Form CDFI 0033 CDFI 0033 Financial Education and Counseling Pilot Program Applica

Financial Education and
Counseling Pilot Program
FY 2009 Application

OMB No. 1559-0034
Paperwork Reduction Act Notice
This submission requirements package is provided to Applicants for awards under the Financial Education and Counseling Pilot
Program. The Estimated average burden associated with this collection of information is 40 hours per respondent, depending on
individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should
be directed to the Department of the Treasury, Community Development Financial Institutions Fund, 601 Thirteenth Street, N.W., Suite
200 South, Washington, DC 20005.
All materials are available on the CDFI Fund Website: www.cdfifund.gov.
Catalog of Federal Domestic Assistance Number:

21.010

FY 2009 FEC Pilot Program Application

FY 2009 FINANCIAL EDUCAION AND
COUNSELING PILOT PROGRAM
TABLE OF CONTENTS
Introduction And Instructions ........................................................1
CDFI Fund: Mission and Programs........................................................................................ 1
The Financial Education and Counseling (FEC) Pilot Program................................................... 1
Application Eligibility Factors ................................................................................................. 2
Application Submission Requirements .................................................................................... 3
Contacting the CDFI Fund..................................................................................................... 4
CDFI Fund Contact List ................................................................................................. 4

PArt I: Applicant Information .........................................................5
PArt II: FEC PILOT Program Proposal..........................................10
Suggested Application Page Limits ............................................................................ 10
Executive Summary ............................................................................................................ 10
Implemenation Plan ........................................................................................................... 11
Proposed Impact and Effective Use ..................................................................................... 12
Organizational Capacity ...................................................................................................... 14
Budget and Program Funding.............................................................................................. 16
Sources and Uses of Funds ......................................................................................... 16

Part III: Forms and Certifications.................................................17
Standard Form 424............................................................................................................. 17
Environmental Review Form................................................................................................24
Assurances and Certifications.............................................................................................. 26
501(C)(4) Questionnaire .....................................................................................................30

FY 2009 FEC Pilot Program Application

INTRODUCTION AND INSTRUCTIONS
N O T E : Capitalized terms (other than titles) are defined in the Notice of Funds Availability (NOFA)

inviting applications for the FY 2009 funding round of the Financial Education and Counseling (FEC)
Pilot Program which may be downloaded from the CDFI Fund’s website at www.cdfifund.gov.
Certain terms used throughout the Application have definitions unique to the Financial Education and
Counseling Pilot Program. Applicants should make sure that they are familiar with these definitions
by consulting the NOFA.

CDFI Fund: Mission and Programs
The mission of the Community Development Financial Institutions Fund (the CDFI Fund) is to
expand the capacity of financial institutions to provide credit, capital, and financial services to
underserved populations and communities in the United States. The CDFI Fund achieves its
mission by directly investing in and supporting Community Development Financial Institutions
(CDFIs), Community Development Entities (CDEs), and other financial institutions through the
following programs and initiatives:
− CDFI Program (includes Financial Assistance (FA) and Technical Assistance (TA)),
− Bank Enterprise Award (BEA) Program,
− New Markets Tax Credit (NMTC) Program,
− Native Initiatives,
− Capital Magnet Fund (CMF), and
− Financial Education and Counseling (FEC) Pilot Program
Information on the CDFI Fund’s programs can be found on the CDFI Fund’s website at
www.cdfifund.gov. From the homepage, click on “What We Do” then “Information for
Applicants.” Click on the link for the various programs of interest.

The Financial Education and Counseling (FEC) Pilot
Program
Through the FEC Pilot Program, the CDFI Fund shall provide grants to Eligible Organizations to
enable such organizations to provide a range of Financial Education and Counseling Services to
Prospective Homebuyers, with the goals of:
(i)

increasing the financial knowledge and decision-making capabilities of Prospective
Homebuyers;

(ii)

assisting Prospective Homebuyers to develop monthly budgets, build personal savings,
finance or plan major purchases, reduce debt, improve financial stability, and set and
reach financial goals;

(iii)

helping Prospective Homebuyers to improve credit scores by understanding the
relationship between credit histories and credit scores; and

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FY 2009 FEC Pilot Program Application

(iv) educating Prospective Homebuyers about the options available to build savings for
short- and long-term goals.
The ultimate program goals of the FEC Pilot Program are to identify successful methods
resulting in Positive Behavioral Change for financial empowerment, and to establish program
models for organizations to carry out effective Financial Education and Counseling Services to
Prospective Homebuyers.
Funding can be requested for all expenses related to the administration, operation and
implementation of a FEC Pilot Program, which include but are not limited to personnel,
professional services, materials and supplies, equipment and capital expenditures, other
program expenses, and indirect expenses that support the program and staff – provided that no
more than 15 percent of the funds may be used to support such indirect expenses. FEC Pilot
Program grant funds are intended to offer financial support for the Applicant to implement the
strategies outlined in this Application. Please refer to the FY 2009 FEC Pilot Program NOFA for
additional information regarding use of funds.

Application Eligibility Factors
An Applicant must be an Eligible Organization in order to apply under the FY 2009 funding
round. In addition to meeting the criteria as outlined in the FY 2009 FEC Pilot Program NOFA, all
Applicants are required to submit an online Applicant Information Questionnaire with their
Application via their myCDFIFund account. For reference purposes, a copy of the Applicant
Information Questionnaire is included in the Application (see Part I).
As further specified in the FY 2009 FEC Pilot Program NOFA, in order to be deemed an Eligible
Organization, the Applicant must be a certified CDFI, a US Department of Housing and Urban
Development (HUD) approved Housing Counseling Agency, a Credit Union, a governmental
entity (State government, Local government or Tribal government), or a Collaborative Effort of
two or more such entities. In addition, the Applicant must demonstrate that it meets certain
minimum threshold requirements with respect to its experience and ability to provide Financial
Education and Counseling Services resulting in documented Positive Behavioral Changes for
Prospective Homebuyers. Specifically, the Applicant must certify that:
(i)

it has provided Financial Education and Counseling Services for a period of at least
three years immediately prior to the Application deadline;

(ii)

it has at least two full time equivalent positions dedicated to the development and/or
delivery of Financial Education and Counseling Services;

(iii)

it has provided Financial Education and Counseling Services to at least 100 Potential
Homebuyers in the past year, or has served an average of at least 150 clients per
year over the past three years, and subsequently tracked Positive Behavioral Change
outcomes with respect to such services; and

(iv)

it has independent budget resources of at least $50,000 currently available for the
provision of Financial Education and Counseling Services.

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FY 2009 FEC Pilot Program Application

These certifications will be made as part of the Applicant Information Questionnaire. Applicants
that cannot provide these certifications will be deemed not to have the minimum requisite
experience and ability to administer an award under the FEC Pilot Program, and will not be
eligible for FEC Pilot Program awards.

