The Community Development Financial Institutions Program - Certification Application

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Overview

Product Table
Asset Info Table
Staff Alloc Table
DS Table
TM Table
Board Table
Accountability Table

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Sheet 1: Product Table

PRODUCT TABLE		OMB No. 1559-0028
Instructions: Complete the table below based on the products the Applicant currently offers.
Product	Product Category	Product Description

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Sheet 2: Asset Info Table

ASSET INFORMATION TABLE
Curent YTD:
Instructions: Complete the table below using the Applicant's current Year-to-Date Financial Statements that are attached to the application. Do not enter consolidated financial statement information unless the Applicant is the parent entity.
	Dollar Amount	% of Total Assets
TOTAL ASSETS		100%
Assets Dedicated to Financing Products and Related Financing Activities
Cash and Cash Equivalents
Balance Sheet Account Name:
Balance Sheet Account Name:
Balance Sheet Account Name:
Sub-Total
Loans Receivable and/or Equity Investments
Balance Sheet Account Name:
Balance Sheet Account Name:
Balance Sheet Account Name:
Sub-Total
Loans Purchased from CDFIs
Balance Sheet Account Name:
Balance Sheet Account Name:
Balance Sheet Account Name:
Sub-Total
Other Financing Assets
Balance Sheet Account Name: (e.g. Loan Guarantees)
Balance Sheet Account Name:
Balance Sheet Account Name:
Sub-Total
Financing Related Activities
Balance Sheet Account Name:
Balance Sheet Account Name:
Balance Sheet Account Name:
Sub-Total
Subtotal Assets Dedicated to Financing Products and Related Financing Activities
Development Services Assets
Balance Sheet Account Name:
Balance Sheet Account Name:
Balance Sheet Account Name:
Sub-Total
Total Financing Activities Assets
Major Non-Financing Assets
Balance Sheet Account Name:
Balance Sheet Account Name:
Balance Sheet Account Name:
Sub-Total
Liquid Assets Available for Financing in Next Three Months
Sources:
Cash and Cash Equivalents
Balance Sheet Account Name:
Balance Sheet Account Name:
Balance Sheet Account Name:
Sub-Total
Other Financing Assets
Balance Sheet Account Name:
Balance Sheet Account Name:
Balance Sheet Account Name:
Sub-Total
Off Balance Sheet and Other Sources
Other: (e.g. Lines of Credit)
Other
Other
Sub-Total
Total Liquid Assets Available for Financing Transactions in Next Three Months:
Projected Dollar Amount of Financing Transactions to be made in Next Three Months:
Projected Number of Transactions in Next Three Months:

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Sheet 3: Staff Alloc Table

STAFF ALLOCATION TABLE
Instructions: Complete the table below based on the Applicant's current allocation of staff resources. Estimate the number of FTEs devoted to activities directly related to the Applicant's Financial Products. Estimate FTEs devoted to Development Services that directly support the Applicant's Financial Products. List each category of FTEs related to Major Non-Financing Activities separately as indicated in lines 1-3. These categories should be self-identified and may include, for example, staff devoted to real estate development or management.
	# of FTEs	% of Total FTEs
Total Number of Full-Time Equivalent (FTE) Staff		100%
Financing Activities
FTEs devoted to provision of Financial Products
FTEs devoted to Financing Related Activities
Subtotal for FTEs devoted to Financing Activities
FTEs devoted to Development Services
Total FTEs devoted to Financing Activities and Development Services
Major Non-Financing Activities
1
2
3
Total Major Non-Financing Activities

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Sheet 4: DS Table

DEVELOPMENT SERVICES TABLE
Instructions: Complete the table below for each Development Service Activity provided by the Applicant.
Approximately what percentage of Development Services clients apply for Financial Products from your organization?							%
Development Service Activities (Name & Topic)	Related Products	Format (classroom, one on one, other)	Provider (Applicant, Affiliate or Other)	If the Provider is an Affiliate or Other, enter organization name	Estimated Clients per year (#)	Estimated % of Development Service clients receiving Applicant's financing	Estimated % of Development Service clients receiving Applicant's financing in the Target Market(s)
Example:
Pre-purchase Counseling	Mortgages	Classroom	Applicant	n/a	100	80%	80%
				TOTALS		%	%

