OPM 1647C Local Independent Application

OMB APPROVED
No. 3206-0131

COMBINED FEDERAL CAMPAIGN
2015 Application Instructions for
Local Independent Organizations and
Members of Federations
decision is final for administrative purposes.
Appellants should ensure that their appeals are
complete and responsive to the actual reasons for
the LFCC denial decision.

BACKGROUND
Enclosed is the model application for use by local
independent organizations applying to participate
in the Combined Federal Campaign (CFC) and for
use by local federation members to submit to the
local 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.

Each LFCC determines the application deadline
for organizations seeking local eligibility. Since
local dates will vary, please check with the local
CFC for local application deadlines and filing
information. Local campaign contact information
can be found on the CFC website at
www.opm.gov/cfc/Search/Locator.asp.
If a local application form is available, OPM
suggests that organizations use the local
application provided when applying to the CFC.
The CFC will not accept application forms with
modifications to any of the certification statements.

All required documents and attachments must be
complete and submitted before the application
deadline each year. The CFC 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.

In order to determine whether an organization may
participate in the campaign, the LFCC may request
evidence of corrective action regarding any prior
violation of regulation or directive, sanction, or
penalty, as appropriate. The LFCC will decide
whether the organization has demonstrated, to the
LFCC’s satisfaction, that the organization has
taken appropriate corrective action. Failure to
demonstrate satisfactory corrective action or to
respond to the LFCC’s request for information
within 10 business days of the date of the request
may result in a recommendation to OPM that the
organization will not be included in the Charity
List. The Director’s decision will be communicated in writing to the organization.

Documents that did not exist at the time of the
application deadline will not be accepted during
the appeals process. Organizations that apply for
local eligibility and are found ineligible will have
an opportunity to appeal to the Local Federal
Coordinating
Committee
(LFCC)
for
reconsideration. If found ineligible on appeal by
the LFCC, the organization may appeal the
LFCC’s decision to the Director of the Office of
Personnel Management (OPM). The Director's

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OPM Form 1647-C
Rev. August 2014

Contact Telephone Contact person’s telephone
number, if different than the organization’s telephone number.

DEFINITIONS
Organization
Name of the applicant
organization, as it appears in the IRS Business
Master File. If the name of the organization differs
from the name that appears on the IRS
determination letter, IRS Form 990, or audited
financial statements, official documentation from
the IRS or state government authorizing use of this
name must accompany the application. The EIN
must be included.

Fax Contact person’s fax number.
Contact E-Mail Address(es) Contact person’s
electronic mail address. Applicants are encouraged to provide more than one email address.
Website Address
List one complete Internet
address of the applicant organization (no e-mail
addresses). This information is required, if the
organization has an Internet address.

Employer Identification Number (EIN) The
nine-digit EIN assigned to the organization by the
IRS and appearing on the IRS Form 990 submitted
with this application.

Disbursement Address List the address where
paper checks will be sent, if different from mailing
address. Post office boxes may be used for the
disbursement address.

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.

Electronic Funds Transfer (EFT) Information
List the Routing and Account numbers, along with
the name of the financial institution, where funds
should be disbursed. This is an optional method
for receipt of CFC contributions. NOTE: Some
campaigns may elect not to disburse funds
electronically.

Organization Address A physical street address
must be provided - Post Office Box addresses will
not be accepted. This is the administrative office
address that will be used to assign a 5-digit CFC
code.
Check the box below the address to denote that it
is different from the address submitted with the
2014 CFC application.

INSTRUCTIONS
For details regarding CFC eligibility requirements
for local independent organizations and federation
members, refer to CFC Guidance Memoranda on
the CFC website at www.opm.gov/cfc.

Service Office Address The location where
services are provided (if different from the
Organization Address).

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
a refusal to certify and will result in the denial of
the application.

