Form CDFI 0019 CDFI 0019 CDE Certification Application
New Markets Tax Credit (NMTC) Program - Community Development Entity (CDE) Certification Application
CDE_Application_Revised_7_28_09 REV
New Markets Tax Credit (NMTC) Program - Community Development Entity (CDE) Certification Application
OMB: 1559-0014
Community Development Financial Institutions Fund
CDE Certification Application
Community
Development
Financial
Institutions
Fund
CDE
Certification
Application
(07.15.09)
PAPERWORK REDUCTION ACT NOTICE
CDFI -0019
OMB Control Number 1559-0014
This submission requirements package is provided to applicants for Community Development Entity (CDE) certification under the New Markets Tax Credit (NMTC) Program. Applicants are not required to respond to this collection of information unless it displays a currently valid OMB number. The estimated average burden associated with this collection of information is 3.75 hours per applicant. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Certification and Training Program Manager, Department of the Treasury, Community Development Financial Institutions Fund, 601 13th Street, NW, Suite 200 South, Washington, DC 20005.
CDFI FUND MISSION
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.
WHAT IS A COMMUNITY DEVELOPMENT ENTITY (CDE)?
A Community Development Entity (CDE) is a domestic corporation or partnership that is an intermediary vehicle for the provision of loans, investments, or financial counseling in Low-Income Communities (LICs), under the New Markets Tax Credit (NMTC) Program.
CDE CERTIFICATION DESIGNATION
An entity seeking CDE certification must submit a CDE Certification Application to the CDFI Fund as directed herein. To qualify as a CDE, an Applicant CDE must at the time of application submission:
Be a legally established entity and a domestic corporation or partnership for Federal tax purposes;
Have a primary mission of serving or providing investment capital to LICs or Low-Income Persons; and
Establish accountability to LICs through representation on its governing or advisory board.
Through the CDE Certification Application, an entity may apply for certification solely on its own behalf, or on behalf of itself and one or more Subsidiary Applicants, provided that each applicant entity is legally established at the time of application. Each entity and subsidiary entity seeking CDE certification must have a valid Employer Identification Number (EIN) at the time the CDE Certification Application is submitted.
NOTE: Community Development Financial Institutions (CDFIs) and Specialized Small Business Investment Companies (SSBICs) seeking CDE certification automatically qualify as CDEs and do not need to complete this Certification Application. Such entities should register electronically for CDE certification on the CDFI Fund’s website at www.cdfifund.gov.
NOTE: Subsidiaries and Affiliates of certified CDEs, CDFIs, and SSBICs do not automatically qualify as CDEs. The parent CDE must submit this CDE Certification Application to have its Subsidiary entities certified as CDEs.
NOTE: Section 7701(a)(4) of the Internal Revenue Code defines "domestic" when applied to a corporation or partnership to mean created or organized in the United States or under the law of the United States or of any State unless, in the case of a partnership, the Secretary provides otherwise by regulations.
Organizations incorporated in US territories are not considered "domestic" corporations or partnerships for the purpose of this definition.
CDE CERTIFICATION BENEFIT
Benefits of being certified as a CDE include being able to apply to the CDFI Fund to receive a New Markets Tax Credit (NMTC) allocation to offer its investors in exchange for equity investments in the CDE and/or its subsidiaries; or to receive loans or investments from other CDEs that have received NMTC allocations.
New Market Tax Credit Program
Under the NMTC Program, taxpayers may claim a credit against Federal income taxes for Qualified Equity Investments made to acquire stock or other capital interests in designated CDEs. Substantially all of the Qualified Equity Investments must be used by the CDE to, among other things, make loans to, or equity investments in, qualified businesses or CDEs operating in Low-Income Communities. The investor (either the original purchaser or a subsequent holder) receives a tax credit for a seven-year period equal to five percent of the total amount paid for the stock or capital interest, at the time of purchase, for each of the first three years, and six percent annually for the remaining four years.
