201508-1 CDFI Fund Annual Certification and Data Collection Repor

CDFI Fund Annual Certification and Data Collection Report Form

CDFI Fund Annual Certification and Data Collection Report Form

Purpose:

The primary intent of the Annual Certification and Data Collection Report Form (the “Form”) is to ensure that Community Development Financial Institutions (CDFI) continue to meet the requirements to be certified CDFIs.¹ It is also a method to ensure that organizational information is updated annually. The financial and portfolio data will be used by the CDFI Fund to gain insight on the CDFI industry. Information provided in these sections will not impact a CDFI’s certification status or applications for CDFI Fund programs.

Instructions:

Please complete the Form using data from your organization’s most recently completed fiscal year. Please refer to the CDFI Fund Annual Certification and Data Collection Report Form Instructions for detailed instructions on how to complete the Form. Definitions for the terms used in these materials may be found in the CDFI Fund Glossary.

Documents needed to complete the Form (if applicable to your organization):

You should refer to the following documents for your organization when completing this report:

• Balance Sheet (Statement of Financial Position),

• Income Statement (Statement of Activities or Statement of Operations or Profit and Loss Statement), and

• For Banks and Thrifts, Consolidated Reports of Condition and Income; or

• For Credit Unions, 5300 Call Report.

All financial statements should be the final, audited reports from your organization’s most recently completed fiscal year. All data should be taken directly from these documents where possible.

Amendment to CDFI Certification Application Information:

There are four (4) parts to the Annual Certification and Data Collection Report Form: Part I. Organization Information; Part II. Verification of CDFI Re-Certification Eligibility; Part III. Selected Financial Information; and Part IV. Loan and Investment Portfolio Values. Part II requires the organization to confirm that it continues to meet the CDFI certification eligibility criteria as outlined in the CDFI Certification Application. Additional information will be required, as needed, to verify that the organization meets specific requirements.

If your organization’s response to any of the Certification eligibility criteria questions in Part II is “No” or if your organization’s EIN has changed, you must submit the “Certification Amendment” Form with the updates in order for your organization to maintain the status as a certified CDFI.

Changes that require submission of a Certification Amendment

If any of the following information changed since your organization was last approved or re-certified as a Certified CDFI, you are required to submit a Certification Amendment.

• EIN

• Articles of Incorporation

• Bylaws

• Charter

• Primary Mission

• Target Market

• Accountability Method

• Status as a Non-Government Entity

Please Note: Eligibility questions not answered in the affirmative will result in a review of CDFI certification eligibility, which may result in revocation of CDFI certification if the Certification Amendment form and necessary documentation are not submitted.

Part I. Organization Information

	Organization Information			Entry Type
	Organization Identification Number			Autocomplete
	Date			Autocomplete
1.	Organization Information
1a.	Organization Name			Text Box
1b.	Employer Identification Number (EIN)			Text Box
1c.	Fiscal Year End
1d.	Tax Status
1e.	Certified CDFI Serving Native Communities
2.	Organization Type - Select one of the following
	☐ Bank or Thrift		☐ Venture Capital Fund			☐ Depository Institution Holding Company
	☐ Credit Union		☐ Loan Fund
2a.		FDIC Charter Number (Banks and Thrifts Only)			Text Box
2b.		Bank Holding Company Number (Banks and Thrifts Only)			Text Box
2c.		Office of Thrift Supervision (OTS) Docket Number (Thrifts Only)			Text Box
2d.		NCUA Number (Credit Unions Only)			Text Box
3.	Line of Business
3a.		Primary Line of Business
3b.		Secondary Line of Business
4. Credit Union Membership (Credit Unions Only)
4a.		Total Number of Credit Union Members						Amount
4b.		Total Number of Credit Union Members in the Target Market(s)						Amount
5.	Full-Time Equivalent (FTE) Staff Time
5a.		Percentage of FTE and contractor time dedicated to providing Financial Products and/or Services (Unregulated Only)						Amount
5b.		Percentage of FTE and contractor time dedicated to providing Development Services (Unregulated Only)						Amount
5c.		Total number of Full Time Equivalent Staff (All CDFIs)						Amount