Telephone Organization’s telephone number.
Contact Person The contact person is the individual to whom the CFC will direct communications. This may be any individual in the organization.
Contact Title Self-explanatory

Item 1
Include as Attachment A supporting statements
and/or documentation demonstrating to the
satis-faction of the LFCC that the organization
has a substantial local presence in the
geographical area covered by the local
campaign. Attachment A must also include a

Contact Address
Contact person’s mailing
address if different than the organization's
Address. Post Office Boxes may be used.
Participation decision letters and other CFC
communications will be sent to the contact person
at this address.

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OPM Form 1647-C
Rev. August 2014

organization that do not have an IRS determination letter for the local organization must
provide a certification signed by either the Chief
Executive Officer (CEO) or CEO equivalent of the
national organization and dated on or after October
1, 2014, 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.

description of the actual services, benefits,
assistance, or program activities. provided by the
organization in calendar year 2014 and how those
programs, services, benefits, etc. affect human
health and welfare of the target population (see
Certification #4). Organizations are encouraged to
list the number of beneficiaries of each service
and/or the value of financial assistance provided in
each location.
Substantial local presence is defined as a staffed
facility, office or portion of a residence dedicated
exclusively to that organization, available to
members of the public seeking its services or
benefits. The facility must be open at least 15
hours a week and have a telephone dedicated
exclusively to the organization. The office may be
staffed by volunteers. Substantial local presence
cannot be met on the basis of services provided
solely through an “800” telephone number or by
disseminating information or publications via the
U.S. Postal Service, the Internet, or a combination
thereof. (Information on the geographic boundaries of local CFC Campaigns can be found on the
CFC
website
at
www.opm.gov/cfc/Search/Locator.asp.)

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
Check the appropriate box.

If the office where the services are provided (as
described in Attachment A) is different from the
organization’s main address (as listed on page 8),
enter the address of the location where the services
are provided.

Listing of a national organization, as well as its
local affiliate organization, is permitted. Each
national or local organization must individually
meet all of the eligibility criteria and submit
independent documentation as required in 5 C.F.R.
§950.202, §950.203 or §950.204 to be included in
the Charity List, except that a local affiliate of a
national organization that is not separately
incorporated, in lieu of its own 26 USC 501(c)(3)
tax exemption letter and, to the extent required by
§950.204(b)(2)(ii), audited financial statements,
may submit the national organization’s 26 USC
501(c)(3) tax exemption letter and audited
financial statements, but must provide its own pro
forma IRS Form 990 (see Item 6) for CFC
purposes.

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.
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

A national organization may waive its listing in the
National/International or International parts of the
Charity List in favor of its local affiliate by
following the procedures set forth in 5 C.F.R.
§950.201(c).

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OPM Form 1647-C
Rev. August 2014

the information must be provided to OPM or the
LFCC upon request. Note that GAAP requires the
use of the accrual method of accounting. No other
basis of accounting is acceptable under GAAP.
The cash basis, modified cash basis, modified
accrual, and any other methods are not acceptable.

Item 4
Self-explanatory. Human health and welfare
services provided in calendar year 2014 must be
reflected in Attachment A.
Item 5
Check the appropriate box.

OR

Organizations with $250,000 or more in annual
revenue, as reported on the IRS Form 990, are
required to submit an annual audit of fiscal
operations by an independent certified public
accountant in accordance with Generally
Accepted Auditing Standards (GAAS). 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
2015 (i.e. ending on or after June 30, 2013).


Organizations with total revenue of less
than $100,000: the certifying official must
certify the organization has controls in place to
ensure funds are properly accounted for and it
can provide accurate timely financial
information to interested parties. It is not
required to submit financial documentation with
the CFC application or maintain its financial
records in accordance with GAAP.
Bona-fide chapters or local affiliates of a national
organization that are not separately incorporated
whose pro forma IRS Form 990 reports revenues
over $250,000 and whose financial operations are
covered by an audit of the national organization
may submit the national organization’s audited
financial statements together with a certification
from the national organization’s Chief Executive
Officer (CEO) or CEO equivalent stating that it
operates as a bona-fide affiliate in good standing of
the national organization and is covered by the
national organization’s 26 U.S.C. 501(c)(3) tax
exemption, IRS Form 990 and audited financial
statements. (See requirements under Item #2 for
bona-fide chapters or local affiliates.)