Applying for NMTC Allocations
The CDFI Fund allocates NMTC authority to for-profit and non-profit CDEs through a competitive application process pursuant to a Notice of Allocation Availability (NOAA) published in the Federal Register. NMTC Allocation Application materials and guidance are available from the CDFI Fund’s website at www.cdfifund.gov. For-profit CDE NMTC Allocation awardees can provide their investors the tax credit in exchange for stock or capital interests. A Non-profit CDE NMTC Allocation awardee must demonstrate to the CDFI Fund, prior to receiving an Allocation Agreement, that: 1) it controls one or more for-profit Subsidiary CDE(s); and 2) it intends to transfer the entire NMTC Allocation to its for-profit Subsidiary CDE(s).
For-profit and non-profit entities that do not apply to the CDFI Fund for NMTC Allocations may obtain CDE certification in order to receive Qualified Low-Income Community Investments from for-profit CDE NMTC Allocation recipients.
Maintaining CDE Certification
Each CDE NMTC Allocation awardee, as well as CDEs that are recipients of Qualified Low-Income Community Investments (QLICIs) from other CDEs, may be required to annually certify to the Fund that it continues to meet the Primary Mission and Accountability requirements by providing the information below. The Fund may revoke a CDE’s certification if it fails to provide the requested information.
Information indicating that the entity remains accountable to the LIC(s) it is serving; and
A certification statement certifying that no material changes have occurred to affect their current status as a CDE.
APPLICATION PROCESS OVERVIEW
Note: Each Applicant CDE and each Subsidiary Applicant must have its own valid Employer Identification Number (EIN) prior to submission of the Certification Application. Failure to include this information for any entity will result in the rejection of the entire application. For more guidance on obtaining an EIN, refer to the CDFI Fund’s CDE Certification Frequently Asked Questions document at www.cdfifund.gov.
Additional Questions and Resources: Please contact the CDFI Fund Program Staff if you have questions regarding the CDE Certification application. CDFI Fund Program Staff can be contacted by telephone at (202) 622-6355, and by e-mail at [email protected]. Information regarding the CDE Certification application and process can also be obtained by visiting the CDFI Fund’s CDE Certification page located at www.cdfifund.gov.
Application Completion Steps:
Carefully review the following documents from the CDFI Fund’s CDE Certification webpage located at www.cdfifund.gov:
The CDE Certification Guidance as published in the Federal Register; and
The CDE Certification Frequently Asked Questions document.
Create a (or access an existing) customized web portal “myCDFI Fund” user account located at the CDFI Fund’s homepage, www.cdfifund.gov. Account holders can then access the CDFI Fund Information and Mapping System (CIMS) program, which helps determine the eligibility of geographic areas under the NMTC Program.
Complete the CDE Certification Application. Failure to properly complete the appropriate sections of the Application may result in the CDFI Fund’s rejection of the entire Certification Application.
Provide the required Document Attachments, including legal entity establishment documents, Internal Revenue Service (IRS) assignment of EIN, and additional documents demonstrating the entity’s Primary Mission as directed. Copy the Documentation Attachments double-sided (front and back) to minimize the Certification Application package.
Mail one original and one copy of the Certification Application, including documentation attachments, to the address indicated below. Both the original and copy should be secured with a binder clip, without staples, tabbed dividers, or other forms of binding.
Public Debt Warehouse & Operations Center Dock 1
Attn: CDFI Fund – Awards Management, A2-D
257 Bosley Industrial Park Drive
Parkersburg WV 26101
Attn: Manager, Franchising Unit
CDE Certification Application
1-304-480-8071 (only used on shipping labels when using overnight delivery services)
Faxed or E-mailed Certification Applications WILL NOT be accepted.
BASIC INFORMATION – APPLICANT CDE
Select the Application Type being submitted (check one):
Type A: An Applicant CDE that is applying for initial CDE certification only on behalf of itself.
Type B: An Applicant CDE that is applying for initial CDE certification on behalf of itself and one or more subsidiary entities.
