This document has been posted to the CDFI Fund website for informational purposes or for the specifically expressed use only. Any alteration, modification or unauthorized reproduction of this document is prohibited and may be unlawful. The CDFI Fund is not responsible for any alteration, modification, or unauthorized reproduction of this document that has not been expressly approved by the CDFI Fund.

Bank Enterprise Award Program

2010 Application

Word Attachments

Table of Contents

Mandatory Forms (Required of All Applicants)

Environmental Review Form

Required Forms as Applicable For Applicant:

Certification 1. ETAs or New Branches

Certification 2. Certification of Disbursement

Certification 3. Certification of Integrally Involved CDFI Partners

Certification 4. Certification of Baseline Period Qualified Activities

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	NO
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)?
Are there any activities proposed in the Application that involve:
Historical or archeological sites listed on the National Register of Historic Places or that may be eligible for such listing?
Wilderness areas designated or proposed under the Wilderness Act?
Wild or scenic rivers proposed or listed under the Wild and Scenic Rivers Act?
Critical habitats of endangered or threatened species?
Natural landmarks listed on the National Registry of Natural Landmarks?
Coastal barrier resource systems?
Coastal Zone Management Areas?
Sole Source Aquifer Recharge Areas designated by EPA?
Wetlands?
Flood plains?
Prime and unique farmland?
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.

NOTIFICATION
As stated in 12 CFR 1815.105, if the 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: The Applicant supplying to the Fund all information necessary for the Fund to perform or have performed any required environmental review; The Applicant not using any Fund Financial Assistance to perform any of the proposed actions in the Application requiring an environmental review until approval is received from the Fund; and The outcome of the required environmental review. In addition, as stated in 12 CFR 1815.106, if the 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 Fund Financial Assistance for any action that is not a categorical exclusion.

Certification 1. ETAs or New Branches

Applicant Name:

Signing the certification on the SF 424 certifies that the Applicant has complied with the conditions listed below (as applicable for the selected activities). Leave blank if not applicable because the Applicant is not seeking an award in the Service Activities category.

ETAs

The Applicant does hereby certify that (i) the Applicant has entered into, and is in compliance with, the Financial Agency Agreement with the Treasury Department; and (ii) each ETA for which the Applicant is seeking a BEA Award possesses ALL of the characteristics listed below:

Is an individually owned account at a Federally-insured financial institution;

Permits a minimum of four cash withdrawals and four balance inquiries per month, which are included in the monthly fee, through any combination of proprietary ATM transactions and/or over-the-counter transactions;

Allows access to the insured depository institution’s on-line point-of-sale network (if any);

Requires no minimum balance except as required by Federal or state law;

Provides a monthly statement;

Provides the same consumer protections that are available to other account holders at the financial institution;

Is offered only to individuals receiving Federal benefit, wage, salary, or retirement payments;

Allows set-off only for fees directly related to the account; and

Is subject to a maximum monthly account-servicing fee of $3.00.

Is in compliance with its Financial Agency Agreement with the U.S. Department of Treasury.

Certification for Opening Retail Branches

The Applicant does hereby certify that on (enter date branch opened for business), the Applicant opened a new branch office located at: (enter address of branch office). The Applicant has not operated a retail branch office in the same census tract in which it is opening such new branch office within the three years prior to opening said branch on the aforementioned date; and such new branch office will remain in operation for at least the next five years.

Certification 2. Certification of Disbursement

Applicant Name:

The Applicant, by its undersigned Authorized Representative, does hereby certify that the documentation which the Applicant has provided to the CDFI Fund, a copy of which is attached hereto, evidencing a disbursement of the proceeds of the loan(s) to the borrower(s) listed below, in the amounts listed below, is true and accurate. This Certification is incorporated into the Award Agreement by and between the Applicant and the Community Development Financial Institutions Fund (the "Fund"), and made a material part thereof.

Name and Title of Authorized Representative

Date

Service Provided / Borrower / Investee	Total Dollar Value Or Amount Of Transaction	Amount Disbursed To Date	Date Of Execution Mm/DD/YY	Date Of Initial Disbursement MM/DD/YY	Date Of Final Disbursement MM/DD/YY	Type Of Activity (Abbreviation Only)

Certification 3: Certification of Integrally Involved CDFI Partners

Applicant Name:

A CDFI that receives an Equity Investment, Equity-Like Loan or CDFI Support Activity (loan, technical assistance, or qualifying deposit) from an Applicant is considered a CDFI Partner. Signing the certification on the SF 424 certifies that the Applicant has verified that the CDFI Partners listed below have been found to be “Integrally Involved in a Distressed Community” as defined in the FY 2010 NOFA and BEA Program Interim Rule. This Certification is incorporated into the Award Agreement by and between the Applicant and the Fund, and made a material part thereof.

Name and Title of Authorized Representative

Date

CDFI Partner	City, State	Name of Distressed Community

Certification 4: Certification of Baseline Period Qualified Activities

Applicant Name:

An Applicant that includes a dollar value for an Assessment Period Qualified Activity must report the corresponding Baseline Period Qualified Activity. Signing the certification on the SF 424 certifies that the Applicant has verified that the transactions included in the Baseline Period dollar values listed below are Qualified Activities as defined in the 2010 NOFA and BEA Program Interim Rule. This Certification is incorporated into the Award Agreement by and between the Applicant and the Fund, and made a material part thereof.

Name and Title of Authorized Representative

Date

CDFI RELATED ACTIVITIES
Reporting	Baseline Period
Equity Investments / Equity-Like Loans
CDFI Support Activities
DISTRESSED COMMUNITY FINANCING ACTIVITIES
Reporting	Baseline Period
Affordable Home Mortgage Loans
Affordable Housing Development Loans & Project Investments
Small Business Loans and Project Investments
Home Improvement Loans
Education Loans
Commercial Real Estate Loans & Project Investments
SERVICE ACTIVITIES
Reporting	Baseline Period
Deposits
Community Services
Financial Services
Targeted Financial Services
Targeted Retail Savings/Investment Products