Application Submission Requirements
The 2009 FEC Pilot Program Application consists of:
● Part I -- Applicant Information Questionnaire/Signature Page (completed online in
organization’s myCDFIFund account)
● Part II -- FEC Program Proposal, including Sources and Uses of Funds Table (submitted
through myCDFIFund account as attachments)
● Part III – Forms and Certifications: (i) Standard Form 424; (ii) Environmental Review
Form; (iii) Assurances and Certifications; (iv) 501(c)(4) Questionnaire (all submitted
through myCDFIFund account as attachments).
All Applicants must register User and Organization accounts in myCDFIFund, the CDFI Fund’s
Internet-based interface, and submit their Application materials through this interface. As the
myCDFIFund account is the CDFI Fund’s primary means of communication with Applicants and
Awardees, organizations must make sure that they update the contact information in their
myCDFIFund accounts before the applicable Application deadline. For more information on
myCDFIFund accounts, please see the “Frequently Asked Questions” link posted at
https://www.cdfifund.gov/myCDFI/Help/Help.asp.
The Applicant is required to complete and submit, through its myCDFIFund account, the online
Applicant Information Questionnaire/Signature Page, the FEC Program Proposal (including
Sources and Uses Table), and all required Forms and Certifications (listed in Part III of the
application) by 5:00 p.m. EST on November 19, 2009.

Applications submitted to the CDFI Fund in any form or fashion other than through
the process described above will be deemed ineligible for consideration.

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FY 2009 FEC Pilot Program Application

Contacting the CDFI Fund
CDFI Fund staff will respond to questions and provide support concerning FEC Pilot Program
funding related to the FY 2009 FEC Pilot Program NOFA between the hours of 9:00 a.m. and
5:00 p.m. EST, until two (2) business days before the application deadline of November 19, 2009.
The CDFI Fund will not respond to phone calls or e-mail inquiries received after 5:00 p.m. EST
on November 17, 2009, until after the Application deadline.
CDFI Fund Contact List (Not toll-free phone numbers)
Office

Phone Number

Main Office:

(202) 622-8662
www.cdfifund.gov
(202) 622-7754 (fax)

Program Support:

(202) 622-6355

Compliance and
Monitoring Support
IT Support
Legal Support

Email Address

Type of Question
General Fund inquires

[email protected]

Inquiries regarding the Application
(202) 622-6330
[email protected]
Questions about the status of
(202) 622-7754 (fax)
compliance of prior awards including
outstanding reports
(202) 622-2455
[email protected]
Registering and creating accounts on
myCDFIFund inquiries
If you have any questions or matters that you believe require response by the Fund’s
Office of Legal Counsel, please refer to the document titled “How to Request a Legal
Review,” found on the CDFI Fund’s web site at www.cdfifund.gov.

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FY 2009 FEC Pilot Program Application

PART I: APPLICANT INFORMATION
NOTE: The following questionnaire is to be completed by the Applicant online, through the
organization’s myCDFIFund interface. All questions are contained in the FEC Signature Page;
however, the order of questions online varies from the order presented below. Applicants that
do not complete and submit their answers using the online form will be deemed ineligible for
consideration for a FEC Pilot Program award.
1.

Applicant Award Request
Total dollar amount of award requested in this Application: $400,000 1 .

2.

Applicant Information 2 :
(a) Applicant Name:
(b) Applicant Employer Identification Number:
(c) Applicant DUNS Number: ____________________________
(d) Applicant Eligibility Criteria (check all that apply):
___ Housing Counseling Agency (HUD-Approved agency, in active status as of
Application Date)
___ CDFI (currently certified by the CDFI Fund of the U.S. Department of the
Treasury)
___ Credit Union (as defined in the FY 2009 FEC Pilot Program NOFA)
___ State, Local or Tribal governmental entity (ad defined in the FY 2009 FEC Pilot
Program NOFA)
___ A Collaborative Effort consisting of two or more of the above four entities (as
defined in the FY 2009 FEC Pilot Program NOFA)
NOTE: As specified in the FY 2009 FEC Pilot Program NOFA, an Applicant must be able to
be classified as at least one of these five entity-types in order to be deemed eligible to
apply. Applicants that cannot be so classified will not be reviewed under the 2009 FEC Pilot
Program. The CDFI Fund reserves the right to collect additional information (e.g., articles of
incorporation; charter information; Agency documentation) to verify that the Applicant is
properly classified as satisfying at least one of these designations.

1

The CDFI Fund anticipates making five awards of $400,000 each in FY 2009. All Applicants are therefore required to apply for a
$400,000 award. However, the CDFI Fund reserves the right to provide any grant in an amount other than $400,000 or in an
amount other than that which the Applicant requested. The CDFI Fund reserves the right to fund, in whole or in part, any, all or
none of applications submitted.
2
An Application submitted on behalf of a Collaborative Effort must select one organization to serve as the primary administrator of
the FEC Pilot Program award. This lead organization should be identified as the Applicant, and must be able to assert that it can
satisfy each of the minimum threshold criteria necessary to be deemed an Eligible Organization.

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FY 2009 FEC Pilot Program Application

(e) Applicant’s date of incorporation or formation (month/day/year): 3 _________
(f) Applicant’s fiscal year end (month/day): ______
(g) Applicant’s total assets as of the date of this Application: $_________
(h) Applicant’s total budget resources dedicated to the provision of Financial Education
and Counseling Services 4 : $________
(i) Applicant’s total number of FTEs 5 : _______
(j) Applicant’s total number of FTEs that are dedicated to the provision of Financial
Education and Counseling Services 6 : ______
(k) Total number of Potential Homebuyers receiving Financial Education and Counseling
Services provided by the Applicant in:
Calendar Year 2008:
Calendar Year 2007:
Calendar Year 2006:
3-YEAR TOTAL 7 :

________
________
________
________

NOTE: As specified in the FY 2009 FEC Pilot Program NOFA, and reiterated in the footnotes
accompanying certain fields above, Applicants must demonstrate that they meet certain
minimum threshold requirements with respect to their experience and ability to provide
Financial Education and Counseling services in order to be deemed eligible to apply.
Applicants that have not satisfied these minimum requirements will not be reviewed under
the 2009 FEC Pilot Program. The CDFI Fund reserves the right to collect additional
information (e.g., audited financial statements; organizational charts; articles of
incorporation; staff rosters; client records) to verify that the Applicant has, in fact, satisfied
these minimum threshold requirements.

3.

Does the Applicant have any Affiliates that are applying for an award under the FY 2009
funding round of the FEC Pilot Program?
(check one): ___ Yes

___ No

3

In order to be deemed eligible to apply for a FEC Pilot Program award in 2009, the Applicant must have been in existence as a
legal entity since at least October 1, 2006.
4
In order to be deemed eligible to apply for a FEC Pilot Program award in 2009, the Applicant must have at least $50,000 of budget
resources dedicated to the administration of Financial Education and Counseling Services.
5
FTEs may include the time of more than one staff person, board member, volunteer, or outside contractor. For example, if two
staff persons share responsibility, their combined work must total at least 37.5 hours per week to constitute one FTE.
6
In order to be deemed eligible to apply for a FEC Pilot Program award in 2009, the Applicant must have at least two FTEs
dedicated to the provision of Financial Education and Counseling Services.
7
In order to be deemed eligible to apply for a FEC Pilot Program award in 2009, the Applicant must have served at least 100
Potential Homebuyers in 2008, or an average of 150 Potential Homebuyers over the past three years.