Type C: An Applicant CDE, which is already certified, that is applying for CDE certification on behalf of one or more subsidiary entities.
Enter Name of Applicant CDE: __________________________________________________________
Is the Applicant CDE already certified as a CDE? YES NO
If yes, provide the CDE Certification Application Control Number of the Applicant CDE: _________________________
Enter the number of Subsidiary Applicant(s) submitted under this application: ___________
For Type B and Type C Applications, complete the table below for all subsidiaries submitted under this Application:
Name of Subsidiary (Application Type B & C Only) |
Employer Identification Number (EIN) |
EXPRESS OPTIONS (See page 10) [All boxes must be checked to utilize the Express Option] |
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Additional Subsidiary Applicants
(Copy this page as necessary.)
Name of Subsidiary (Application Type B & C Only) |
Employer Identification Number (EIN) |
EXPRESS OPTIONS (See page 10) [All boxes must be checked to utilize the Express Option] |
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Enter structure of the Applicant CDE (check all that apply)
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Products and Services that are, or will be, offered by the Applicant CDE (check all that apply)
Real estate financing (check only one accompanying sub-category) Retail Industrial/Manufacturing Community Facilities Hospitality/Tourism Office Space For-sale Housing Business financing Mixed-use (housing commercial, retail) Microenterprise financing Financing other CDEs Loan purchase from other CDEs Financial Counseling and Other Services |
Structure of the Applicant CDE’s Controlling Entity (check all that apply)
Not Applicable – Applicant CDE does not have a Controlling Entity |
Market Served and Estimated % of Total Activities (should total 100 percent)
_____ percent - Major urban areas (Counties in Metropolitan Area with a population equal to or greater than 1 million include both central city and surrounding suburbs)
_____ percent - Minor urban areas (Counties in Metropolitan Area with a population of less than 1 million include both central city and surrounding suburbs)
_____ percent - Rural areas
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Applicant Organizational Address(es):
Mailing Address |
Shipping Address (if different, for overnight deliveries) |
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Applicant Contact Information
Authorized Representative: |
Applicant Contact (if different than AR): |
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Name |
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Phone |
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Fax |
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I hereby certify that all of the information provided in connection with the above-named Applicant CDE’s certification as a CDE is true, accurate and complete. The submission of such information has been duly authorized by the above-named Applicant CDE’s governing body. |
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Authorized Representative Signature: |
Date: |
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Estimate how long this Certification Application form took to complete: ________ hours
Certifications and Signature
REQUIRED:
I certify, on behalf of the Applicant CDE and, if applicable, its Subsidiary Applicants, that it/they will, at all times during the course of its/their designation as a CDE, direct a minimum of sixty percent of its/their activities (including loans, investments and related technical assistance) to Low-Income Persons, to persons or organizations located in Low-Income Communities, or to other organizations that principally serve Low-Income Persons or residents of Low-Income Communities.
I further certify that the Applicant CDE and, if applicable, its Subsidiary Applicant(s), will maintain accountability to the Low-Income Communities that it/they serve, through their representation on the governing board or on an advisory board(s) to the Applicant CDE (and, if applicable Subsidiary Applicants), at all times during the course of its/their designation as a CDE.
The Applicant CDE and, if applicable, its Subsidiary Applicant(s) acknowledges that it may be required to periodically certify to the Fund that it continues to comply with the above certification requirements, and to notify the Fund if the Applicant CDE and, if applicable, its Subsidiary Applicant(s) fails to comply with these requirements. The Applicant CDE and, if applicable, its Subsidiary Applicant(s) acknowledges further that a failure to comply with these requirements may result in the Applicant CDE and, if applicable, its Subsidiary Applicant(s) losing its designation as a CDE, as well as the revocation of NMTC Allocations provided to the Applicant CDE or Subsidiary Applicants and/or the recapture of NMTCs claimed by investors for making Qualified Equity Investments in the Applicant CDE or Subsidiary Applicants.