Include as Attachment C a copy of the auditor’s
report and the organization’s complete audited
annual financial statements.
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.
The organization must certify that it accounts for
its funds 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 GAAS. Note that GAAP requires
the use of the accrual method of accounting. No
other basis of accounting is acceptable under
GAAP. The cash basis, modified cash basis, modified accrual, and any other methods are not
acceptable.
OR

Organizations with total revenue of at
least $100,000 but less than $250,000: the
certifying official must certify that the
organization accounts for its funds in
accordance with GAAP and has an audit of its
fiscal operations completed annually by an
independent certified public accountant in
accordance with GAAS. The organization is not
required to submit a copy of the audited financial
statements with the CFC application. However,

4

Bona-fide chapters of a national organization that
are not separately incorporated whose pro forma
IRS Form 990 reports revenues of at least
$100,000 but less than $250,000 and whose
financial operations are covered by an audit of the
national organization may certify it has an audit of
its fiscal operations completed annually if it, at the
time of the certification, is in good standing of the
national organization and is covered by the
national organization’s 26 U.S.C. 501(c)(3) tax
exemption, IRS Form 990 and audited financial
statements. This organization is not required to
submit with its application the national
organization’s audited financial statements.
However, it must be able to supply this
documentation to the LFCC or OPM upon request.
(See requirements under Item #2 for bona-fide
OPM Form 1647-C
Rev. August 2014

chapters or local affiliates.)

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 2013
(i.e. ending on or after June 30, 2013).
Organizations with total revenue of less than
$100,000 are not required to use the accrual
method of accounting.

Item 6
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 2015 (i.e. June 30,
2013). 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.

Item 7
Calculate and enter the organization’s annual
percentage for administrative and fundraising
expenses. This percentage is computed from the
IRS Form 990 submitted with this application.
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).

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 for additional information
on the IRS Form 990 requirements, including the
presentation of the governing body and expenses.

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.

A complete IRS Form 990 is required, including
all supplemental statements and schedules, if
applicable, with the exception of Schedule B, to be
eligible for the CFC. If the Internal Revenue
Service 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.

Item 8

The CFC uses Part VII of the IRS Form 990 to
verify that a majority of the governing body served
without compensation. The IRS Form 990
instructions define a director/trustee as member of
the governing body with voting rights. These are
the individuals that will be reviewed. Cases where
50% of the board received compensation and 50%
of the board was not compensated will be denied,
regardless of the amount of the compensation.

Pro forma IRS Form 990 Instructions – The
IRS Form 990 (long form) can be downloaded
from the IRS website (www.irs.gov). The following sections must be completed: Page 1, Items AM; Part I (Summary) Lines 1-4 only; Part II
(Signature Block); Part VII (Compensation section
A only); Part VIII (Statement of Revenues); Part
IX (Statement of Functional Expenses), and; Part
XII (Financial Statements and Reporting).

Item 9
Self-explanatory

Item 10

Self-explanatory

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OPM Form 1647-C
Rev. August 2014

Taxonomy Codes
Each organization can
identify up to three categories, in priority order,
which most closely identify the type of mission,
services, and activities provided. The corresponding letters will be printed in your organization’s
listing in the CFC charity list (see example below)
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:

Item 11
Self-explanatory
Item 12
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.