Part II. Verification of CDFI Re-Certification Eligibility

	CDFI Certification Criteria			Entry Type
1.	Legal Entity
1a.	The organization continues to be the same legal entity, duly formed and in good standing, since it was certified by the CDFI Fund.
1b.	The organization has not amended its organizational documentation (e.g., articles of incorporation, bylaws, charter) since the organization’s CDFI certification was last approved by the CDFI Fund.
2.	Primary Mission
	The Primary Mission of the organization, as evidenced in board-approved organizational documents, has not changed since the organization’s CDFI certification was last approved by the CDFI Fund.
3.	Financing Entity
3a.	The organization continues to be an entity whose predominant business activity is the provision, in Arms-Length Transactions, of Financial Products, as reflected on its financial statements and executed notes.
3b.	The organization continues to maintain Sufficient Capital to continue Financing Activities that support the provision of Financial Products for at least three months from the end of the organization’s fiscal year.
3c.	The organization continues to dedicate a Predominance of its Assets to Financial Products.
3d.	The organization continues to dedicate a Predominance of staff time to the provision to Financial Products.
4.	Development Services
4a.	The organization, directly or through an Affiliate, or through a contract with another provider, continues to meet the Development Services criteria requirements.
4b.	Please identify the Development Services provided by the organization during the last fiscal year and the associated Financial Products offered in conjunction with those services.
	Development Services	Financial Product	Total Clients Served			Target Market Clients Served
			Amount			Amount
			Amount			Amount
			Amount			Amount
			Amount			Amount
			Amount			Amount
	If “Other” is selected, enter a description of the Development Services.				Text Box
5.	Target Market
5a.	At least 60% of the organization’s Transactions are directed towards serving its approved Target Market(s).
5b.	The organization reviewed its approved Target Market maps in CIMS and verified that its Target Market(s) have not changed since its CDFI certification was last approved by the CDFI Fund.
6.	Accountability
6a.	The organization continues to maintain Accountability to clients in its approved Target Market through representation on its governing board, or otherwise, since the Respondent’s CDFI certification was last approved by the CDFI Fund.
6b.	The organization maintained the same method or set of methods for providing Accountability to the organization’s approved Target Market since the organization’s CDFI certification was last approved by the CDFI Fund.
7.	Non-Governmental Entity
	The organization continues to not be an agency or instrumentality of the United States, or any state or political subdivision thereof, and that such has not changed since the organization’s CDFI certification was last approved by the CDFI Fund.

Part III. Selected Financial Information

Selected Balance Sheet Information

Report Balance Sheet figures below as of the most recent fiscal year end (FYE). Values will correspond to the organization type selected in Part I.

	Value	Entry Type
1.	Are the following values being taken from audited financial statements?
2. Assets
2a.	Unrestricted Cash and Cash Equivalents	Amount
2b.	Restricted Cash and Cash Equivalents	Amount
2c.	Cash and Cash Equivalents (add unrestricted and restricted cash and cash equivalents amounts)	Calculated
2d.	Average Assets	Amount
2e.	Current Assets	Amount
2f.	Allowance for Loan and Lease Losses Reserve (ALLL)	Amount
2g.	Total Assets	Amount
3. Liabilities
3a.	Current Liabilities	Amount
3b.	Total Liabilities	Amount
4. Net Assets, Net Worth, or Equity Information
4a.	Temporarily Restricted Net Assets	Amount
4b.	Permanently Restricted Net Assets	Amount
4c.	Unrestricted Net Assets	Amount
4d.	Tier 1 Capital (Banks and Thrifts Only)	Amount
4e.	Total Net Assets (add temporarily restricted, permanently restricted, and unrestricted net asset amounts)	Calculated
4f.	Total Net Worth (Credit Unions Only)	Amount
4g.	Total Equity (For-profit Entities Only)	Amount

Selected Income Statement Information

Report Income Statement figures below as of the most recent FYE.

	Value	Entry Type
5. Income
5a.	Interest Income	Amount
5b.	Earned Revenue	Amount
5c.	Operating Revenue	Amount
5d.	Total Revenue	Amount
6. Expenses
6a.	Interest Expense	Amount
6b.	Provision for Loan Losses	Amount
6c.	Operating Expenses	Amount
6d.	Total Expenses	Amount

Capital Detail

Submit detailed Capital figures as of the most recent FYE, these values should equal the Total Capital available for Financing Activities, the activities that support the provision of Financial Products.

	Capital Category	Entry Type
7.	Financing Debt	Amount
8.	Grants	Amount
9.	Equity Investments	Amount
10.	Deposits	Amount
11.	Secondary Capital, Uninsured (Credit Unions Only)	Amount
12.	Net Assets or Retained Earnings	Amount
	Total Capital	Calculated

Part IV. Loan and Investment Portfolio Values

1. Loan and Investment Portfolio

Report total outstanding Loan and Investment portfolio information for the most recent FYE.