OPTIONAL FOR APPLICANT CDE’S APPYING FOR CERTIFICATION ON BEHALF OF ONE OR MORE SUBSIDIARY CDE APPLICANTS:
EXPRESS OPTION - Applicant CDEs (Type B or C) seeking to certify Subsidiary Applicants as CDEs that have the same Primary Mission, Service Area, and Board(s) as the Applicant CDE, may make the following certification by checking the following box below:
I certify, on behalf of Applicant CDE, that the designated Subsidiary Applicant CDE(s) listed in this application, for which all three boxes were checked in the Basic Information Section, are legal entities (having filed the necessary paperwork with the appropriate state agencies), have valid EINs, and
have the same Primary Mission as the Applicant CDE and there have been no unapproved material changes to the Applicant CDE’s Primary Mission; and
have the same Service Area as the Applicant CDE and there have been no unapproved material changes to the Applicant CDE’s Service Area; and
have the same Accountability as the Applicant CDE and there have been no unapproved material changes to the Applicant CDE’s Accountability.
Selecting the option above requires that no further application materials be submitted for those subsidiary CDEs listed on the Applicant’s Basic Information page and for which all three boxes under the EXPRESS OPTION have been checked; EXCEPT LEGAL ENTITY DOCUMENTATION.
Authorized Representative Signature: |
Date: |
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BASIC INFORMATION
Name of Subsidiary CDE |
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Subsidiary CDE Employer Identification Number |
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Contact Name |
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Contact Telephone |
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Contact Email |
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Mailing Address
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Market Served and Estimated % of Total Activities (should total 100 percent)
_____ percent - Major urban areas in a Metropolitan Area with a population equal to or greater than 1 million (include both central city and surrounding suburbs).
_____ percent - Minor urban areas in a Metropolitan Area with a population of less than 1 million (include both central city and surrounding suburbs).
_____ percent - Rural areas
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Type of Entity (check all that apply)
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Products and Services that are, or will be, offered by the Subsidiary CDE (check all that apply)
Real estate financing (check only one accompanying sub-category) Retail Office Space Industrial/Manufacturing For-sale Housing Community Facilities Business financing Hospitality/Tourism Mixed-use (housing commercial, retail) Microenterprise financing Financing other CDEs Loan purchase from other CDEs Financial Counseling and Other Services |
Type A & B Only
Criteria: LEGAL ENTITY
As of the date its CDE Certification Application is submitted (signed by Authorized Representative), the Applicant, and relevant subsidiaries, must be duly organized and validly exist under the laws of the state jurisdiction in which it is incorporated or established AND be a domestic corporation or partnership for federal tax purposes. Legal documents must be submitted for the Applicant and all subsidiaries, INCLUDING subsidiaries using the EXPRESS OPTION)
APPLICANT CDE: ______________________________________________________________
EVIDENCE OF LEGAL ENTITY STATUS
Is the Applicant CDE a domestic corporation or partnership for federal tax purposes? YES NO
If no, the applicant is not eligible to apply for certification as a CDE and therefore should not submit a CDE Certification Application.
NOTE: Section 7701(a)(4) of the Internal Revenue Code defines "domestic" when applied to a corporation or partnership to mean created or organized in the United States or under the law of the United States or of any State unless, in the case of a partnership, the Secretary provides otherwise by regulations.
Organizations incorporated in US territories are not considered "domestic" corporations or partnerships for the purpose of this definition.
If the Applicant CDE is an LLC:
Does the LLC have more than one Member? YES NO
If “NO” to the question above, has the LLC elected to be treated as a corporation for federal tax purposes? YES NO
* Attach, if the Applicant is a single member LLC, a copy of the Applicant’s official IRS Documentation of tax classification election as a corporation (e.g. submitted IRS Form 8832 or IRS acceptance of Form 8832.)