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FY 2009 FEC Pilot Program Application

NOTE: The answer to question 3 must be “No.” An Applicant and its Affiliates may
collectively submit only one Application under this round of the FEC Pilot Program.
If separate Applications are received from multiple Affiliated entities, the CDFI Fund reserves
the right to reject all such Applications. For purposes of this requirement, in addition to
assessing whether Applicants are Affiliates or Subsidiaries, the CDFI Fund will consider
whether Applicants constitute a common enterprise. A common enterprise may exist: (i)
where the activities described in Applications submitted by separate entities are, or will be,
operated and/or managed such that, in fact or effect, they may be viewed as a single entity;
(ii) where the Applications submitted by separate entities contain significant narrative,
textual or other similarities; or (iii) where the strategies and/or activities described in
Applications submitted by separate entities are so closely related, in fact or effect, they may
be viewed as substantially identical Applications. In such cases, the CDFI Fund reserves the
right to reject all Applications received from all such entities, to select a single Application as
the only one that will be considered for an award, and/or, in the event that an Application is
selected to receive an award, to deem certain activities ineligible.

4.

Identify the type of service area that the Applicant will serve (check one).
National service area
Multi-state service area
Statewide (or territory-wide) service area
Local service area (e.g., neighborhoods, cities, a county or contiguous
counties, or metropolitan areas) within a state or territory
NOTE: An Applicant serving a metropolitan area that crosses multiple states (e.g., the
Washington, D.C. or Philadelphia metropolitan areas) should check “Multi-state service
area.”

5.

Identify the particular geographical areas that the Applicant will serve. An Applicant that
is serving a national service area must identify the seven states with the largest amount
of projected activities:
State(s):
County(ies):

6.

Estimate the percentage of activities (by number of clients served) that will be directed
to each of the following markets.
% Major urban areas (Counties in metropolitan area with a population equal to
or greater than 1 million, including both central city and surrounding suburbs)
% Minor Urban areas (Counties in metropolitan area with a population less
than 1 million, including both central city and surrounding suburbs)
% Non-metropolitan counties

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FY 2009 FEC Pilot Program Application

7.

Please indicate the Applicant’s predominant targeted program participants: (check only
one):
____ Low-Income/Low-Wealth
____
____
____
____

Minorities (please identify): ___________________
Residents of rural communities
Native populations
Other targeted populations (e.g., military personnel; disabled populations)
(please identify): _____________________
____ Other providers of Financial Education and Counseling Services
____ None of the above

8.

Please indicate the Applicant’s predominant anticipated delivery strategy described in its
Application: (check only one):
____ Classroom
____ Internet/Distance Learning
____ One-on-One Financial Counseling
____ Other (please identify): _____________________

9.

Estimate the number of hours required to complete the entire Application package (the
Application package includes the Part I: Applicant Information completed through the
myCDFIFund account Signature Page; Part II: FEC Program Proposal (including Sources
and Uses of Funds Table); and, Part III: Forms and Certifications: ________ hours
NOTE: For the purpose of estimating hours, Applicants should focus only on the amount of
time it took to complete the questions asked in the Application materials. Other activities
that are carried out in the normal course of business and are only indirectly related to the
completion of this Application (e.g., developing a business strategy or marketing plan; etc.)
should not be included in this estimation.

10.

Applicant Mailing Information:
Mailing address (provide nine-digit zip code):

Address for overnight deliveries (if different from mailing address, include 9-digit zip
code):

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FY 2009 FEC Pilot Program Application

11.

Authorized Representative Information:
Name, title, and mailing address, if different from Applicant:

Telephone number:

Fax number:

E-mail address:

12.

Contact Person Information (if different from Authorized Representative):
Name, title, and mailing address, if different from Applicant:

Telephone number:

Fax number:

E-mail address:
By signing this Application, the Applicant makes the Assurances and Certifications, set
forth in the Assurances and Certifications (pages vi-ix) of the Application, which
Assurances and Certifications are made a part hereof and will continue in effect until the
Applicant enters into an Assistance Agreement with the CDFI Fund.
I hereby certify that all of the information provided by the Applicant in this Application
and in the supporting documentation, Assurances and Certifications in support of this
Application is true, correct, and complete. The execution and submission of this
Application has been duly authorized by the governing body of the Applicant and, in the
case of an Application submitted as part of a Collaborative Effort, the governing bodies
of the other members of the Collaborative Effort.

Applicant Name:
Authorized Representative Signature:
Name (print)

Title

Date:

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FY 2009 FEC Pilot Program Application

PART II: FEC PILOT PROGRAM PROPOSAL
•

The Applicant will use the specified MS Word template provided in the Application documents
available from the CDFI Fund’s website to respond to the FEC Pilot Program Proposal questions.
No Applicant will be provided an opportunity to provide supplemental information for the FEC
Program Proposal unless the CDFI Fund explicitly requests clarifying information during the review
phase.

•

Each section in the Application has suggested page limitations. FEC Pilot Program Proposals must
be single-spaced and use a 12-point font with 1-inch margins, and may not exceed 25 total pages.
Suggested Application Page Limits
FEC Program Proposal Sections
Suggested Maximum Number of Pages
Executive Summary
One (1) page
Implementation Plan
Six (6) pages
Proposed Impact and Effective Use
Seven (7) pages
Organizational Capacity
Eight (8) pages
Budget and Program Funds
Three (3) pages

•

The Applicant should number each page of its proposal, and should also include its name in the
upper right corner of each page.

•

Do not submit additional materials that are not specifically requested in this Application. The CDFI
Fund will read only the information it requests. It will not read attachments that have not been
specifically requested (such as organizational strategic plans, marketing plans, or letters of
support).

EXECUTIVE SUMMARY
Suggested Length: No more than one (1) page
•

Provide a narrative describing the Applicant’s mission, its proposed activities, its target
market or population, its track record, and impacts to date.

•

Include a paragraph that details the exact amount and intended use of funds. The total
must be indicated on the Sources and Uses Form (see the Budget and Program Funds
section within the Application.)

•

Summarize the key elements of the FEC Pilot Program Proposal, including any innovations,
and the expected outcomes and impacts.

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FY 2009 FEC Pilot Program Application

IMPLEMENATION PLAN
Suggested length: no more than six (6) pages
Applicants will be rated based upon their ability to demonstrate a demand for its FEC services
amongst its target audience; the quality and innovation of the FEC services it intends to offer; and
the quality of its marketing, outreach and delivery strategy.
1. Describe the Applicant’s target audience.
− Provide an overview of the designated target participants’ principal characteristics (such
as demographic, economic, or household characteristics).
− Discuss and quantify the demand for Financial Education and Counseling Services by the
proposed participants. Explain how the Applicant ascertained demand. Discussion
should include indicators of demand such as market studies for specific programs, trends
in financial education, and/or the number of applications and inquiries per month.
2. Describe the Financial Education and Counseling Services that will be provided to
Prospective Homebuyers.
− Briefly describe, for each proposed FEC Program activity: the curriculum and course
content, qualifications of instructors, format (i.e., one-on-one vs. group); frequency of
offerings, fees/costs, etc.
− Discuss how the proposed program activities compare with what is currently offered by
the Applicant, and how the proposed program will address a specific unmet need among
the targeted Prospective Homebuyers. This section should describe any innovative or
unique aspects of the Applicant’s proposed FEC program.
3. Describe the Applicant’s marketing, outreach, and delivery strategy. Discuss the
Applicant’s collaboration, coordination, and partnerships.
− Describe how the Applicant markets, or intends to market, its FEC services.
− Discuss methods the Applicant uses to expand the reach of its marketing. Discuss
efforts to reach out to marginalized or isolated populations.
− Discuss how the Applicant will sustain its delivery mechanisms.
− Describe the Applicant’s collaboration, coordination, and partnerships at the community
or national level (including with banks; credit unions; CDFIs; local, state and tribal
government agencies; local or national initiatives; and other relevant entities).