		Value		Entry Type
1a.	Total Outstanding Loan Portfolio		Amount
1b.	Total Outstanding Investment Portfolio		Amount
1c.	Total Charge-Offs		Amount
1d.	Total Recoveries		Amount
1e.	Total Value of Non-performing Assets		Amount

2. Financial Products Portfolio Breakdown

Select all applicable Financial Products that are present in the organization’s outstanding portfolio:

☐ Loans (including loan acquisitions)

☐ Equity Investments (including Equity Equivalent Investments)

☐ Loan Guarantees

Based on the Financial Products selected above, the Loan, Equity, and Loan Guarantee Portfolio tables will appear on the Form. Your organization will only be required to enter details of the count and value of total and Target Market data for the products that it currently has in its portfolio; for most, this will be limited to the Loan Portfolio Breakdown. The following tables and applicable options will only appear as indicated by the responses to the question above.

3. Loan Portfolio Breakdown

Enter the total number and value of outstanding Loans at the FYE within the portfolio by Loan category, and specify the value of outstanding Loans directed to Target Market borrowers.

	Loans (If Selected)			Total Loan Portfolio (Count)		Total Loan Portfolio (Amount)	Target Market (Count)	Target Market (Amount)
☐	Business Loans		Amount			Amount	Amount	Amount
☐	Commercial Real Estate Loans			Amount		Amount	Amount	Amount
☐	☐	Charter School			Amount	Amount	Amount	Amount
	☐	Commercial	Amount			Amount	Amount	Amount
	☐	Community Facility	Amount			Amount	Amount	Amount
	☐	Health Care Facility	Amount			Amount	Amount	Amount
☐	Consumer Loans		Amount			Amount	Amount	Amount
☐	Intermediary Loans		Amount			Amount	Amount	Amount
☐	Microfinance Loans		Amount			Amount	Amount	Amount
☐	Residential Real Estate Loans			Amount		Amount	Amount	Amount
☐	Other (Please Describe)		Amount			Amount	Amount	Amount
	Description:		Text Box

4. Equity Portfolio Breakdown

Enter the number and value of outstanding Equity and Equity Equivalent Investments by category, and specify the value of such products directed to the Target Market.

	Equity Investments (If Selected)		Total Portfolio (Count)				Total Portfolio (Amount)		Target Market (Count)	Target Market (Amount)
☐	Business Financing			Amount			Amount		Amount	Amount
☐	Commercial Real Estate Financing					Amount		Amount	Amount	Amount
☐	☐	Charter School				Amount	Amount		Amount	Amount
	☐	Commercial		Amount			Amount		Amount	Amount
	☐	Community Facility		Amount			Amount		Amount	Amount
	☐	Health Care Facility		Amount			Amount		Amount	Amount
☐	Consumer Financing			Amount			Amount		Amount	Amount
☐	Intermediary Financing			Amount			Amount		Amount	Amount
☐	Microfinance			Amount			Amount		Amount	Amount
☐	Residential Real Estate Financing				Amount		Amount		Amount	Amount
☐	Other (Please Describe)			Amount			Amount		Amount	Amount
	Description:			Text Box

5. Loan Guarantee Portfolio Breakdown

Enter the number and value of outstanding Loan Guarantees by category, and specify the value of such products directed to the Target Market.

	Loan Guarantees (If Selected)		Total Portfolio (Count)				Total Portfolio (Amount)		Target Market (Count)	Target Market (Amount)
☐	Business Financing			Amount			Amount		Amount	Amount
☐	Commercial Real Estate Financing					Amount		Amount	Amount	Amount
☐	☐	Charter School				Amount	Amount		Amount	Amount
	☐	Commercial		Amount			Amount		Amount	Amount
	☐	Community Facility		Amount			Amount		Amount	Amount
	☐	Health Care Facility		Amount			Amount		Amount	Amount
☐	Consumer Financing			Amount			Amount		Amount	Amount
☐	Intermediary Financing			Amount			Amount		Amount	Amount
☐	Microfinance			Amount			Amount		Amount	Amount
☐	Residential Real Estate Financing				Amount		Amount		Amount	Amount
☐	Other (Please Describe)			Amount			Amount		Amount	Amount
	Description:			Text Box

Organization Attestation

I am the Authorized Representative of [Organization] and, as such, am authorized to submit this Form on its behalf. Further, as Authorized Representative, I attest that all information in this form is accurate, timely, and complete.

Authorized Representative

Authorized Representative Signature Date

1 Emerging CDFIs are not required to complete the Form.

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