Enter the Applicant CDE’s date of incorporation/organization/establishment (month/day/year):_________
Enter the Applicant CDE’s total assets as of the date of this application: $______________
* Attach a copy of one of the following (documents must be signed, stamped, and filed with the appropriate state agency):
Articles of Incorporation
Certificate of Formation
Organization Certificate
Other:_____________________
* Attach any amendments to attached organizing documents, (documents must be signed, stamped, and filed with the appropriate state agency).
EMPLOYER IDENTIFICATION NUMBER (EIN)
Enter CDE’s Employer Identification Number:
* Attach one of the following for the Applicant CDE (documentation must clearly identify both the entity’s legal name and its EIN):
Official letter from IRS providing EIN;
Confirmation fax from local IRS office with the organization’s name and EIN; or
A printout of completed and submitted online SS-4 (with organization’s EIN in upper right hand corner) from IRS’ website, accompanied by a printout of the online confirmation of receipt of EIN from IRS’ website.
Type B & C Only
Criteria: LEGAL ENTITY
As of the date its CDE Certification Application is submitted (signed and mailed by Authorized Representative), the Applicant, and relevant subsidiaries, must be duly organized and validly exist under the laws of the state jurisdiction in which it is incorporated or established AND be a domestic corporation or partnership for federal tax purposes. Legal documents must be submitted for the Applicant and all subsidiaries, INCLUDING subsidiaries using the EXPRESS OPTION.
SUBSIDIARY CDE Name: ____________________________________________________
EVIDENCE OF LEGAL ENTITY STATUS
Is the Subsidiary CDE a domestic corporation or partnership for federal tax purposes? YES NO
If no, the applicant is not eligible to apply for certification as a CDE and therefore should not submit a CDE Certification Application.
NOTE: Section 7701(a)(4) of the Internal Revenue Code defines "domestic" when applied to a corporation or partnership to mean created or organized in the United States or under the law of the United States or of any State unless, in the case of a partnership, the Secretary provides otherwise by regulations.
Organizations incorporated in US territories are not considered "domestic" corporations or partnerships for the purpose of this definition.
If the Subsidiary CDE is an LLC:
Does the LLC have more than one Member? YES NO
If “NO” to the question above, has the LLC elected to be treated as a corporation for federal tax purposes? YES NO
* Attach, if the Subsidiary CDE is a single member LLC, a copy of the Subsidiary CDE’s official IRS Documentation of tax classification election as a corporation (e.g. submitted IRS Form 8832 or IRS acceptance of Form 8832.)
Enter the Subsidiary CDE’s date of incorporation/organization/establishment (month/day/year):________
Enter the Subsidiary CDE’s total assets as of the date of this application: $ _____________
* Attach a copy of one of the following (documents must be signed, stamped, and filed with the appropriate state agency). Indicate which document is submitted below:
Articles of Incorporation
Certificate of Formation
Organization Certificate
Other:_____________________
* Attach any amendments to attached organizing documents, (documents must be signed, stamped, and filed with the appropriate state agency).
EMPLOYER IDENTIFICATION NUMBER (EIN)
Enter CDE’s Employer Identification Number:
* Attach one of the following for each Subsidiary Applicant (documentation must clearly identify both the entity’s legal name and its EIN):
Official letter from IRS providing EIN;
Confirmation fax from local IRS office with the organization’s name and EIN; or
A printout of completed and submitted online SS-4 (with organization’s EIN in upper right hand corner) from IRS’ website, accompanied by a printout of the online confirmation of receipt of EIN from IRS’ website.
Type A & B Only
Criteria: PRIMARY MISSION
A CDE must demonstrate that it has a primary mission of serving, or providing investment capital for LICs or low income persons, and that at least 60 percent of its activities (e.g., loans and investments) are targeted to low income persons or LICs.
