2011 Local Independent Application

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Combined Federal Campaign

2011 Local Independent Application

OMB: 3206-0131

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OMB APPROVED

No. 3206-0131

C ombined Federal Campaign

2010 2011 Application Instructions for

Local Independent Organizations and Members of Federations

Background

Enclosed is the model application for use by local independent organizations applying to participate in the Combined Federal Campaign (CFC) and for use by local federation members to submit to the local 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. The current CFC regulations can be viewed on our website at www.opm.gov/cfc. Additional copies of the application can also be downloaded from the website.

All required documents and attachments must be complete and submitted before the application deadline each year. The CFC will not accept late applications. It is the applicant’s responsibility to submit its application and information by the scheduled deadline. Requests for consideration after the deadline will not be considered.

Applicants whose applications do not contain required documents or who submit incomplete or out-of-date documents will not be permitted to correct their applications during the appeals process.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 local eligibility and are found ineligible will have an opportunity to appeal to the Local Federal Coordinating Committee (LFCC) for reconsideration. If found ineligible on appeal by the LFCC, the organization may appeal the LFCC’s decision to the Director of the Office of Personnel Management (OPM). The Director's decision is final for administrative purposes. Appellants should ensure that their appeals are complete and responsive to the actual reasons for the LFCC denial decision.

Each LFCC determines the application deadline for organizations seeking local eligibility. Since local dates will vary, please check with the local CFC for local application deadlines and filing information. Local campaign contact information can be found on the CFC website at www.opm.gov/cfc/Search/Locator.asp.

If a local application form is available, OPM suggests that organizations use the local application provided when applying to the CFC.

The CFC will not accept application forms with modifications to any of the certification statements.

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

FAXES OR ELECTRONIC SUBMISSIONS OF APPLICATIONS ARE NOT ACCEPTED

DEFINITIONS

Organization Legal name of the applicant organization. If the name of the organization differs from the name that appears on the IRS determination letter, IRS Form 990, or audited financial statements, official documentation from the IRS or state government authorizing use of this name must accompany the application. The EIN 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 this application.

5 Digit CFC Number The 5 digit number assigned to the organization by the CFC. Organizations that did not previously participate in the CFC should leave this field blank.

Mailing Organization Address A physical mailing address must be provided - Post Office Box addresses will not be accepted. This is the administrative office address that will be used to assign a 5-digit CFC code.

Check the box below the address to denote that it is different from the address submitted with the 2010 CFC application.

Service Office Address The location where services are provided (if different from the Organization Address).

Telephone Organization’s telephone number.

Contact Person The contact person is the individual to whom the CFC will direct communications. This may be any individual in the organization.

Contact Title Self-explanatory

Contact Address Contact person’s physical mailing address if different than the organization's

address. Post Office Boxes may be used. Participation decision letters and other CFC communications will be sent to the contact person at 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 Contact person’s electronic mail address. Applicants are encouraged to provide more than one email 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.

Disbursement Address List the address where paper checks will be sent, if different from mailing address. Post office boxes may be used for the disbursement address.

Electronic Funds Transfer (EFT) Information List the Routing and Account numbers, along with the name of the financial institution, where funds should be disbursed. This is an optional method for receipt of CFC contributions. NOTE: Some campaigns may elect not to disburse funds electronically.

INSTRUCTIONS

For details regarding CFC eligibility requirements for local independent organizations and federation members, refer to CFC Guidance Memoranda 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 a refusal to certify and will result in the denial of the application.

Item 1

Please review CFC Memoranda 2004-11, 2006-22, and 2008-10 for guidance on local eligibility criteria.

Check the one appropriate box. Include as Attachment A supporting statements and/or documentation demonstrating to the satis-faction of the LFCC that the organization has a substantial local presence in the geographical area covered by the local campaign, a substantial local presence in the geographical area covered by an adjacent local campaign, or substantial statewide presence. Attachment A must also include a description of the actual services, benefits, assistance, or program activities. provided by the organization in calendar year 2009 2010 and how those programs, services, benefits, etc. affect human health and welfare of the target population (see Certification #4).

Substantial local presence is defined as a staffed facility, office or portion of a residence dedicated exclusively to that organization, available to members of the public seeking its services or benefits. The facility must be open at least 15 hours a week and have a telephone dedicated exclusively to the organization. The office may be staffed by volunteers. Substantial local presence cannot be met on the basis of services provided solely through an “800” telephone number or by disseminating information or publications via the U.S. Postal Service, the Internet, or a combination thereof. (Information on the geographic boundaries of local CFC Campaigns can be found on the CFC website at www.opm.gov/cfc/Search/Locator.asp.)

