2012 National Independent Organization Application - Markup

OMB APPROVED

No. 3206-0131

Combined Federal Campaign

2012 2013 Application Instructions for

National/International Independent Organizations And Members of Federations

Background

Enclosed is the model application for use by national/international independent organizations to apply to participate in the Combined Federal Campaign (CFC) and for use by national/ international federation members to submit to the national/international 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. The Office of Personnel Management (OPM) encourages organizations to apply early.

The application deadline for independent organizations and federations seeking national eligibil­ity is 5:00 p.m. Eastern Standard Time, Tuesday, January 17, 201215, 2013, but applications may be sent to OPM’s Office of CFC as early as Thursday, December 1, 2011Monday, December 3, 2012. A timely application must be received by the deadline at the following address:

Office of Personnel Management

Office of Combined Federal Campaign

ATTN: Chimezie Ihuoma

Room 6484

1900 E Street, NW

Washington, DC 20415

OPM 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.

Federation members must submit their applications to the federation. Copies of these applications should not be sent to OPM.

All required documents and attachments must be complete and submitted before the application deadline. Documents that did not exist at the time of the application deadline will not be accepted during the appeals process. Organizations that apply for national/international eligibility and are found ineligible have only one opportunity to appeal to the Director of OPM. The Director's decision is final for administrative purposes. Therefore, appellants should ensure that their appeals are complete and responsive to the actual reasons for the original denial decision.

OPM suggests that national/international organizations use the model application provided when applying to the CFC. Although not required, submission of this form will expedite the processing of individual applications. OPM 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, OPM may request evidence of corrective action regarding any prior violation of regulation or directive, sanction, or penalty, as appropriate. OPM will decide whether the organization has demonstrated, to OPM’s satisfaction, that the organization has taken appropriate corrective action. Failure to demonstrate satisfactory corrective action or to respond to OPM’s request for information within 10 business days of the date of the request may result in a determination that the organization will not be included in the Charity List.

FAXES OR ELECTRONIC SUBMISSIONS OF APPLICATIONS ARE NOT ACCEPTED

APPLICATION RECEIPT CONFIRMATION

When the application is entered into the CFC database, an email will be sent to the contact person’s email address(es) with instructions to use an online system to enter the organization’s 25-word statement and select up to three taxonomy codes. This information will appear in the CFC Charity List if the application is approved. Please note that the email is not documentation of the approval of the application.

If you do not receive an email confirmation within 48 hours of submission of the application, contact the Office of CFC at [email protected].

Organization’s Program Description and Taxonomy Codes

The organization will be given a Personal Identification Number and be directed to a secure website to register and verify the organization’s information on file with OPM. All approved organizations, regardless of past participation, must register each year. During the registration process applicants will be asked to verify contact information on file with OPM and enter the 25-word statement that will appear in the CFC charity list.

In addition, the organization will be asked to identify up to three program categories, in priority order, which most closely identify the type of mission, services, and activities provided. The corresponding letters will be printed with your organization’s listing in the CFC charity list 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 ActivitiesEducation

C Environmental Quality, Protection &

Beautification

D Animal Related

E Health – General and RehabilitativeCare

F Mental Health, & Crisis Intervention

G Disease, Disorders, Medicinal DisciplinesVoluntary Health Associations & Medical 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 & Grantmaking Foundations

U Science & Technology Research Institutes,

Services

V Social Science Research Institutes, Services

W Public, & Social Societal Benefit: Multipurpose, Other

X Religion -Related, Spiritual Development

Y Mutual & /Membership Benefit Orgs., Other

Z OtherUnknown

DEFINITIONS

Organization Name of the applicant org-anization as it appears on the IRS Business Master File. If the name of the applicant organization differs from the name that appears on the IRS determination letter, the IRS Form 990, or audited financial statements, 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 assigned to the organization by the IRS and appearing on the IRS Form 990 submitted with the 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.

Telephone Organization’s telephone number.

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.

Organization Address The physical street address of the organization. Post Office Boxes may not be used.

Contact Person The individual to whom OPM will direct communications regarding the application. This may be any individual in the organization.

Contact Title Self-explanatory

Contact Address Contact person’s mailing 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 Address(es) Contact person’s electronic mail address. Applicants are en-couraged to provide more than one email address.

INSTRUCTIONS

For details regarding CFC eligibility requirements for national/international independent organ-izations 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 as a refusal to certify and will result in the denial of the application.