APPLICANT CDE: ___________________________________________________________
Indicate type of board-approved organizational document that provides evidence of Applicant’s primary mission of promoting community development:
Articles of Incorporation, Organization, or Formation (signed and filed with appropriate state agency)
Bylaws (board-approved)
Board approved resolution
Annual report containing a signed letter from the Board Chairperson
Board-approved, one-page narrative that specifically states how the organization’s collective activities and products evidence the primary mission certification criteria
Other similar board-approved documents
* Attach: Copy of the Applicant’s organizational documents, as indicated above, that provide evidence of a primary mission of promoting community development.
Enter primary mission of Applicant (as stated in board approved document(s) indicated above):
Type B & C Only
Criteria: PRIMARY MISSION
A CDE must demonstrate that it has a primary mission of serving, or providing investment capital for LICs or low income persons, and that at least 60 percent of its activities (e.g., loans and investments) are targeted to low income persons or LICs.
SUBSIDIARY CDE Name: _______________________________________________________
(Complete and submit requested information for each Subsidiary seeking certification, except those for which the EXPRESS OPTION is selected. Reproduce additional copies of the form as needed.)
Indicate type of board-approved organizational document that provide evidence of Applicant’s primary mission of promoting community development:
Articles of Incorporation, Organization, or Formation (signed and filed with appropriate state agency)
Bylaws (board-approved)
Board approved resolution
Annual report containing a signed letter from the Board Chairperson
Board-approved, one-page narrative that specifically states how the organization’s collective activities and products evidence the primary mission certification criteria
Other similar board-approved documents
* Attach: Copy of the Applicant’s organizational documents, as indicated above, that provide evidence of a primary mission of promoting community development.
Enter primary mission of Applicant (as stated in board approved document(s) indicated above):
Type A & B Only
Criteria: ACCOUNTABILITY & SERVICE AREA
A CDE Applicant must identify the service area that it serves or intends to serve; and demonstrate that it maintains accountability to the LICs in those areas.
APPLICANT CDE:
Select and identify the service area geography the entity currently serves or intends to serve:
Local service area [e.g., county(ies); PMSA(s)]: _______________________________________
State-wide or territory-wide service area: ____________________________________________
Multi-state service area: __________________________________________________________
National service area: ___________________________________________________________
Select and identify the method of accountability maintained to the residents of LICs (check all that apply):
Governing Board of the Applicant CDE
Governing Board of the Applicant CDE’s Controlling Entity
Governing Board of the Subsidiary Applicant
Advisory Board(s)
Enter the number of Advisory Boards used to maintain accountability __________
Enter the names of the Advisory Boards used to maintain accountability
#1 ________________________________________________
#2 ________________________________________________
#3 ________________________________________________
APPLICANT CDE:
Complete one Board Table for each governing and/or advisory board listed.
For governing and advisory boards, the options for how board members may be representative of a Service Area are as follows:
Categories for Board Members: |
Board members may:
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Reside within a NMTC qualified census tract within the designated service area.
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Own, control, or manage a business located in a NMTC qualified census tract within the designated service area(s) that principally employs or provides goods and services to area LIC residents.
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Be an employee or board officer of a non-affiliated community-based or charitable organization providing more than 50% of its program activities and services to LICs within the designated area.
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Be a religious leader whose congregation is located in a NMTC qualified census tract.
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Be an employee of a governmental agency or department that primarily serves LICs, or whose job responsibilities primarily involve serving LICs.
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Be, or work for, an elected official whose constituency is comprised principally of, or are residents of, qualified NMTC census tracts.
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BOARD TABLE
BOARD TYPE: Governing: (TYPE)___________________ Advisory: (NAME)________________________ BOARD COMPOSITION DATE (as of): ____________________ |
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Name (List all board member’s names) |
LIC Representative (yes or no)? |
Category (Choose from category listed above) |
Geographic Area(s) Serve |
Conflict of Interest Certification: Check here to certify that neither board member, nor any of his/her family members, is (are) principal(s) or staff member(s) of the Applicant CDE (or Subsidiary Applicant), its affiliated entities, or its investors.
