Form CDFI Form 0036 CDFI Form 0036 Certification of Material Events

CERTIFICATION OF MATERIAL EVENTS

Organization Name: ____________________________________________________

EIN #: _______________________________________________________________

Certification Control # (if available): _______________________________________

Definition:

A “Material Event” is an occurrence that affects an organization’s strategic direction, mission, or business operation and, thereby, its status as a certified Community Development Entity (CDE) and/or Community Development Financial Institution (CDFI), and/or its compliance with the terms and conditions of its assistance/allocation agreement. For additional guidance on what constitutes a Material Event, refer to the “Frequently Asked Questions (FAQ): Material Event Occurrence and Reporting” document available on the Fund’s website.

Instructions:

This form is to be used by CDFI Fund Awardees, applicants, and certified CDEs and CDFIs, to report potential Material Events to the CDFI Fund. The Certification of Material Events form must be signed by the organization’s Authorized Representative. The completed form should be addressed to the attention of the Compliance Monitoring and Evaluation Manager and faxed to (202) 622-7754.

Please check the appropriate box for the reporting entity as of the date this form is signed:

□ I certify that no Material Event has occurred in the reporting entity since the date of its most recent certification/re-certification and/or the most recent submission of a Material Events Form.

□ A Material Event(s) has (have) occurred in the above-named organization. I certify that the event(s) listed below constitute all of such Material Events (attach additional pages if needed).

Explanation of Material Event

Please provide a narrative explanation regarding the Material Event affecting the organization including, a timeline and the name and contact information of key people involved in the action.

Date of Material Event(s):

Explanation of Material Event(s):

Please answer the following questions with respect to the Material Event(s) affecting the organization:

Will the event(s) have any effect on the key personnel (e.g., management team and/or Governing Board) of the organization? □ Yes □ No If yes, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Will the event(s) have any effect on the organization’s business strategy (e.g., project selection criteria, product/investment criteria, investments in unrelated entities, etc.)? □ Yes □ No If yes, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Will the event(s) have any effect on the organization’s CDFI and/or CDE certification status (e.g., Accountability, Target Market/Service Area, etc.)? □ Yes □ No If yes, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Will the event(s) have any effect on the organization’s ability to administer any current or anticipated awards from one or more of the CDFI Fund’s award programs, including drawing down undisbursed and/or raising additional Qualified Equity Investments (QEIs)? □ Yes □ No If yes, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Will the event(s) result in any changes to one or more myCDFI Fund accounts (e.g., legal name, EIN, fiscal year, etc.)? □ Yes □ No If yes, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ If a prior awardee or allocatee, will the event(s) have any effect on the organization’s ability to comply with the reporting requirements set forth in the organization’s award agreement? □ Yes □ No If yes, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ If a prior awardee or allocatee, will the event(s) cause the organization to be in non-compliance with an existing award agreement and/or necessitate the organization to seek an amendment to its existing award agreement? □ Yes □ No If yes, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Will the event(s) have any effect on a pending application with one or more of the CDFI Fund’s Programs? □ Yes □ No If yes, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

To the best of my knowledge and belief, all information contained in this certification statement is true and correct. My signature indicates authorization on behalf of the organization’s governing body.

Authorized Representative Signature:_____________________________________

Date: ________________________ Title:___________________________________

According the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 1559-XXXX.  The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instruction, search existing data resources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Expires xx/xx/xxxx.

CDFI Form 0036 4