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FY 2009 FEC Pilot Program Application

PROPOSED IMPACT AND EFFECTIVE USE
Suggested length: no more than seven (7) pages
Applicants will be rated based upon:
1) The Applicant’s ability to identify, track and monitor output and impact performance
measurements that result in Positive Behavioral Changes for Prospective Homebuyers, which
may include:
(i) increasing Prospective Homebuyers’ financial knowledge and decision-making
capabilities;
(ii) assisting Prospective Homebuyers in developing monthly budgets, building personal
savings, financing or planning for major purchases, reducing debt, improving financial
stability and setting and reaching financial goals;
(iii) instructing Prospective Homebuyers on methods to improve credit scores through
understanding the relationship between credit histories and credit scores; or
(iv) building Prospective Homebuyers’ savings to achieve short- and long-term goals.
2) The extent to which the Applicant’s program model can be replicated by other providers of FEC
services.
1. Select Metrics. Awardees will be required to collect information and evaluate the impact
of their FEC programs using five (5) metrics – two (2) output measures required by the
CDFI Fund, and three (3) impact measures which may be chosen by the Applicant based
upon the impacts that it hopes to achieve for its program participants.
a. The two output measures required to be collected by all Awardees are:
-

The number of participants served annually; and

-

The total hours of class time/instruction/counseling provided, per person, on an annual
basis

b. The three impact measures may be chosen by the Applicant. The following list is
provided for illustrative purposes. The Applicant may choose impact measures from this list
below, or may submit its own impact measures. All Applicants must submit three impact
measures.
-

Percent change in average household savings levels

-

Total number/percentage of participants that established long-term savings goals

-

Percentage point changes in participant credit scores

-

Total number/percentage of participants that increased the use of budgeting tools

-

Percent change in average household debt outstanding

-

Total number/percentage of participants that established a bank relationship/opened an
account with a bank or credit union

-

Total number/percentage of participants that improved bill payment history

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FY 2009 FEC Pilot Program Application

-

Total number/percentage of participants able to obtain mortgages

2. Describe the Applicant's method of evaluating and documenting Positive
Behavioral Change in its program participants as a result of the FEC program as
captured by the above measures:
− Identify which impact measures the Applicant intends to track.
− For each of the five measures selected (two outcome measures and three impact
measures), provide a brief narrative describing:
‰ the type of data that will need to be collected;
‰ how that data will be captured;
‰ what quantitative measurements will be used to document any Positive
Behavioral Changes on the part of the program participants over time;
‰ the ranges of results that will be used to classify outcomes as “highly successful,”
“successful,” or “less than successful;” and the basis for determining these
thresholds;
‰ the timeline for implementation and impact measurement; and
‰ the procedures and systems in place (or that will be developed) allowing the
Applicant to track the FEC program impact measures over time.
3. Discuss the extent to which the Applicant believes that its program model can be
replicated by other providers.
− Discuss specific program design features, outreach methods or other aspects of the
Implementation Plan that the Applicant believes increases the likelihood that the
program can be readily adopted by other providers.
− Discuss the extent to which the Applicant’s methodologies for documenting and
evaluating Positive Behavioral Changes, as described above, can be replicated by other
providers.
− Discuss Applicant’s strategy for sharing program outcomes, including both “best
practices” and “lessons learned,” with other service providers at the conclusion of
Applicant’s FEC Pilot Program grant.

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FY 2009 FEC Pilot Program Application

ORGANIZATIONAL CAPACITY
Suggested length: no more than eight (8) pages
Applicants will be rated based upon: (i) the capacity, skills, size and experience of the Applicant’s
management team and key staff; (ii) the Applicant’s track record of providing financial education and
counseling services; (iii) the Applicant’s track record of administering grants and Federal funding; and
(iv) the overall financial health and viability of the organization.
1. Describe the capacity, skills, and experience of the Applicant’s management
team and key staff.
− Identify up to five persons (from the management team, the governing board, staff,
consultants, or contractors) who are integral to implementation (e.g., instructor, content
developer or marketing professional). For each person identified, provide a brief (1-2
paragraph) description of: (i) the position held by the individual including role and
responsibilities; (ii) the individual’s capacity, skills, and experience as it relates to his or
her position; and (iii) the individual’s role in carrying out the FEC activities.
− If the Applicant uses consultants, contractors, volunteers, or other non-staff individuals
to carry out key roles in its FEC activities, describe (i) how such individuals are selected;
(ii) their time commitment and length of involvement with the Applicant; and (iii) their
role in the proposed FEC activities.
− For any vacancies or new positions, describe the status of filling the position and the
strategy for doing so, as well as the expected date of filling the position.
2. Discuss the Applicant’s track record of successfully providing Financial Education
and Counseling services to Prospective Homebuyers, and documenting Positive
Behavioral Changes.
− Describe the Applicant’s track record of creating and delivering FEC services, including
the number of clients served. Be sure to address, in particular, experience in working
with isolated or marginalized populations.
− Describe how this track record relates to the activities proposed with the FEC Pilot
Program grant; how it informed the Applicant’s development of this proposal; and how it
will increase Applicant’s likelihood of introducing successful FEC services to Potential
Homebuyers.
− Describe Applicant’s experiences in collecting and analyzing outcome data from
Applicant’s program participants, tracking these results over time, and reporting findings.
3. Discuss the extent to which the Applicant has been successful in using grants
and Federal funding to provide financial education and counseling.
− Provide a list of all federal government awards that the Applicant and/or any Affiliates
have received over the past three years. Include the name of the award, the amount of
the award, the name of the awarding entity or agency, the date in which the award was
made, and, if applicable, the control # of the award.
− Describe the extent to which the Applicant has been successful in administering these
awards. If the Applicant failed to meet a performance measure or financial requirement

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FY 2009 FEC Pilot Program Application

−

with respect to any award, describe what caused the failure and whether issues leading
to the failure have been addressed or resolved.
Discuss any other experience that the Applicant has in administering awards from other
entities (e.g., state or local governments, foundations), particularly large monetary
awards with substantial compliance requirements.

4. Discuss the Applicant’s financial health.
−

−

−

Discuss whether the Applicant conducts annual audits. If it does, have any of the
Applicant’s completed auditor reports within the past three years (or, if shorter, for the
period from inception) indicated any of the following:
•

An opinion other than qualified?

•

A going-concern paragraph?

•

Repeated findings of reportable conditions?

•

Material weaknesses in internal control?

If yes to any of the above, indicate the fiscal years of the occurrence and describe the
circumstances and corrective action taken.
Have the Applicant’s financial statements shown negative net income (or if a non-profit,
negative change in net assets) in any of the past three years, or if in business for less
than three years, for the period of time it has operated? If yes, please explain and
describe when the entity expects to achieve profitability. Non-profit organizations should
provide an explanation if annual contributions and revenues do not exceed expenditures.
Has the Applicant ever filed for bankruptcy or otherwise defaulted on financial
obligations to a third party? If yes, please explain the circumstances, indicate the fiscal
year in which they occurred, and describe the corrective action being taken.