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
Total # of board members |
%of LIC Reps |
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For each board member designated as a LIC Representative, complete an LIC Representative Form, have the LIC Representative sign the form and submit with the application.
If the applicant entity intends to maintain accountability to the residents of its LIC through their representation on Advisory Board(s), provide a narrative statement, detailing the following for each Advisory Board named above:
The process by which members are selected for the Advisory Board;
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ow often the Advisory Board meets (to be accountable, a board must meet at least annually);
How the Advisory Board solicits, or intends to solicit, feedback from LIC residents, and how often this information is, or will be, collected (e.g., feedback collected semi-annually at community meetings, feedback collected annually through surveys, etc.); and
How the information is used, or will be used, to influence the Governing Board’s actions in developing the organization’s policies (e.g., an Advisory Board representative sits on the Governing Board; a member of the Advisory Board presents reports to the Governing Board, etc.).
Type B & C Only
Criteria: ACCOUNTABILITY & SERVICE AREA
A CDE Applicant must identify the service area that it serves or intends to serve; and demonstrate that it maintains accountability to the LICs in those areas.
SUBSIDIARY CDE Name: ________________________________________________________
(Complete and submit requested information for each Subsidiary seeking certification, except those for which the EXPRESS OPTION is selected. Reproduce additional copies of the form as needed.)
Select and identify the service area geography the entity currently serves or intends to serves:
Local service area [e.g., county(ies); PMSA(s)]: _______________________________________
State-wide or territory-wide service area: ____________________________________________
Multi-state service area: __________________________________________________________
National service area: ___________________________________________________________
Select and identify the method of accountability maintained to the residents of LICs (check all that apply):
Governing Board of the Applicant CDE
Governing Board of the Applicant CDE’s Controlling Entity
Governing Board of the Subsidiary Applicant
Advisory Board(s)
Enter the number of Advisory Boards used to maintain accountability __________
Enter the names of the Advisory Boards used to maintain accountability
#1 ________________________________________________
#2 ________________________________________________
#3 ________________________________________________
SUBSIDIARY CDE Name: ________________________________________________________
Complete one Board Table for each governing and/or advisory board listed.
For governing and advisory boards, the options for how board members may be representative of a Service Area are as follows:
Categories for Board Members:
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Board members may:
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Reside within a NMTC qualified census tract within the designated service area.
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B |
Own, control, or manage a business located in a NMTC qualified census tract within the designated service area(s) that principally employs or provides goods and services to area LIC residents.
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Be an employee or board officer of a non-affiliated community-based or charitable organization providing more than 50% of its program activities and services to LICs within the designated area.
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Be a religious leader whose congregation is located in a NMTC qualified census tract.
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Be an employee of a governmental agency or department that primarily serves LICs, or whose job responsibilities primarily involve serving LICs.
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Be, or work for, an elected official whose constituency is comprised principally of, or are residents of, qualified NMTC census tracts.
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BOARD TABLE
BOARD TYPE: Governing: (TYPE)___________________ Advisory: (NAME)________________________ BOARD COMPOSITION DATE (as of): ____________________ |
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Name (List all board member’s names) |
LIC Representative (yes or no)? |
Category (Choose from category listed above) |
Geographic Area(s) Serve |
Conflict of Interest Certification: Check here to certify that neither board member, nor any of his/her family members, is (are) principal(s) or staff member(s) of the Applicant CDE (or Subsidiary Applicant), its affiliated entities, or its investors.
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
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There is no conflict of interest. |
Total # of board members |
%of LIC Reps |
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For each board member designated as a LIC Representative, complete an LIC Representative Form, have the LIC Representative sign the form and submit with the application.
