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pdf COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Basic Applicant Information
Basic Information
Name
DUNS #
EIN
MyTest CDFI
11‐1234567
Type of Organization
Congressional District
FY End Date (mm/dd)
Mailing Address
Street 1
Street 2
City
State
Zip Code
Shipping Address
Street 1
Street 2
City
State
Zip Code
Authorized Representative
Name
Phone
Fax
Email
Application Contact
Name
Phone
Fax
Email
Is the Applicant a Subsidiary of any Insured Depository Institution (IDI) or a Depository
Institution Holding Company (DIHC) (i.e. does any IDI or DIHC control 25% or more of any class
of the Applicant’s voting shares or otherwise control, in any manner, the election of a majority
of directors of the Applicant)?
Does the Applicant want to be designated as a Native American CDFI?
If “Yes”, indicate the percentage of activities provided to Native
American communities during the most recent fiscal year
Date
I hereby certify that all of the information provided in connection with the above‐named entity’s certification as a
CDFI is true, accurate and complete. The submission of such information has been duly authorized by the above‐
named entity’s governing body.
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Affiliate Information
MyTest CDFI (EIN: 11‐1234567)
Affiliate Information
Affiliate Name
Affiliate EIN
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Legal Entity
MyTest CDFI (EIN: 11‐1234567)
Evidence of Incorporation/Organization/Establishment
Date of Incorporation/Organization/Establishment
For Regulated Institutions
Applicant's Federal or State Regulator
If "Other" ‐ Please List
Charter Number
FDIC Insurance Certificate Number
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Primary Mission
MyTest CDFI (EIN: 11‐1234567)
Applicant
Y/N
Indicate the type of board‐approved
organizational documents that
provide evidence of the primary
mission of promoting community
development of the Applicant.
Organizational Documents
Articles of Incorporation or organization (signed and filed)
Bylaws (board‐approved)
Board 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
NCUA Low‐Income designation letter (for credit unions only)
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Primary Mission
MyTest CDFI (EIN: 11‐1234567)
Product Table
Product
Product Category
Product Description
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Primary Mission
MyTest CDFI (EIN: 11‐1234567)
Enter EIN Below
Enter Name Below
Affiliate or Subsidiary
Yes / No
Indicate the type of board‐approved
organizational documents that
provide evidence of the primary
mission of promoting community
development of the Applicant's
Affiliate or Subsidiary.
Organizational Documents
Articles of Incorporation or organization (signed and filed)
Bylaws (board‐approved)
Board 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
NCUA Low‐Income designation letter (for credit unions only)
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Financing Entity
MyTest CDFI (EIN: 11‐1234567)
TOTAL ASSETS
$0
% of Total
Assets
0%
Sub‐Total
$0
0%
Sub‐Total
$0
0%
Sub‐Total
$0
0%
Sub‐Total
$0
0%
Asset Information Table
Dollar Amount
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
Loans Receivable and/or Equity Investments
Balance Sheet Account Name
Balance Sheet Account Name
Balance Sheet Account Name
Loans Purchased from CDFIs
Balance Sheet Account Name
Balance Sheet Account Name
Balance Sheet Account Name
Other Financing Assets
Balance Sheet Account Name
Balance Sheet Account Name
Balance Sheet Account Name
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Financing Entity
MyTest CDFI (EIN: 11‐1234567)
Financing Related Activities
Balance Sheet Account Name
Balance Sheet Account Name
Balance Sheet Account Name
Sub‐Total
$0
0%
$0
0%
Sub‐Total
$0
0%
Total Financing Activities Assets
$0
0%
Sub‐Total
$0
0%
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
Major Non‐Financing Assets
Balance Sheet Account Name
Balance Sheet Account Name
Balance Sheet Account Name
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Financing Entity
MyTest CDFI (EIN: 11‐1234567)
Liquid Assets Available for Financing in Next Three Months
Cash and Cash Equivalents
Balance Sheet Account Name
Balance Sheet Account Name
Balance Sheet Account Name
Sub‐Total
$0
Sub‐Total
$0
Sub‐Total
$0
Other Financing Assets
Balance Sheet Account Name
Balance Sheet Account Name
Balance Sheet Account Name
Off Balance Sheet and Other Sources
Other
Other
Other
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
$0
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Financing Entity
MyTest CDFI (EIN: 11‐1234567)
Total Number of Full‐Time Equivalent (FTE) Staff
0.00
% of Total
FTEs
0%
Financing Activities
FTEs devoted to provision of Financial Products
FTEs devoted to Financing Related Activities
Sub‐Total for FTEs devoted to Financing Activities
0.00
0%
Development Services
FTEs devoted to Development Services
Total FTEs devoted to Financing Activities and Development Services
0.00
0%
0.00
0%
Staff Allocation Table
# of FTEs
Major Non‐Financing Activities
1
2
3
Total Major Non‐Financing Activities
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Target Market ‐ Current Year
MyTest CDFI (EIN: 11‐1234567)
Is the Applicant's primary business activity to provide Financial Products to CDFIs and/or emerging CDFIs?