Item 1

Check the one appropriate box. Include Attach-ment A. CFC eligibility requirements mandate that a national/international organization demon-strate it provided services in at least 15 different states or one foreign country over the three year period immediately preceding the start of the campaign’s application year. A schedule listing a detailed description of the services in each state (minimum 15) or foreign country (minimum 1), including the year of service, must be included with the application. The schedule must make a clear showing of national and/or international presence. Simply providing a list of states or countries where an organization conducts or provides real services, benefits or program activities is not sufficient. An organization must provide a detailed description of the ser­vices and activities it provided, and the year in which those services were provided, in each state or foreign country. Applicants are strongly encouraged tomust document the dollar amounts of financial assistance (if applicable) and the number of beneficiaries of each service it lists in Attachment A. The schedule must also include human health and welfare services that were provided in calendar year 2011 2012 (see Certification #3).

A sample Attachment A format is included in these instructions. OPM encourages applicants to use this format, but it is not a requirement.

This requirement cannot be met on the sole basis of services provided through an “800” telephone number or by disseminating information and publications via the U.S. Postal Service, the Internet, or a combination thereof. Broad descriptions of services and identical repetitive narratives will not be accepted at the sole discretion of OPM if they do not allow OPM to adequately determine that real services were provided or to accurately determine the individuals or entities who benefited. Providing listings of affiliated groups does not sufficiently demonstrate provision of real services by the applicant. Location of residence of organization members or location of residence of visitors to a facility does not substantiate provision of services in the location of residence. However, organizations that issue student scholarships or fellowships must indicate the state in which the recipient resides, not the state of the school or place of fellowship. Mere dissemination of information does not demonstrate provision of real services.

While it is not expected that an organization maintain an office in each state or foreign country, a clear showing must be made of the actual services, benefits, assistance or program activities provided in each state or foreign country. De minimis services, benefits, assistance, or other program activities in any state or foreign country will not be accepted as a basis for qualification as a national or international organization.

Organizations are encouraged to review CFC guidance on Attachment A, specifically CFC Memoranda 2004-10, 2006-21, and 2008-8 which includes “Suggestions for Attachment A”. These are available at www.opm.gov/cfc.

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.

National/international 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 current list of subordinates that are covered by the group exemption. The EIN on the applicant’s Form 990 must match the EIN on the current list of subordinates.

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, dated on or after October 1, 2012, 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, IRS Form 990 and audited financial statements. 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).

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 verify their current tax-exempt status prior to submitting a CFC application. This can be done by contacting the IRS at (877) 829-5500.

Item 3

Self-explanatory. Human health and welfare services provided in calendar year 2011 2012 must be reflected in Attachment A.

Item 4

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

Include as Attachment C a copy of the auditor’s report and the organization's complete audited annual financial statements. 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 2012 2013 (i.e. ending on or after June 30, 20102011).

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.

Item 5

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 20122013. 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 schedules, if applicable, with the exception of Schedule B, to be eligible for the CFC. If the IRS 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. Organizations that file these forms must submit a pro forma IRS Form 990 (see instructions below).

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 2012 2013 (i.e. ending on or after June 30, 20102011).

Pro forma IRS Form 990 Instructions – The IRS Form 990 can be downloaded from the IRS website (www.irs.gov). The following sections must be completed: Page 1, Items A-M, Part I (Summary), Lines 1-4 only, Part II (Signature Block), Part VII (Compensation - sections A and Bonly); Part VIII (Statement of Revenues), Part IX (Statement of Functional Expenses), and Part XII (Financial Statements and Reporting). (If you filed a 2009 IRS Form 990 because your fiscal period ended prior to December 31, 2010, the Financial Statements and Reporting shown as Part XII above is located in Part XI. In this instance you must provide Part XI, not Part XII.)

Item 6

Calculate and enter the organization’s annual per­centage for administrative and fundraising expenses based on the formula below.

Add 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 divide 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%).

Charities which do not reflect administrative and fundraising expenses in the Statement of Functional Expenses of the IRS Form 990, resulting in a 0% rate, but show such expenses on the audited financial statement will be denied unless the audited financial statements specifically state that these services were donated.

Item 7

Self-explanatory

Item 8

Self-explanatory

Item 9

Self-explanatory

Item 10

Self-explanatory

Item 11

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.