If the applicant entity intends to maintain accountability to the residents of its LIC through their representation on Advisory Board(s), provide a narrative statement, detailing of the following for each Advisory Board named above:
The process by which members are selected for the Advisory Board;
H
ow often the Advisory Board meets (to be accountable, a board must meet at least annually);
How the Advisory Board solicits, or intends to solicit, feedback from LIC residents, and how often this information is, or will be, collected (e.g., feedback collected semi-annually at community meetings, feedback collected annually through surveys, etc.); and
How the information is used, or will be used, to influence the Governing Board’s actions in developing the organization’s policies (e.g., an Advisory Board representative sits on the Governing Board; a member of the Advisory Board presents reports to the Governing Board, etc.).
LOW INCOME REPRESENTATIVE FORM
(Complete and submit requested information for each proposed LIC representative. Reproduce additional copies of the form as needed.)
Board Member’s Name: ______________________________________________
Service Area BOARD MEMBER (not Applicant) represents (e.g. County(ies), (P)MSA, State(s), National): _______________________________________________
How is the Board Member representative of LICs? (Check and complete information in only one category below)
A. Is a resident of a LIC. Provide the information below.
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Board Member’s Complete Home Address:
Census Tract (11 digit FIPS code):
Attach the “Address Geocoder Report” from The Fund’s CIMS mapping program.
B. Is a small business owner who controls, operates or manages a business located in a LIC that: a) provides goods and services to LIC residents; or b) principally employs LIC residents.
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Business Name:
Business’ Complete Street Address:
Census Tract (11 digit FIPS code):
Attach the “Address Geocoder Report” from The Fund’s CIMS mapping program.
Provide a clear and concise description of the goods and/or services the business provides to the LIC, and/or how it was determined that the business principally employs LIC residents.
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Description of goods and/or services:
Explain how and what percentage of LIC residents the business employs:
C. Is an employee or board member of a non-affiliated community-based or charitable organization that provides more than 50 percent of its activities or services to Low-Income Persons and/or LICs. Provide ALL of the information below.
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Board Member Title:
Charitable organization name:
Organization Website Address:
Geographic area organization serves (County(ies), State, or Metropolitan Statistical Areas):
Describe the organization’s primary activities and services that directly benefit Low-Income Persons and/or Communities:
Primary Low-Income Mission Certification:
The organization named above has a primary mission to serve low-income persons and/or communities, and more than 50% of the organization’s program activities and services are directed to benefiting low-income persons and/or communities.
D. Is a religious leader whose congregation is based in an LIC.
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Board Member Title:
Religious Entity Name:
Religious Entity’s Complete Street Address:
Census Tract (11 digit FIPS code):
Attach the “Address Geocoder Report” from The Fund’s CIMS mapping program.
E. Is a governmental agency/department employee that primarily serves LICs, or is a governmental agency/department employee whose job responsibilities primarily involve serving LICs.
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Board Member Title:
Agency/Department Name:
Agency/Department Website:
Geographic area agency/\department Serves (County(ies), state, or Metropolitan Statistical Areas):
Describe the Agency/Department’s primary activities and services, or the Board Member’s primary job responsibilities, that benefit Low-Income Persons and/or Communities:
Primary Low-Income Mission Certification:
The agency/department has a primary mission, or the Board Member has primary responsibilities, to serve low-income persons and/or communities, and more than 50% of the agency/department’s program activities and services, or more than 50% of the Board Member’s responsibilities, are directed to benefiting low-income persons and/or communities.
F. Is, or works for, an elected official whose constituency is comprised primarily of LICs or residents of LICs. Provide information below.
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Board Member organization title:
Elected Official Name:
Elected Official’s Geographic Jurisdiction:
Explain how it was determined that the elected official’s constituency is comprised primarily of LICs or LIC residents:
Attach the “Address Geocoder Report” from The Fund’s CIMS mapping program.
The LIC representative identified above certifies that all of the information provided by the Applicant CDE is true and accurate.
LIC Representative Signature: |
Date: |
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Page
| File Type | application/msword |
| File Title | Criteria: LEGAL ENTITY |
| Author | wilbrahams |
| Last Modified By | Wolfgang, Dawn |
| File Modified | 2013-07-11 |
| File Created | 2013-07-11 |
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