Substantial Local Presence in the Local Campaign Area - provide the hours and days per week of operation (a minimum of 15 hours per week is required), the organization’s dedicated telephone number, and the county and state where the applicant organization’s office is located. The organization address or the service address must be located in one of the counties served by the local campaign.

If the office where the services are provided is different from the organization’s main address (as listed on page 8), enter the address of the location where the services are provided.

Substantial Local Presence in the geographical area covered by an adjacent local campaign. An adjacent local campaign is defined as a local campaign whose geographic border touches the geographic border of another local campaign. Provide the hours and days per week of operation (a minimum of 15 hours per week is required), the organization’s dedicated telephone number, and the county and state where the applicant organization’s office is located. Applicant organizations are responsible for providing a complete application to each campaign area in which it wishes to participate. The organization address or the service address must be located in one of the counties served by an adjacent campaign area. Participation in a local campaign via an adjacency determination does not grant the organization a substantial local presence in the adjacent local campaign and participation via adjacency cannot be used to establish adjacency to local campaigns bordering the adjacent campaign area.

If the office where the services are provided (as described in Attachment A) is different from the organization’s main address (as listed on page 8), enter the address of the location where the services are provided.

Substantial statewide presence is defined as providing or conducting real services, benefits, assistance or program activities in the previous year (calendar year 20092010) covering 30 percent of a state’s geographic boundaries or providing or conducting real services, benefits, assistance or program activities affecting 30 percent of a state’s population. Substantial statewide presence cannot be met on the basis of services provided solely through an “800” telephone number or by disseminating information and publications via the U.S. Postal Service, the Internet, or a combination thereof. Applicant organizations are responsible for providing a complete application to each campaign area in which it wishes to participate.

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, documentation from the IRS or state government authorizing this name change must accompany the application.

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. If the subordinate’s EIN is different from the EIN on the group exemption letter, EIN documentation from the IRS must be provided.

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 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.

Please review CFC Memorandum 2009-4 for more information on this requirement and examples of supporting documentation (www.opm.gov/cfc).

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

Check the appropriate box.

Listing of a national organization, as well as its local affiliate organization, is permitted. Each national or local organization must individually meet all of the eligibility criteria and submit independent documentation as required in 5 C.F.R. §950.202, §950.203 or §950.204 to be included in the Charity List, except that a local affiliate of a national organization that is not separately incorporated, in lieu of its own 26 USC 501(c)(3) tax exemption letter and, to the extent required by §950.204(b)(2)(ii), audited financial statements, may submit the national organization’s 26 USC 501(c)(3) tax exemption letter and audited financial statements, but must provide its own pro forma IRS Form 990, (see Item 6) page 1 and Part V only, for CFC purposes. The local organization must submit a certification from the Chief Executive Officer (CEO) or CEO equivalent of the national organization stating that it operates as a bona-fide chapter or affiliate in good standing of the national organization and is covered by the national organization's 26 USC 501(c)(3) tax exemption, IRS Form 990 and audited financial statements.

A national organization may waive its listing in the National/International or International parts of the Charity List in favor of its local affiliate by following the procedures set forth in 5 C.F.R. §950.201(c).

Item 4

Self-explanatory. Human health and welfare services provided in calendar year 2009 2010 must be reflected in Attachment A.

Item 5

Check the appropriate box.

Organizations with $250,000 or more in annual revenue, as reported on the IRS Form 990, are required to submit an annual audit of fiscal operations by an independent certified public accountant in accordance with Generally Accepted Auditing Standards (GAAS). 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 2010 2011 (i.e. ending on or after June 30, 20082009).

Include as Attachment C a copy of the auditor’s report and the organization’s complete audited annual financial statements. The audited financial statements must include all statements and audit notes as required by GAAP. The Independent Auditor’s Report must include the signature of the auditor or the auditing firm.

The organization must certify that it accounts for its funds in accordance with Generally Accepted Accounting Principles (GAAP) and has an audit of its fiscal operations completed annually by an independent certified public accountant in accordance with GAAS. Note that GAAP requires the use of the accrual method of accounting. No other basis of accounting is acceptable under GAAP. The cash basis, modified cash basis, modified accrual, and any other methods are not acceptable.