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Sheet 5: TM Table

TARGET MARKET TABLE

Instructions: Complete the tables below for the Applicant’s most recently completed fiscal year and year to date activities. If the applicant has less than one full year of operations, only complete the table reflecting the current year to date activities. Complete all columns and rows that are applicable. However, DO NOT DOUBLE COUNT transactions in more than one Target Market, (for example, a transaction to a borrower that is both a resident of an Investment Area served by the Applicant and is a member of an Other Targeted Population served by the Applicant may only be counted in one of the two Target Markets). Note: If an Applicant does not track its activities in categories on this table, it may estimate the amount of activities directed to its Target Market(s). In such cases, please identify that the data is estimated by answering the “Estimated Values” question on the table. Then, in the Target Market Criteria section of the application, provide the narrative explaining how the estimates were derived.

Target Market Activity for Current Year to Date:

Products Categories

Loans

Equity Invests

Loan Purchases

Loan Guarantee

Totals (by TM)

All Other Activities

Target Market Type

#

$

#

$

#

$

#

$

#

$

Deposits/Shares

# of Members (for CUs)

DS

#

$

Total Activity

TM Name

TM 1:

TM 2:

TM 3:

TM 4:

TM 5:

Total TM Activity

Total TM Activity as % of Total Activity

Estimated Values? (Yes / No):

Target Market Activity for Most Recent FYE:

Products Categories

Loans

Equity Invests

Loan Purchases

Loan Guarantee

Totals (by TM)

All Other Activities

Target Market Type

#

$

#

$

#

$

#

$

#

$

Deposits/Shares

# of Members (for CUs)

DS

#

$

Total Activity

TM Name

TM 1:

TM 2:

TM 3:

TM 4:

TM 5:

Total TM Activity

Total TM Activity as % of Total Activity

Estimated Values? (Yes / No):

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Sheet 6: Board Table

BOARD TABLE

Instructions: Complete the table below by listing each member of the board of directors or advisory board or similar entity and indicating whether or not and how each member is representative of the Applicant's Target Market(s), (Investment area (IA), Low-Income Target Population (LITP), and/or an Other Targeted Population (OTP)). Information provided is for Internal Fund use only. Note: An individual may be accountable to more than one Target Market, (for example, a board member might be a resident of an Investment Area and work for an organization that primarily serves a Low-Income Target Population). If a board member is not representative of the designated Target Market(s), indicate "No" in the second column. If the Applicant is using multiple boards (governing and/or advisory) to provide accountability to its Target Market(s), complete a separate Board Table for each board.

Board Type

Governing:

Advisory:

Date of Board Composition:

Conflict of Interest Certification - Check here to certify that none of the board members listed on the table below that are Target Market Representatives, nor any of their family members, are principals or staff members of the Applicant CDFI, its subsidiaries, its affiliates, or its investors:

Target Market Representation

Investment Area

Low-Income Targeted Population

Other Targeted Populations

Government Representation

Board Member Name

TM Rep: (Y/N)

IA: (Y/N)

Type of Representative

Describe how represents of TM

LITP: (Y/N)

LITP Geographies

Type of Representative

Describe how represents of TM

OTP: (Y/N)

OTP Type(s):

OTP Geographies:

Type of Representative

Describe how represents of TM

Government Rep. or Official: (Y/N)

Title and Agency

If special powers or authority, Describe:

Total TM Reps:

Total Board Members:

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Sheet 7: Accountability Table

ACCOUNTABILITY CHART
Instructions: Complete the table below by listing each of the Applicant's Target Markets, as represented by the maps created for this application. Indicate which method(s) are used to be accountable to the Target Market(s), and if boards are used, which board member(s) represent the Target Market(s).
	Accountability Methods			Representative members
Target Market Name (same as map name)	Governing Board (Y/N)	Advisory Board(s)	Other Mechanism(s):	Governing Board Members	Advisory Board Members	If further explanation of Accountibility is necessary, provide discussion