N O T E : The CDFI Fund reserves the right to contact other governmental organizations to review an

Applicant’s award status, and reserves the right to obtain audited financial statements from an
Applicant to review its financial conditions, prior to making an award determination.

- 15 -

FY 2009 FEC Pilot Program Application

BUDGET AND PROGRAM FUNDING
Suggested length: no more than three (3) pages
Applicants will be rated based upon their ability to demonstrate that the FEC Pilot Program funding is
necessary and appropriate in order for the Applicant to provide critical FEC services.
1. Complete Table – Sources and Uses of Funds. The Applicant may add more
rows/items as necessary.
2. Describe how the FEC Pilot Program grant will support the operations of the
proposed FEC program.
− Include a brief summary of the listed sources.
− Describe how the funds listed will be used to deliver the proposed FEC program.
− Discuss the extent to which the Applicant’s activities will effectively leverage other
resources (public and private) to achieve greater impact relative to expenses.
Sources and Uses of Funds
Proposed Time Line

Services Start Date:

Completed Date:

Source of Capital
Source of Funds
FEC Pilot Program

Type of Funding

Expected Amount

Estimated Date
of Receipt

Grant

$400,000

3/1/2010

Total Sources of Capital:

$400,000

Use of Funds
Categories

Description

Expected
Amount

Total Use of Funds

$0

Estimated Date(s)
of Expenditure

Curriculum Development
Program Marketing
Participant Recruitment
Program Delivery Expense:
Materials
Outcome Measurement
Compliance and Monitoring

- 16 -

FY 2009 FEC Pilot Program Application

PART III: FORMS AND CERTIFICATIONS
THIS PAGE INTENTIONALLY LEFT BLANK

- 17 -

FY 2009 FEC Pilot Program Application

OMB Number: 4040-0004
Expiration Date: 01/31/2009

Application for Federal Assistance SF-424
*1. Type of Submission:

*2. Type of Application

Preapplication

New

Application

Continuation

Changed/Corrected Application

Revision

3. Date Received :

Version 02
* If Revision, select appropriate letter(s)

*Other (Specify)

4. Applicant Identifier:

5a. Federal Entity Identifier:

*5b. Federal Award Identifier:

State Use Only:
6. Date Received by State:

7. State Application Identifier:

8. APPLICANT INFORMATION:
*a. Legal Name:
*b. Employer/Taxpayer Identification Number (EIN/TIN):

*c. Organizational DUNS:

d. Address:
*Street 1:
Street 2:
*City:
County:
*State:
Province:
*Country:
*Zip / Postal Code
e. Organizational Unit:
Department Name:

Division Name:

f. Name and contact information of person to be contacted on matters involving this application:
Prefix:

*First Name:

Middle Name:
*Last Name:
Suffix:
Title:
Organizational Affiliation:

*Telephone Number:
*Email:

Fax Number:

OMB Number: 4040-0004
Expiration Date: 01/31/2009

Application for Federal Assistance SF-424
*9. Type of Applicant 1: Select Applicant Type:

Type of Applicant 2: Select Applicant Type:

Type of Applicant 3: Select Applicant Type:

*Other (Specify)

*10 Name of Federal Agency:

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

*12 Funding Opportunity Number:

*Title:

13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):

*15. Descriptive Title of Applicant’s Project:

Version 02

OMB Number: 4040-0004
Expiration Date: 01/31/2009

Application for Federal Assistance SF-424

Version 02

16. Congressional Districts Of:
*a. Applicant:

*b. Program/Project:

17. Proposed Project:
*a. Start Date:

*b. End Date:

18. Estimated Funding ($):
*a. Federal
*b. Applicant
*c. State
*d. Local
*e. Other
*f. Program Income
*g. TOTAL

*19. Is Application Subject to Review By State Under Executive Order 12372 Process?
a. This application was made available to the State under the Executive Order 12372 Process for review on
b. Program is subject to E.O. 12372 but has not been selected by the State for review.
c. Program is not covered by E. O. 12372
*20. Is the Applicant Delinquent On Any Federal Debt? (If “Yes”, provide explanation.)
Yes

No

21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements
herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply
with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject
me to criminal, civil, or administrative penalties. (U. S. Code, Title 218, Section 1001)
** I AGREE
** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or
agency specific instructions
Authorized Representative:
Prefix:

*First Name:

Middle Name:
*Last Name:
Suffix:
*Title:
*Telephone Number:

Fax Number:

* Email:
*Signature of Authorized Representative:
Authorized for Local Reproduction

*Date Signed:
Standard Form 424 (Revised 10/2005)
Prescribed by OMB Circular A-102

OMB Number: 4040-0004
Expiration Date: 01/31/2009

Application for Federal Assistance SF-424
*Applicant Federal Debt Delinquency Explanation
The following should contain an explanation if the Applicant organization is delinquent of any Federal Debt.

Version 02

ENVIRONMENTAL REVIEW FORM
Applicant Name: _____________________________________________
The Fund’s environmental review requirements are set forth in 12 CFR Part 1815. The Applicant
should review such regulations carefully before completing this section. In order to assure
compliance with those regulations and other requirements related to the environment, the
Applicant shall provide the following information:
YES
1. Are there any actions proposed in the Application that do not constitute a
“categorical exclusion” as defined in 12 CFR 1815.110?
If YES, would any of these actions normally require an environmental impact
statement (see 12 CFR 1815.108)?
2. Are there any activities proposed in the Application that involve:
(a) Historical or archeological sites listed on the National Register of Historic Places or
that may be eligible for such listing?
(b) Wilderness areas designated or proposed under the Wilderness Act?
(c) Wild or scenic rivers proposed or listed under the Wild and Scenic Rivers Act?
(d) Critical habitats of endangered or threatened species?
(e) Natural landmarks listed on the National Registry of Natural Landmarks?
(f) Coastal barrier resource systems?
(g) Coastal Zone Management Areas?
(h) Sole Source Aquifer Recharge Areas designated by EPA?
(i) Wetlands?
(j) Flood plains?
(k) Prime and unique farmland?
(l) Properties listed or under consideration for listing on the Environmental Protection
Agency’s List of Violating Facilities?

If YES to any of the above questions, attach a detailed description of each
action, clearly identifying the category in which the action falls.

- 24 -

FY 2009 FEC Pilot Program Application

NO

NOTIFICATION
As stated in 12 CFR 1815.105, if the CDFI Fund determines that the Application proposes actions which
require an environmental assessment or an environmental impact statement, any approval and funding of
the Application will be contingent upon:
1. The Applicant supplying to the CDFI Fund all information necessary for the CDFI Fund to perform or
have performed any required environmental review;
2. The Applicant not using any CDFI Fund Financial Assistance to perform any of the proposed actions in
the Application requiring an environmental review until approval is received from the CDFI Fund; and
3. The outcome of the required environmental review.
In addition, as stated in 12 CFR 1815.106, if the CDFI Fund determines that an Application, or any part
thereof, is not sufficiently definite to perform a meaningful environmental review prior to approval of the
Application, final approval and funding of the Application shall require supplemental environmental review
prior to the taking of any action directly using CDFI Fund Financial Assistance for any action that is not a
categorical exclusion.