Organizations with total revenue of at least $100,000 but less than $250,000: the certifying official must certify that the organization accounts for its funds in accordance with GAAP and has an audit of its fiscal operations completed annually by an independent certified public accountant in accordance with GAAS. The organization is not required to submit a copy of the audited financial statements with the CFC application. However, the information must be provided to OPM or the LFCC upon request. Note that GAAP requires the use of the accrual method of accounting. No other basis of accounting is acceptable under GAAP. The cash basis, modified cash basis, modified accrual, and any other methods are not acceptable.

Organizations with total revenue of less than $100,000: the certifying official must certify the organization has controls in place to ensure funds are properly accounted for and it can provide accurate timely financial information to interested parties. It is not required to submit financial documentation with the CFC application. However, the information must be provided to OPM or the LFCC upon request.

Bona-fide chapters or local affiliates of a national organization that are not separately incorporated whose pro forma IRS Form 990 reports revenues over $250,000 and whose financial operations are covered by an audit of the national organization may submit the national organization’s audited financial statements together with a certification from the national organization’s Chief Executive Officer (CEO) or CEO equivalent stating that it operates as a bona-fide affiliate in good standing of the national organization and is covered by the national organization’s 26 U.S.C. 501(c)(3) tax exemption, IRS Form 990 and audited financial statements. (See requirements under Item #2 for bona-fide chapters or local affiliates.)

Bona-fide chapters of a national organization that are not separately incorporated whose pro forma IRS Form 990 reports revenues of at least $100,000 but less than $250,000 and whose financial operations are covered by an audit of the national organization may certify it has an audit of its fiscal operations completed annually if it, at the time of the certification, is in good standing of the national organization and is covered by the national organization’s 26 U.S.C. 501(c)(3) tax exemption, IRS Form 990 and audited financial statements. This organization is not required to submit with its application the national organization’s audited financial statements or CEO statement evidencing proof of good standing and coverage by the national organization’s documentation. However, it must be able to supply this documentation to the LFCC or OPM upon request. (See requirements under Item #2 for bona-fide chapters or local affiliates.)

Item 6

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 20102011 (i.e. June 30, 2009). The IRS Form 990 must include a signature in the block marked “Signature of officer”; the preparer’s signature alone is not sufficient. Organizations that file the IRS Form 990 electronically may submit a signed copy of the IRS Form 8879-EO or IRS Form 8453-EO in lieu of a signature on the IRS Form 990.

The CFC will compare the number of voting members disclosed in Part I, Line 3 with the number of individuals that have the ‘individual trustee or director’ or ‘institutional trustee’ position selected in Part VII, Column C. If the number in Part I is more than the number in Part VII, the organization must provide an explanation for the difference. Failure to clarify the difference or to timely file an amended IRS Form 990 with the IRS may result in the denial of the application. Please review CFC Memoranda 2009-8 and 2010-5 for additional information on the IRS Form 990 requirements, including the presentation of the governing body and expenses.

A complete IRS Form 990 is required, including all supplemental statements and Schedule Aschedules, if applicable, to be eligible for the CFC. If the Internal Revenue Service does not require the organization to file the Form 990 (long form) it must complete and submit a pro forma IRS Form 990 (see instructions below). IRS Forms 990EZ, 990PF, and comparable forms will not be accepted. However, smaller organizations that file Form 990EZ may submit it with the appropriate pro forma pages as described below depending on whether or not it is a 2007 or 2008 IRS Form 990 attached in lieu of a complete IRS Form 990. Organizations that file these forms must submit a pro forma IRS Form 990.

Pro forma IRS Form 990 Instructions – The IRS Form 990 (long form) can be downloaded from the IRS website (www.irs.gov). If the fiscal period ended before December 31, 2008, the applicant must use the 2007 IRS Form 990 and complete page 1 and Part V for CFC purposes.

If the fiscal period ended on or after December 31, 2008, the applicant must use the 2008 IRS Form 990 (or more recent year, if available). The following sections must be completed: page 1 (Part I (, Summary and Part II, Signature Block), page 7 and 8 (Part VII, ( Compensation sections A and B), ); page 9 (Part VIII, (Statement of Revenues), page 10 (Part IX, (Statement of Functional Expenses), and page 11 (Part XI, (Financial Statements and Report).

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 2010 2011 (i.e. ending on or after June 30, 20082009).

