exaggerated or misleading claims.

11) I certify that the organization named in this application conducts publicity and promotional activities based upon its actual program and operations, that these activities are truthful and non-deceptive, include all material facts, and make no exaggerated or misleading claims.

1210) I certify that the organization named in this application effectively uses the funds contrib­uted by federal personnel for its announced purposes.

13) I certify that the organization named in this application is chartered/incorporated under a governmental entity. This entity or state is __________________________________.

14) I certify that the organization named in this application has in the preceding year received no more than 80 percent of its total support and revenues from government sources. (Revenue from government sources must be computed from the IRS Form 990 by dividing line 1c by line 12.)

15) I certify that the organization named in this application prepares and makes available to the public an annual report that includes a full description of the organization’s activities and sup­porting services and identifies its directors/governing body and chief administrative personnel. Include as ATTACHMENT G a copy of the most recently completed annual report. The annual report must cover the fiscal year ending not more than 18 months prior to January of the campaign year to which the fed­eration is applying or the preceding calendar year. A more frequently published document, such as a quarterly newsletter, may be used to meet this requirement provided that such document is available to the general public upon request and describes the organization’s activities and supporting services and identifies its directors and chief administrative personnel.

1611) I certify that the organization named in this application is in compliance with all statutes, Executive orders, and regulations restricting or prohibiting U.S. persons from engaging in transactions and dealings with countries, entities, or individuals subject to economic sanctions administered by the U.S. Department of the Treasury’s Office of Foreign Assets Control. The organization named in this application is aware that a list of countries subject to such sanctions, a list of Specially Designated Nationals and Blocked Persons subject to such sanctions, and overviews and guidelines for each such sanctions program can be found at http://www.treas.gov/ofac. Should any change in circumstances pertaining to this certification occur at any time, the organization will notify OPM's Office of CFC Operations immediately.

I CERTIFY THAT I HAVE READ ALL THE CERTIFICATIONS SET FORTH IN THIS DOCUMENT AND AFFIRM THEIR ACCURACY. IN ADDITION, THAT BY CHECKING THE BOX NEXT TO THE STATEMENT, I ACKNOWLEDGE AND AGREE TO COMPLY WITH THAT CERTIFICATION.

________________________________

Certifying Official's Signature & Title

________________________________

Date

NOTE:

Applications will not be accepted if submitted electronically or by facsimile.

The certifying official’s signature must be original.

Automatic pens and/or signature stamps may not be used.

Public Burden Statement

We think this form takes an average of 3 hours to complete, including the time for getting the needed data and reviewing both the instructions and completing the form. Send comments regarding our estimate or any other aspects of this form, including suggestions for reducing completion time to Office of Personnel Management (OPM), OPM Forms Officer, Paperwork Reduction Project (3206-0131), Washington, DC 20414-7900. The OMB number 3206-0131 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

13

OPM Form 1647-A

Rev. October 2005October 2006