Certifying Official The certifying official is the individual who has the authority to affirm that all state­ments in the application are accurate. This role cannot be delegated to the federation of which the organization is a member.

IF THE ORGANIZATION IS DENIED

If your organization’s application is denied, it will receive a certified letter stating the reason(s) for the denial. If the organization wishes to appeal the decision to the Director of OPM, the appeal must be received by OPM within ten business days of the receipt of the letter. The appeal should be complete and respond to the reason(s) for the original denial decision.

Additional information or a revision to a submitted document will only be accepted if it existed prior to the application deadline. The CFC will not accept documents that did not exist or were not set forth in final form prior to the application deadline.

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

• Attachment A – Schedule of services by year and state and/or foreign country (See Items 1 & 3)

• Attachment B – IRS determination letter (See Item 2)

• Attachment C – Audited financial statements (See Item 4)

• Attachment D – IRS Form 990 (See Item 5)

THE APPLICATION AND SUPPORTING DOCUMENTATION MUST BE RECEIVED BY THE OFFICE OF PERSONNEL MANAGEMENT BY 5PM (EST), TUESDAY, JANUARY 15, 2013. LATE APPLICATIONS WILL NOT BE ACCEPTED.

2012 2013 CFC National/International Independent Organization and Federation Member

Attachment A Format

The use of this document is not required for Attachment A. If an applicant uses a different format, it is encouraged to detail services it provided under the heading of each state or foreign country. A minimum of 15 or more different states or one foreign country is required. This sample only lists 15 states, but applicants are encouraged to list, at least, a few more.

Several services can be described under any one state. Also, services that are provided in more than one state can be described under the heading of each of those states. All dates must be within the period of January 1, 2009 2010 – December 31, 20112012.

Foreign Country(ies)

Location	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #1 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #2 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #3 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #4 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #5 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #6 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #7 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #8 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #9 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #10 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #11 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #12 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #13 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #14 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

State #15 [enter state name]

City	Date	Service Description (including who provided the service)	Number of Beneficiaries

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

• Attachment A – Schedule of services by year and state and/or foreign country (See Items 1 & 3)

• Attachment B – IRS determination letter (See Item 2)

• Attachment C – Audited financial statements (See Item 4)

• Attachment D – IRS Form 990 (See Item 5)

THE APPLICATION AND SUPPORTING DOCUMENTATION MUST BE RECEIVED BY THE OFFICE OF PERSONNEL MANAGEMENT BY 5PM (EST), TUESDAY, JANUARY 17, 2012. LATE APPLICATIONS WILL NOT BE ACCEPTED.

OMB APPROVED

No. 3206-0131

Combined Federal Campaign

2012 2013 Application for

National/International Independent Organizations

and Members of Federations

(Federation members must complete this application to be kept on file by their federation.

This is an annual requirement. The application may be requested by OPM.)

Organization:

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

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

Telephone: ( )___________________ Website Address: ____________________________

Organization Address: ___________________________________________________________

____________________________________________________________

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

Contact Person: ____________________________________________________________

Contact Title: ____________________________________________________________

Contact Address:

(If different from the above address - Post Office Box Addresses are acceptable for the Contact Address.. All OPM correspondence will be sent to this address.)

Contact Telephone: ( )_________________ Fax: ( )_____________________

Contact E-Mail Address(es): _________________________________________________________

SELECTION OF NATIONAL/INTERNATIONAL OR INTERNATIONAL:

A national/international organization may be listed in either the national/international part of the Charity List or the International part of the Charity List. The organization will be listed in the appropriate section based on the response to Item #1.

1) Place a check in the one appropriate box:

National/International Part

I certify that the organization named in this application provided or conducted real ser­vices, benefits, assistance, or program activities in 15 or more different states or one foreign country over the three-year period immediately preceding the start of the campaign application year. (Include as ATTACHMENT A, a schedule listing those states or foreign countries where the program activities have been provided over within the 2010 -2012 period last three (3) calendar years and a detailed description of the activities, including the year in which those services were provided, in each state or foreign country listed. See recommended format for Attachment A on page 6 of the application instructions.)

- OR -

International Part

I certify that the organization named in this application provided or conducted real ser­vices, benefits, assistance, or program activities in a foreign country over the three-year period immediately preceding the start of the campaign application year. (Include as ATTACHMENT A, a schedule listing each country where program activities have been pro­vided over within the last three (3) calendar years2010-2012 period and a detailed description of the program activities, including the year in which those services were provided in each country listed. See recommended format for Attachment A on page 6 of the instructions.)