Item 7

Calculate and enter the organization’s annual percentage for administrative and fundraising expenses. This percentage is computed from the IRS Form 990 submitted with this application. Depending on which year’s IRS Form 990 is submitted, the percentage will be calculated based on information contained on the:

(A) 2007 IRS Form 990 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);

(B) 2008 (or more recent) IRS Form 990 by

aAdding the amount in Part IX (Statement of Functional Expenses), Line 25, Column C (Management and General Expenses) to the amount in Line 25, Column D (Fundraising Expenses), and divideing the sum by Part VIII (Statement of Revenue), Line 12, Column A (Total Revenue).

No other methods may be used to calculate this percentage. All percentages must be listed to the tenth of a percent (e.g. 15.7%).

Item 8

Self-explanatory

Item 9

Self-explanatory

Item 10

Self-explanatory

Item 11

Self-explanatory

Item 12

Each federation and 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.

Item 13

Include as Attachment E, a statement in 25 words or less that describes the organization’s program activities. The statement should not repeat the organization's name. The organization must also provide the legal name as registered with the IRS if the organization does business under a different name. All organizations must include their IRS Employee Identification Number (EIN) regardless of whether or not they are operating under a "dba" (“doing business as”). The organization must also include a telephone number that can be reached from any location in the U.S. and the organization’s administrative and fundraising rate. The legal name, telephone number, EIN, taxonomy codes (see below), and administrative and fundraising rate will NOT count as part of the 25-word statement. An Internet address where information on the organization can be obtained may be included and will not count toward the 25 words. OPM will not be responsible for incorrect Internet addresses. E‑mail addresses are not accepted.

Taxonomy Codes Each organization can identify up to three categories, in priority order, which most closely identify the type of mission, services, and activities provided. The corresponding letters will be printed in your organization’s listing in the CFC charity list (see example below) 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 Environmental 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

Special design text used to draw attention to an organization title, such as special fonts, capitalization, quotations, and underlining, are not accepted. Any statement that uses special features, or exceeds 25 words will be edited by the LFCC. Organizations will be listed by their legal IRS recognized name as it appears on the IRS determination letter only unless the appropriate legal documentation permitting otherwise is provided with the application. See Item 2. The format is as follows:

0000 Name of Organization (legal name of organization, if applicable) (202)555-1234 www.opm.gov/cfc EIN#123456789 The description will contain no more than 25 words. It should be worded so the donor understands the program services provided. 4.2% B,V,O

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

Local CFC applications must be sent to the local campaign office. Do not send applications to the Office of Personnel Management. Note that each campaign area sets its own application deadline. For more information on the local application deadlines and addresses, please contact the Principal Combined Fund Organization (PCFO) representative in your area. Contact information can be found at www.opm.gov/cfc/Search/Locator.asp.

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

Attachment A – Documentation of local presence, adjacent presence, or statewide presence (See Item 1)
Attachment B – IRS determination letter (See Item 2)
Attachment C – Audited Financial Statements (if total revenues are $250,000 or greater) (See Item 5)
Attachment D – IRS Form 990 (See Item 6)
Attachment E – 25-word statement (See Item 13)

OMB APPROVED

NO. 3206-0131

Combined Federal Campaign

2010 2011 Application for

Local Independent Organizations and

Members of Federations

Organization:

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

5 Digit CFC Number (If a previous participant in the CFC): ___ ___ ___ ___ ___

Organization Address:

____________________________________________________________

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

Check this box if the above address is different from the address submitted with the 2010 CFC application:

Telephone: ( ) ____________________________________________

Contact Person:

Contact Title: _________________________________________________________

Contact Address: _________________________________________________________

(If different from the above address – Post Office Boxes are acceptable for the Contact Address. All CFC correspondence will be sent to this address.)

Contact Telephone: ( )____________ __ Fax: ( )________________________

Contact E-Mail Address: _________________________________________________________

Website Address (required, if available): ________________________________________

Disbursement Address: _________________________________________________________________ (This is the address where paper checks will be sent.)

Electronic Funds Transfer (EFT) information (Optional):

Routing Number (9 digits): __ __ __ __ __ __ __ __ __

ACCT: ___________________________________________

Financial Institution: _________________________________

OPM Form 1647-C

Rev. November 2009

File Type	application/msword
File Title	COMBINED FEDERAL CAMPAIGN
Author	Jennifer Hirschmann
Last Modified By	crrumbau
File Modified	2010-10-28
File Created	2010-09-13

2011 Local Independent Application