A Arts, Culture, and Humanities
B Education
C Environment
D Animal Related
E Health Care
F Mental Health & Crisis Intervention
G Voluntary Health Associations & Medical
Disciplines
H Medical Research
I Crime & Legal Related
J Employment
K Food, Agriculture & Nutrition
L Housing & Shelter
M Public Safety, Disaster Preparedness & Relief
N Recreation & Sports
O Youth Development
P Human Services
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
V Social Science
W Public & Societal Benefit
X Religion-Related
Y Mutual $ Membership Benefit
Z Unkown

Item 13
Include as Attachment E, a statement in 25
words or less that describes the organization’s
program activities. The statement should not
repeat the organization's name. The organization
must also provide the legal name as registered with
the IRS if the organization does business under a
different name. All organizations must include
their IRS Employee Identification Number (EIN)
regardless of whether or not they are operating
under a "dba" (“doing business as”). The
organization must also include a telephone number
that can be reached from any location in the U.S.
and the organization’s administrative and
fundraising rate. The legal name, telephone
number, EIN, taxonomy codes (see below), and
administrative and fundraising rate will NOT count
as part of the 25-word statement. An Internet
address where information on the organization can
be obtained may be included and will not count
toward the 25 words. OPM will not be responsible
for incorrect Internet addresses. E-mail addresses
are not accepted.

Special design text used to draw attention to an
organization title, such as special fonts, capitalization, quotations, and underlining, are not accepted.
Any statement that uses special features, or
exceeds 25 words will be edited by the LFCC.
Organizations will be listed by their legal IRS
recognized name as it appears on the IRS
determination letter only unless the appropriate
legal documentation permitting otherwise is
provided with the application. See Item 2. The
format is as follows:

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OPM Form 1647-C
Rev. August 2014

should be worded so the donor understands the
program services provided. 4.2% B,V,O
Certifying Official The certifying official is the
individual who has the authority to affirm that all
statements in the application are accurate.

00000 Name of Organization (IRS BMF name
of organization, if applicable) (202)555-1234
www.opm.gov/cfc
EIN#123456789
The
description will contain no more than 25 words. It

Local CFC applications must be sent to the local campaign office. Do not send applications to the U.S.
Office of Personnel Management. Note that each campaign area sets its own application deadline. For
more information on the local application deadlines and addresses, please contact the Principal
Combined Fund Organization (PCFO) representative in your area.
Contact information can be found at www.opm.gov/cfc/Search/Locator.asp.
REQUIRED ATTACHMENTS (failure to provide any of these documents may result in a denial)
 Attachment A – Documentation of local presence (See Item 1)
 Attachment B – IRS determination letter (See Item 2)
 Attachment C – Audited Financial Statements (if total revenues are $250,000 or greater) (See
Item 5)
 Attachment D – IRS Form 990 (See Item 6)
 Attachment E – 25-word statement (See Item 13)

7

OPM Form 1647-C
Rev. August 2014

OMB APPROVED
NO. 3206-0131

COMBINED FEDERAL CAMPAIGN
2015 APPLICATION FOR LOCAL INDEPENDENT
ORGANIZATIONS AND MEMBERS OF FEDERATIONS
Organization:
Employer Identification Number (EIN): __ __ - __ __ __ __ __ __ __
5 Digit CFC Number (If a previous participant in the CFC):

___ ___ ___ ___ ___

Organization Address:____________________________________________________________
____________________________________________________________
(Post Office Box addresses are not accepted and may result in automatic disqualification.)
Check this box if the above address is different from the address submitted with the 2014 CFC application:

Telephone:

_____________________________________________________

Contact Person:

_________________________________________________________

Contact Title:

_________________________________________________________

Contact Address:

_________________________________________________________

(If different from the above address – Post Office Boxes are acceptable for the Contact Address. All CFC
correspondence will be sent to this address.)