2) I certify that the Internal Revenue Service (IRS) recognizes the organization named in this

applica­tion as tax-exempt under 26 U.S.C. 501(c)(3) to which contributions are tax deductible pursuant to 26 U.S.C. 170(c)(2). (Include as ATTACHMENT B a copy of the most recent IRS deter­mination letter. See instructions for additional information.)

3) I certify that the organization named in this application is a human health and welfare organi-­ zation providing services, benefits, or assistance to, or conducting activities affecting human

health and welfare. The services, benefits, assistance, or program activities affecting human health and welfare provided in calendar year 2011 2012 are reflected in ATTACHMENT A.

4) I certify that the organization named in the application accounts for its funds on an accrual basis 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 generally accepted auditing standards (GAAS). (Include as ATTACH-MENT C a copy of the auditor’s report and the complete audited financial statements for a fiscal period ending not more than 18 months prior to January 20122013. )

5) Place a check in the one appropriate box:

I certify that the organization named in this application prepares and submits to the IRS a complete copy of the organization’s IRS Form 990 (long form). (Include as ATTACHMENT D a copy of the complete IRS Form 990 for a period ending not more than 18 months prior to January 20122013, including signatures in the box marked “Signature of Officer” or in IRS Forms 8879-EO or 8453-EO. The preparer’s signature alone is not sufficient. IRS Forms 990EZ, 990PF, and comparable forms are not acceptable substitutes.)

- OR -

I certify that the organization named in this application is not required to prepare and submit an IRS Form 990 (long form) to the IRS. (Include as ATTACHMENT D a pro forma IRS Form 990 for a period ending not more than 18 months prior to January 20122013. See application instructions for pro forma IRS Form 990 requirements. IRS Forms 990 EZ, 990PF, and comparable forms are not acceptable substitutes.)

6) I certify that the administrative and fundraising rate for the organization named in this

application is __ __ . __%. This percentage has been computed from information on the IRS Form 990 submitted with this application. See the instructions for information on the formula.

7) I certify that an active and responsible governing body, whose members have no material conflict of interest and a majority of whom serves without compensation, directs the organization named in this application.

8) I certify that the organization named in this application prohibits the sale or lease of CFC contributor lists.

9) I certify that the organization named in this application conducts publicity and promotional activities based upon its actual program and operations, and that these activities are truthful and non-deceptive, include all material facts, and make no exaggerated or misleading claims.

10) I certify that the organization named in this application effectively uses the funds contrib­uted for its announced purposes.

11) I certify that the organization named in this application 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, or individuals subject to economic sanctions administered by the U.S. Department of the Treasury’s Office of Foreign Assets Control. The organization named in this application is aware that a list of countries subject to such sanctions, a list of Specially Designated Nationals and Blocked Persons subject to such sanctions, and overviews and guidelines for each such sanctions program can be found at http://www.treas.gov/ofac. Should any change in circumstances pertaining to this certification occur at any time, the organization will notify OPM's CFC Operations immediately.

Certifying Official

I, ____________________________________, am the duly appointed representative

(Print Name)

of ____________________________________ authorized to certify and affirm all statements

(Print Organization)

enclosed in this application. I certify that I have read all the certifications set forth in this document and affirm their accuracy. In addition, by checking the box next to the statement, I acknowledge and agree to comply with that certification.

______________________________

(Signature)

______________________________

(Typed or Printed Name)

______________________________

(Title)

Date Completed ______________________ ______________________________

The application must be received by 5PM (EST) January 17, 201215, 2013. Send the application to:

Office of Personnel Management

Office of Combined Federal Campaign

ATTN: Chimezie Ihuoma

Room 6484

1900 E Street, NW

Washington, DC 20415

NOTE:

Applications will not be accepted if submitted electronically or by facsimile.

The certifying official’s signature must be original.

Automatic pens and/or signature stamps may not be used.

Public Burden Statement

We think this form takes an average of 3 hours to complete, including the time for getting the needed data and reviewing both the instructions and completing the form. Send comments regarding our estimate or any other aspects of this form, including suggestions for reducing completion time to Office of Personnel Management (OPM), CFC Operations, (3206-0131), Washington, DC 20414-7900. The OMB number 3206-0131 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

15

OPM Form 1647-A

Rev. October 2011July 2012