- 25 -

FY 2009 FEC Pilot Program Application

ASSURANCES AND CERTIFICATIONS
SIGNING THE CERTIFICATION ON THE SF 424 CERTIFIES THAT THE APPLICANT WILL COMPLY WITH
THE ASSURANCES AND CERTIFICATIONS LISTED BELOW IF AN AWARD IS MADE. CERTAIN OF THESE
ASSURANCES AND CERTIFICATIONS MAY NOT BE APPLICABLE TO THE APPLICANT. AN APPLICANT MAY
NOT MODIFY ANY OF THE ASSURANCES AND CERTIFICATIONS.
A. Standard Form 424B: Assurances -Non-Construction Programs

As the duly authorized representative of the
Applicant, I certify that the Applicant:
1. Has the legal authority to apply for Federal
assistance, and the institutional, managerial and
financial capability (including funds sufficient to
pay the non-Federal share of project costs) to
ensure proper planning, management and
completion of the project described in this
Application.
2. Will give the Awarding agency, the Comptroller
General of the United States, and if appropriate,
the State, through any authorized representative,
access to and the right to examine all records,
books, papers, or documents related to the
Award; and will establish a proper accounting
system in accordance with generally accepted
accounting standards or agency directives.
3. Will establish safeguards to prohibit employees
from using their positions for a purpose that
constitutes or presents the appearance of
personal or organizational conflict of interest, or
personal gain.
4. Will initiate and complete the work (activities in
Application) within the applicable time frame
after receipt of approval of the Awarding agency.
5. Will comply with the Intergovernmental
Personnel Act of 1970 (42 U.S.C. 4728-4763)
relating to prescribed standards for merit systems
for programs funded under one of the nineteen
statutes or regulations specifies in Appendix A of
OPM’s Standards for a Merit System of Personnel
Administration (5 CFR 900, Subpart F).
6. Will comply with all Federal statutes relating to
nondiscrimination. These include but are not
limited to: (a) Title VI of the Civil Rights Act of
1964 (P.L.88-352) which prohibits discrimination
on the basis of race, color or national origin; (b)
Title IX of the Education Amendments of 1972,
as amended (20 U.S.C.1681-1683, 1685-1686),
which prohibits discrimination on the basis of
sex; (c) Section 504 of the Rehabilitation Act of
1973, as amended (29 U.S.C.794), which
prohibits discrimination on the basis of
handicaps; (d) the Age Discrimination Act of
1975, as amended (42 U.S.C.6101-6107), which
prohibits discrimination on the basis of age; (e)
the Drug Abuse Office and Treatment Act of 1972
(P.L. 92-255), as amended, relating to

nondiscrimination on the basis of drug abuse; (f)
the Comprehensive Alcohol Abuse and Alcoholism
Prevention, Treatment and Rehabilitation Act of
1970 (P.L.91-616), as amended, relating to
nondiscrimination on the basis of alcohol abuse
or alcoholism; (g) Sections 523 and 527 of the
Public Health Service Act of 1912 (42 U.S.C. 290
dd-3 and 290 ee-3), as amended, relating to
confidentiality of alcohol and drug abuse patient
records; (h) Title VIII of the Civil Rights Act of
1968 (42 U.S.C.3601 et seq.), as amended,
relating to nondiscrimination in the sale, rental or
financing of housing; (i) any other
nondiscrimination provisions in the specific
statute(s) under which Application for Federal
assistance is being made; and (j) the
requirements of any other nondiscrimination
statutes which may apply to the Application.
7. Will comply, or has already complied, with the
requirements of Titles II and III of the Uniform
Relocation Assistance and Real Property
Acquisition Policies Act of 1970 (P.L. 91-646)
which provide for fair and equitable treatment of
persons displaced or whose property is acquired
as a result of Federal or federally assisted
programs. These requirements apply to all
interests in real property acquired for project
purposes regardless of Federal participation in
purchases.
8. Will comply with the provisions of the Hatch Act
(5 U.S.C.1501-1508 & 7324-7328) which limit the
political activities of employees whose principal
employment activities are funded in whole or in
part with Federal funds.
9. Will comply, as applicable, with the provisions of
the Davis-Bacon Act (40 U.S.C. 276a to 276a-7),
the Copeland Act (40 U.S.C. 276c and 18 U.S.C.
874), and the Contract Work Hours and Safety
Standards Act (40 U.S.C. 327-333), regarding
labor standards for federally assisted construction
subagreements.
10. Will comply, if applicable, with flood insurance
purchase requirements of Section 102(a) of the
Flood Disaster Protection Act of 1973 (P.L. 93234) which requires recipients in a special flood
hazard area to participate in the program and to
purchase flood insurance if the total cost of
insurable construction and acquisition is $10,000
or more.
11. Will comply with environmental standards which
may be prescribed pursuant to the following: (a)

- 26 -

FY 2009 FEC Pilot Program Application

12.

13.

14.

15.

16.

17.

18.

institution of environmental quality control
measures under the National Environmental
Policy Act of 1969 (P.L.91-190) and Executive
Order 11514; (b) notification of violating facilities
pursuant to EO 11738; (c) protection of wetlands
pursuant to EO 11990; (d) evaluation of flood
hazards in floodplains in accordance with EO
11988; (e) assurance of project consistency with
the approved State management program
developed under the Coastal Zone Management
Act of 1972 (16 U.S.C. 1451et seq.); (f)
conformity of Federal actions to State
Implementation Plans under Section 176(c) of
the Clear Air Act of 1955, as amended (42 U.S.C.
7401 et seq.); (g) protection of underground
sources of drinking water under the Safe Drinking
Water Act of 1974, as amended, (P.L.93-523);
and (h) protection of endangered species under
the Endangered Species Act of 1973, as
amended, (P.L.93-205).
Will comply with the Wild and Scenic Rivers Act
of 1968 (16 U.S.C. 1271 et seq.) related to
protecting components or potential components
of the national wild and scenic rivers system.
Will assist the Awarding agency in assuring
compliance with Section 106 of the National
Historic Preservation Act of 1966, as amended
(16 U.S.C. 470), EO 11593 (identification and
protection of historic properties), and the
Archaeological and Historic Preservation Act of
1974 (16 U.S.C. 469a-1 et seq.).
Will comply with P.L. 93-348 regarding the
protection of human subjects involved in
research, development, and related activities
supported by this Award of assistance.
Will comply with the Laboratory Animal Welfare
Act of 1966 (P.L. 89-544, as amended, 7 U.S.C.
2131 et seq.) pertaining to the care, handling,
and treatment of warm blooded animals held for
research, teaching, or other activities supported
by this Award of assistance.
Will comply with the Lead-Based Paint Poisoning
Prevention Act (42 U.S.C. 4801 et seq.) which
prohibits the use of lead based paint in
construction or rehabilitation of residence
structures.
Will cause to be performed the required financial
and compliance audits in accordance with the
Single Audit Act of 1984.
Will comply with all applicable requirements of all
other Federal laws, executive orders, regulations
and policies governing this program.

1.

2.

3.

4.

5.