Contact Telephone:

____________ __

Fax:

________________________

Contact E-Mail Address(es): _________________________________________________________
Website Address (required, if available):

________________________________________

Disbursement Address: _________________________________________________________________

(This is the address where paper checks will be sent.)
Electronic Funds Transfer (EFT) information (Optional):
Routing Number (9 digits): __ __ __ __ __ __ __ __ __
ACCT: ___________________________________________
Financial Institution: _________________________________

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OPM Form 1647-C
Rev. August 2014

1)

I certify that the organization named in the application has a substantial local presence in
the geographical area covered by the local campaign. (Substantial local presence is
defined in the Instructions as Item 1.) Include as ATTACHMENT A supporting
statements and/or documentation of substantial local presence in the geographical
area covered by the local campaign and a description of the programs, services,
benefits, etc. provided by the organization in calendar year 2014 and how those
programs, services, benefits, etc. affect human health and welfare of the target
population.
Service Office Address (if different from Organization Address on previous page):
_____________________________________________________
_____________________________________________________
Hours of Operation Per Each Day of the Week (Example: Monday-Friday, 9AM5PM; Saturday, 10AM – 3PM; Sunday, Closed):
_____________________________________________________
_____________________________________________________
Organization’s Dedicated Phone Number: ____________________________
County and State Where Office is Located: __________________________________

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) and 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)

Place a check in the one appropriate box:
I certify that the organization named in this application is not part of a group exemption.
- OR I certify that the organization named in this application is part of a group exemption.
- OR I certify that the organization named in this application is a bona-fide chapter or affiliate that
operates under a national organization’s single corporation tax-exemption.

4)

I certify that the organization named in this application is a human health and welfare
organization 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 2014 are reflected in ATTACHMENT
A.
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OPM Form 1647-C
Rev. August 2014

5)

Place a check in the one appropriate box:
I certify that the organization named in this application reports total revenue of $250,000 or
more on its IRS Form 990 (or pro forma IRS Form 990) covering a period ending not more
than 18 months prior to January 2015 and meets both of the following two conditions:
 accounts for its funds on the 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 ATTACHMENT 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 2015.
- OR I certify that the organization named in this application reports total revenue of at least
$100,000 but less than $250,000 on its IRS Form 990 (or pro forma IRS Form 990) covering
a period ending not more than 18 months prior to January 2015 and meets both of the
following two conditions:
 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).
- OR I certify that the organization named in this application reports total revenue of less than
$100,000 on its IRS Form 990 (or pro forma IRS Form 990) covering a period ending not
more than 18 months prior to January 2015 and has controls in place to ensure funds are
properly accounted for and that it can provide accurate timely financial information to
interested parties.

6)

Check 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. (Include as ATTACHMENT D a copy
of the complete IRS Form 990 for a period ending not more than 18 months prior to
January 2015, 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 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 2015. See application
instructions for pro forma IRS Form 990 requirements. IRS Forms 990 EZ, 990PF, and
10

OPM Form 1647-C
Rev. August 2014

comparable forms are not acceptable substitutes.)
7)

I certify that the administrative and fundraising rate for the organization named in this
application is __ __.__%. This percentage is computed from the IRS Form 990 submitted
with this application.

8)

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.

9)

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

10)

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.

11)

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

12)

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.

13)

Include as ATTACHMENT E a 25-word statement for listing in the campaign charity list.
(See Instructions Item 13 for additional required information on the optional taxonomy
codes.)

CERTIFYING OFFICIAL
I, ____________________________________, am the duly appointed representative
(Print Name)
of ____________________________________ authorized to certify and affirm all statements
(Print Organization Name)
enclosed in this application. I certify that I have read all the certifications set forth in this document
11

OPM Form 1647-C
Rev. August 2014

and affirm their accuracy. In addition, by checking the box next to the certification, the organization
named in this application acknowledges and agrees to comply with that certification.
______________________________
(Signature)
______________________________
(Typed or Printed Name)
______________________________
(Title)
Date Completed ______________________
Send the application to the appropriate local CFC office. For contact information, visit
www.opm.gov/cfc.

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 (32060131), Washington, DC 20415-7900. 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.

12

OPM Form 1647-C
Rev. August 2014