Target Market Activity for Current Year
to Date
Estimated Values?
Target Market
Type
Total Activity
TM 1
TM 2
TM 3
TM 4
TM 5
Total TM Activity
Total TM Activity as % of Total Activity
Products Categories
Loans
#
$
Equity Invests
Loan Purchases
#
#
$
$
Loan Guarantee
#
$
Totals (by TM)
#
$
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Target Market ‐ Current Year
MyTest CDFI (EIN: 11‐1234567)
Target Market Activity for Current Year
to Date
Estimated Values?
Products Categories
# of
Target Market
Deposits/Sh Members
Type
ares ($)
(for CUs)
Total Activity
TM 1
TM 2
TM 3
TM 4
TM 5
Total TM Activity
Total TM Activity as % of Total Activity
All Other Activities
# of Dev
Services #
$
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Target Market ‐ Most Recent FYE
MyTest CDFI (EIN: 11‐1234567)
Target Market Activity for Most Recent
FYE
Estimated Values?
Target Market
Type
Total Activity
TM 1
TM 2
TM 3
TM 4
TM 5
Total TM Activity
Total TM Activity as % of Total Activity
Products Categories
Loans
#
$
Equity Invests
Loan Purchases
#
#
$
$
Loan Guarantee
#
$
Totals (by TM)
#
$
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Target Market ‐ Most Recent FYE
MyTest CDFI (EIN: 11‐1234567)
Target Market Activity for Most Recent
FYE
Estimated Values?
Products Categories
# of
Target Market
Deposits/Sh Members
Type
ares ($)
(for CUs)
Total Activity
TM 1
TM 2
TM 3
TM 4
TM 5
Total TM Activity
Total TM Activity as % of Total Activity
All Other Activities
# of Dev
Services #
$
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Accountability
MyTest CDFI (EIN: 11‐1234567)
Board Tables
Board Type
Date of Board Composition
Total Target Market Representatives
Total Board members
I hereby certify that none 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.
Board Member Name
TM Rep
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Accountability
MyTest CDFI (EIN: 11‐1234567)
Investment Area
Board Member Name
IA
Type of Representative
Describe how represents of TM
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Accountability
MyTest CDFI (EIN: 11‐1234567)
Low‐Income Targeted Population
Board Member Name
LITP
Type of Representative
Describe how represents of TM
LITP Geographies
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Accountability
MyTest CDFI (EIN: 11‐1234567)
Other Targeted Population
Board Member Name
OTP
Type of Representative
Describe how represents of TM
OTP Type(s)
OTP
Geographies
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Accountability
MyTest CDFI (EIN: 11‐1234567)
Government Representation
Board Member Name
Gov't Rep
or Official
Title and Agency
If special powers or authority,
describe
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Accountability
MyTest CDFI (EIN: 11‐1234567)
Accountability Methods
Target Market Name (same as map Governing
name)
Board
Advisory Board(s)
Other Mechanism(s)
Provide further
explanation of
Accountability, if
necessary
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Accountability
MyTest CDFI (EIN: 11‐1234567)
Representative Members
Target Market Name (same as map name)
Governing Board Members
Advisory Board Members
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Development Services
MyTest CDFI (EIN: 11‐1234567)
Development Services Table
Development
Service Activities
(Name & Topic)
Related Products
Format
Provider
Est % of Dev
Est % of Dev
Service
Clients
Est.
Service
Organization
Clients
Clients
Receiving
Name (if Affiliate
Per Year Receiving Applicant's
or Other)
(#)
Applicant's Financing in
Financing
the Target
Market(s)
Description of how
Development Services
activity is provided in
conjunction with the
Applicant’s products
COMMUNITY DEVELOPMENT FINANCIAL INSTITUTIONS FUND
CDFI Certification Application
Criteria: Non‐Governmental Entity
MyTest CDFI (EIN: 11‐1234567)
Non‐Governmental Entity
Y/N
Do one or more government entities or officials control the election or appointment of a majority of the members of the Applicant's
board of directors, or control a substantial minority of such directors?
Does a majority or substantial minority of the Applicant’s board of directors consist of government officials (elected, appointed,
employees, etc.)?
Do the Applicant’s organizing/establishing documents or by‐laws require that a certain number of the Applicant’s board of directors be
government employee’s or elected/appointed government officials?
Do one or more government entities have veto power over the selection of the Applicant’s executive director, CEO, or comparable
officer, or specific investment decisions?
Does any government entity provide more than 50% of the Applicant’s operating and/or capital budget?
If the Applicant receives operating and/or capital funds from a government entity, does that government entity have the ability to
control the use of those funds (for example, does a government entity have veto power over the lending/investing transactions made
with those funds)?
Does any government entity manage any aspect of the Applicant’s operations?
Are any of the employee’s of the Applicant government employees or employees of an organization controlled by one or more
government entities?
Does any government entity manage any aspect of the Applicant’s operations?
If the Applicant organization is controlled by another entity, is that entity controlled by one or more government entities?
| File Type | application/pdf |
| Author | markovitzp |
| File Modified | 2013-01-17 |
| File Created | 2013-01-17 |