6.

C. Certification Regarding Debarment,
Suspension, and Other Responsibility
Matters -- Primary Covered Transactions:
Instructions for Certification
1.

B. Additional Certifications

In addition to the assurances and certifications
provided by the Applicant pursuant to OMB Standard
Form 424B, the Applicant hereby assures and certifies
that:

It is duly organized and validly existing under the
laws of the jurisdiction in which it was
incorporated or otherwise established, and is (or
within 30 days will be) authorized to do business
in any jurisdiction in which it proposes to
undertake activities specified in this Application;
Its Board of Directors (or similar governing body)
has by proper resolution or similar action
authorized the filing of this Application, including
all understandings and assurances contained
herein, and directed and authorized the person
identified as the authorized representative of the
Applicant to act in connection with this
Application and to provide such additional
information as may be required;
It will comply with all applicable requirements of
the Community Development Banking and
Financial Institutions Act of 1994 (the Act) [12
U.S.C. 4701 et seq.], regulations implementing
the Act and all other applicable Department of
the Treasury regulations and implementing
procedures (and any regulations or procedures
which are later promulgated to supplement or
replace them);
It will comply, as applicable and appropriate, with
the requirements of OMB Circulars (e.g., A-110
and A-133) and any regulations and circulars
which are later promulgated to supplement or
replace them, including standards for fund
control and accountability;
It has not knowingly and willfully made or used a
document or writing containing any false,
fictitious or fraudulent statement or entry as part
of this Application or any related document,
correspondence or communication. (The
Applicant and its authorized representative
should be aware that, under 18 U.S.C. 1001,
whoever knowingly and willfully makes or uses
such document or writing shall be fined or
imprisoned for not more than five years, or
both); and
The information in this Application, and in these
assurances and certifications in support of the
Application, is true and correct to the best of the
Applicant’s knowledge and belief and the filing of
this Application has been duly authorized.

2.

- 27 -

By signing and submitting this Application, the
prospective primary participant (the Applicant) is
providing the certification set out below.
The inability of a person to provide the
certification required below will not necessarily
result in the denial of participation in this covered
transaction. The prospective Applicant shall
submit an explanation of why it cannot provide

FY 2009 FEC Pilot Program Application

3.

4.

5.

6.

7.

8.

the certification set out below. The certification
or explanation will be considered in connection
with the Fund’s determination whether to enter
into this transaction (approval and funding of the
Application). However, failure of the Applicant to
furnish a certification or an explanation shall
disqualify such person from participation in this
transaction.
This certification is a material representation of
fact upon which reliance is placed when the Fund
determines to enter into this transaction. If it is
later determined that the Applicant knowingly
rendered an erroneous certification, in addition to
other remedies available to the Federal
Government, the Fund may terminate this
transaction for cause or default.
The Applicant shall provide immediate written
notice to the Fund if at any time the Applicant
learns that its certification was erroneous when
submitted or has become erroneous by reason of
changed circumstances.
The terms “covered transactions,” “debarred,”
“suspended,” “ineligible,” “lower tier covered
transaction,” “participant,” “person,” “primary
covered transaction,” “principal,” “proposal”, and
“voluntarily excluded,” as used in this clause
(certification), have the meanings set out in the
Definitions and Coverage sections of the rules
implementing Executive Order 12549. You may
contact the Fund for assistance in obtaining a
copy of those regulations (31 CFR part 19).
The Applicant agrees by submitting this
Application that, should the proposed covered
transaction be entered into, it shall not knowingly
enter into any lower tier covered transaction with
a person who is debarred, suspended, declared
ineligible, or voluntarily excluded from
participation in this covered transaction, unless
authorized by the Fund.
The Applicant further agrees by submitting this
Application that it will include the clause titled
“Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion-Lower Tier
Covered Transaction,” to be provided by the
Fund, without modification, in all lower tier
covered transactions and in all solicitations for
lower tier covered transactions (see 31 CFR part
19, Appendix B).
A participant in a covered transaction may rely
upon a certification of a prospective participant in
a lower tier covered transaction that it is not
debarred, suspended, ineligible, or voluntarily
excluded from the covered transaction, unless it
knows that the certification is erroneous. A
participant may decide the method and
frequency by which it determines the eligibility of
its principals. Each participant may, but is not
required to, check the Nonprocurement List.

9.

Nothing contained in the foregoing shall be
construed to require establishment of a system of
records in order to render in good faith the
certification required by this clause. The
knowledge and information of a participant is not
required to exceed that which is normally
possessed by a prudent person in the ordinary
course of business dealings.
10. Except for transactions authorized under
paragraph 6 of these instructions, if a participant
in a covered transaction knowingly enters into a
lower tier covered transaction with a person who
is suspended, debarred, ineligible, or voluntarily
excluded from participation in this transaction, in
addition to other remedies available to the
Federal Government, the Fund may terminate
this transaction for cause or default.

D. Certification Regarding Debarment,
Suspension, and Other Responsibility
Matters -- Primary Covered Transactions
1.

2.

The prospective primary participant (the
Applicant) certifies to the best of its knowledge
and belief, that it and its principals:
(a) are not presently debarred, suspended,
proposed for debarment, declared ineligible,
or voluntarily excluded from covered
transactions by any Federal department or
agency;
(b) have not within a three-year period
preceding this Application been convicted of
or had a civil judgment rendered against
them for commission of fraud or a criminal
offense in connection with obtaining,
attempting to obtain, or performing a public
(Federal, State or local) transaction or
contract under a public transaction; violation
of Federal or State antitrust statutes or
commission of embezzlement, theft, forgery,
bribery, falsification or destruction of
records, making false statements, or
receiving stolen property;
(c) are not presently indicted for or otherwise
criminally or civilly charged by a
governmental entity (Federal, State or local)
with commission of any of the offenses
enumerated in paragraph (1)(b) of this
certification; and
(d) Have not within a three-year period
preceding this Application had one or more
public transactions (Federal, State or local)
terminated for cause or default.
Where the Applicant is unable to certify to any of
the statements in this certification, such Applicant
shall attach an explanation to this proposal.

E. Certification Regarding Drug-Free
Workplace Requirements

- 28 -

FY 2009 FEC Pilot Program Application

1.

The Applicant certifies that it will provide a drugfree workplace by:
(a) publishing a statement notifying employees
that the unlawful manufacture, distribution,
dispensing, possession, or use of a
controlled substance is prohibited in the
Applicant’s workplace and specifying the
actions that will be taken against employee
for violations of such prohibition;
(b) establishing a drug-free awareness program
to inform employees about:
(i) the dangers of drug abuse in the workplace;
(ii) the Applicant’s policy of maintaining a drug-free
workplace;
(iii) any available drug counseling, rehabilitation, and
employee assistance program;
(iv) the penalties that may be imposed upon
employees for drug abuse violations occurring in
the workplace
making it a requirement that each employee to be
engaged in the performance of the Award be
given a copy of the statement required by
subparagraph (a);
notifying the employee in the statement required by
subparagraph (a) that, as a condition of
employment in such grant, the employee will:
(i) abide by the terms of the statement; and
(ii) notify the employer of any criminal drug use
statute conviction for a violation occurring in the
workplace no later than five calendar days after
such conviction;
notifying the granting agency in writing, within ten
calendar days after receiving notice of a
conviction under subparagraph (d) (ii) from an
employee or otherwise receiving actual notice of
such conviction;
taking one of the following actions, within 30 days of
receiving notice under subparagraph (d)(ii), with
respect to any employee who is so convicted:
(i) taking appropriate personnel action against such
an employee, up to and including termination,
consistent with the requirements of the
Rehabilitation Act of 1973, as amended; or
(ii) requiring such employee to participate
satisfactorily in a drug abuse assistance or
rehabilitation program approved for such
purposes by a Federal, State, or local health, law
enforcement, or other appropriate agency; and
(c) making a good faith effort to continue to
maintain a drug-free workplace through
implementation of subparagraphs (a), (b),
(c), (d), (e), and (f).
2. The Applicant may insert in the space provided
below the site(s) for the performance of work
(activities carried out by the Applicant) to be
done in connection with the Award (Place of
Performance (Street Address, City, County, State
and zip Code)): Not Applicable

F. Certification Regarding Lobbying
1.

2.

- 29 -

The Applicant certifies, to the best of its
knowledge and belief, that:
(d) No Federal appropriated funds have been
paid or will be paid, by or on behalf of the
Applicant, to any person for influencing or
attempting to influence an officer or
employee of any agency, a Member of
Congress, an officer or employee of
Congress, or an employee of a Member of
Congress in connection with the Awarding of
any Federal contract, the making of any
Federal grant, the making of any Federal
loan, the entering into of any cooperative
agreement, and the extension, continuation,
renewal, amendment, or modification of any
Federal contract, grant, loan, or cooperative
agreement;
(e) If any funds other than Federal appropriated
funds have been paid or will be paid to any
person for influencing or attempting to
influence an officer or employee of any
agency, a Member of Congress, an officer or
employee of Congress, or an employee of a
Member of Congress in connection with this
Application, the undersigned shall complete
and submit Standard Form LLL, “Disclosure
Form to Report Lobbying, “ in accordance
with its instructions; and
(f) The Applicant shall require that the language
of this certification be included in the Award
documents for all sub-awards of all tiers
(including subcontracts, subgrants, and
contracts under grants, loans, and
cooperative agreements) and that all
subrecipients shall certify and disclose
accordingly.
This certification is a material representation of
fact upon which reliance is placed when this
transaction is made or entered into. Submission
of this certification is a prerequisite for making or
entering into this transaction imposed by section
1352, title 31, U.S. Code. Any person who fails
to file the required certification shall be subject to
a civil penalty of not less than $10,000 and not
more than $100,000 for each such failure.

FY 2009 FEC Pilot Program Application

501(C)(4) QUESTIONNAIRE
This questionnaire is necessary for the CDFI Fund to determine whether an Applicant with a 501(c)(4) designation from the IRS is eligible to receive an
award from the Fund (see 2 U.S.C. 1601 et al). Please read all definitions before responding to the questions and continue to refer to such definitions in
responding to this questionnaire. If the answer to any question is yes, please describe in detail the facts and circumstances, subject matter, date(s),
names and titles of all individuals and their employers and their organizations on a separate sheet(s) of paper. The CDFI Fund reserves the right to seek
follow-up responses from an Applicant. Failure to complete this questionnaire and, if applicable, respond timely to follow-up questions, will delay the
Fund’s processing of the Application, and may result in the disqualification of the Application from further consideration. After submitting responses to
this questionnaire, the Applicant is under a continuing obligation to: (1) supplement its responses upon a change in circumstances; and (2) revise or
modify its responses within 10 business days of having actual or constructive knowledge that the responses previously submitted and certified are no
longer complete, accurate, or true. You may call the CDFI Fund’s Office of Legal Counsel at (202) 622-8662 if you have any questions about this form.

Scope: The scope of this questionnaire is limited to activities on or after January 1, 1996.
Questions
1. Has any officer, employee, director, partner, proprietor, or board member contacted1 a Covered Executive

‰ Yes
‰ No

2. Has any officer, employee, director, partner, proprietor, or board member contacted a Covered Executive

‰ Yes
‰ No

3. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered Executive

‰ Yes
‰ No

4. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered Executive

‰ Yes
‰ No

5. Has any officer, employee, director, partner, proprietor, or Board member engaged in efforts supporting and

‰ Yes
‰ No

6. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered Executive

‰ Yes
‰ No

7. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered Executive

‰ Yes
‰ No

Branch Official2 with regard to the formulation, modification, or adoption of Federal legislation (including
legislative proposals)

Branch Official with regard to the formulation, modification, or adoption of a Federal rule, regulation, Executive
Order, or any other program, policy, or position of the United States Government?
Branch Official with regard to the administration or execution of a Federal program or policy (including the
negotiation, award, or administration or a Federal contract, grant, loan, permit, or license)?
Branch Official with regard to the nomination or confirmation of a person for a position subject to confirmation
by the United States Senate?
coordinating the contact by others of a Covered Executive Branch Official including preparation and planning
activities, research and other background work that was intended, at the time performed, for a purpose
described in Questions 1-4?
Branch Official with regard to the formulation, modification, or adoption of Federal legislation (including
legislative proposals)?

Branch Official with regard to the formulation, modification, or adoption of a Federal rule, regulation, Executive
Order, or any other program, policy, or position of the United States Government?

‰ Yes

8. Has any officer employee, director, partner, proprietor, or Board member contacted a Covered Executive Branch ‰ No
Official with regard to the administration or execution of a Federal program or policy (including the negotiation,
award, or administration of a Federal contract, grant, loan, permit, or license)?

9. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered Executive

‰ Yes
‰ No

10. Has any officer, employee, director, partner, proprietor, or Board member engaged in efforts supporting and

‰ Yes
‰ No

Branch Official with regard to the nomination or confirmation of a person for a position subject to confirmation
by the United States Senate?

coordinating the contact by others of a Covered Legislative Branch Official3 including preparation and planning
activities, research and other background work that was intended, at the time performed, for a purpose
described in Questions 6-9?

Signature
Signing the certification on SF 424 certifies that the answers to the 501(c)(4) Questionnaire and the written explanations attached thereto are true,
accurate, and complete to the best of its information, knowledge, and belief and that, since January 1, 1996, the Applicant has not engaged in Lobbying
Activities as defined in Section 3 (7) of the Lobbying Disclosure Act of 1995, P.L. 104-65, as amended.
“Contacted” means any oral or written communication including an electronic communication.
“Covered executive branch official” means: (a) the President; (b) the Vice President; (c) any officer or employee, or any other individual functioning in the capacity of such an
officer or employee, in the Executive Office of the President; (d) any officer or employee serving in an Executive Level I-V position, a “Schedule C” position, or any official in a
Senior Executive Service position; (e) any member of the uniformed services serving at grade 0-7 or above; or (f) any officer or employee serving in a position of a
confidential, policy-determining, policy-making, or policy-advocating character.

2

FY 2009 FEC Pilot Program Application

3 “Covered legislative branch official” means: (a) a member of Congress; (b) an elected officer of either House of Congress; and (c) any employee of the House or Senate,
including employees of Members, committees, leadership and working groups or caucuses organized to provide legislative services or other assistance to Members of
Congress.

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FY 2009 FEC Pilot Program Application