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pdfAppendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
CDFI Bond Guarantee Program: Assurances and Certifications for Qualified Issuer and Guarantee Applications
Instructions: The term Applicant as used in these Assurances and Certifications includes all entities that are proposed to participate in the Bond
Issue including: the Qualified Issuer, Program Administrator, Servicer, and Eligible CDFI(s). Each Applicant should submit a separate signed SF
424 and these Assurances and Certifications as part of a Qualified Issuer and/or Guarantee Application. Signing the certification on the SF 424
and initialing each page below certifies that the Applicant will comply with, perform as described, and maintain compliance with the Assurances
and Certifications in each section listed below if its Application is approved. Certain of these Assurances and Certifications may not be applicable
to the Applicant. An Applicant may not modify any of the Assurances and Certifications.
A. General Assurances and Certifications
Instructions: Each Applicant (as that term is defined in this document) must review the following assurances and certifications. With the
exception of paragraphs 17, 18, 19, 20, 21, and 22 below, the inability of the Applicant to provide the General Assurances and Certifications in
section A below will render the Applicant ineligible to participate in the CDFI Bond Guarantee Program. If the Applicant cannot provide the
General Assurances and Certifications in paragraphs 17, 18, 19, 20, 21, and 22, the Applicant must submit a written explanation. The CDFI Fund
will consider the explanation provided and determine, in its sole discretion, whether the Applicant is eligible to participate in the CDFI Bond
Guarantee Program. If the Applicant cannot provide any of the other General Assurances and Certifications, it should not submit, or be included
in, a Qualified Issuer or Guarantee Application.
NOTE: Where the Applicant is unable to certify to paragraphs 17, 18, 19, 20, 21, and/or 22 of the General Assurances and Certifications, the
Applicant must attach a written explanation to this Application.
____ Check here if the Applicant is submitting a written explanation.
As the Authorized Representative of the Applicant, I certify as follows:
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 1 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
1. The Applicant has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds
sufficient to pay the non-Federal share of project costs) to ensure proper planning, management and completion of the project described in this
Application.
2. The Applicant’s appropriate senior management, and its counsel, has read the Regulations set forth at 12 C.F.R. 1808, the CDFI certification
regulations set forth at 12 C.F.R. 1805.201, as amended, and the environmental quality regulations set forth at 12 C.F.R. 1815, as well as the
template Bond Documents and Bond Loan documents posted on the CDFI Fund’s website (www.cdfifund.gov/bond) including, but not limited
to, the following: Bond Trust Indenture, Bond Loan Agreement, Bond Purchase Agreement, Collateral Assignment, Reimbursement Note,
Opinion of Bond Counsel, and Opinion of Counsel to the Borrower.
3. The Applicant will give U.S. Department of the Treasury (Treasury, as the awarding agency), the Comptroller General of the United States,
and if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents
related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency
directives.
4. The Applicant will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the
appearance of personal or organizational conflict of interest, or personal gain.
5. The Applicant will initiate and complete the work (the activities proposed in the Application) within the applicable timeframe after receipt of
approval of Treasury.
6. The Applicant will comply with all Federal statutes relating to nondiscrimination. These include, but are not limited to: (a) Title VI of the
Civil Rights Act of 1964 (P.L.88-352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the
Education Amendments of 1972, as amended (20 U.S.C.1681-1683, 1685-1686), which prohibits discrimination on the basis of sex; (c)
Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C.794), which prohibits discrimination on the basis of handicaps; (d) the
Age Discrimination Act of 1975, as amended (42 U.S.C.6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse
Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive
Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L.91-616), as amended, relating to nondiscrimination
on the basis of alcohol abuse or alcoholism; (g) Sections 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 290 dd-3 and 290
ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42
U.S.C.3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 2 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
7.
8.
9.
10.
11.
12.
13.
provisions in the specific statute(s) under which Application for Federal assistance is being made; and (j) the requirements of any other
nondiscrimination statutes which may apply to the Application.
The Applicant will comply, or has already complied, with the requirements of Titles II and III of the Uniform Relocation Assistance and Real
Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable treatment of persons displaced or whose property
is acquired as a result of Federal or federally assisted programs. These requirements apply to all interests in real property acquired for project
purposes regardless of Federal participation in purchases.
The Applicant will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental
quality control measures under the National Environmental Policy Act of 1969 (P.L.91-190) and Executive Order 11514; (b) notification of
violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in
accordance with EO 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal
Zone Management Act of 1972 (16 U.S.C. 1451et seq.); (f) conformity of Federal actions to State Implementation Plans under Section 176(c)
of the Clean Air Act of 1955, as amended (42 U.S.C. 7401 et seq.); (g) protection of underground sources of drinking water under the Safe
Drinking Water Act of 1974, as amended, (P.L.93-523); and (h) protection of endangered species under the Endangered Species Act of 1973,
as amended, (P.L.93-205).
The Applicant will assist Treasury in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16
U.S.C. 470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16
U.S.C. 469a-1 et seq.).
Applicability of Federal Construction Requirements. The Secondary Borrower shall adhere to the following Federal construction standards:
(a) accessibility; (b) environmental impact; (c) safety; (d) historical preservation; (e) seismic activity; and (f) metrification.
The Secondary Borrower shall ensure compliance with the provisions of the Americans with Disabilities Act, to the extent codified in state
and local building codes.
Seismic Safety. The Secondary Borrower shall ensure compliance with Executive Order 12699, Seismic Safety of Federal and Federally
Assisted or Regulated New Building Construction.
The Applicant will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984.
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 3 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
14. The Applicant will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing the
CDFI Bond Guarantee Program.
15. The Applicant will comply with the requirements of Section 106(g) of the Trafficking Victims Protection Act (TVPA) of 2000, as amended
(22 U.S.C. 7104) which prohibits grant award recipients or a sub-recipient from: (a) engaging in severe forms of trafficking in persons during
the period of time that the CDFI Bond Guarantee Program award is in effect; (b) procuring a commercial sex act during the period of time that
the award is in effect; or (c) using forced labor in the performance of the award or subawards under the award.
16. The Applicant is duly organized and validly existing under the laws of the jurisdiction in which it was incorporated or otherwise established,
and is (or within 30 days will be) authorized to do business in any jurisdiction in which it proposes to undertake activities specified in this
Application;
17. The Applicant’s Board of Directors (or similar governing body) has by proper resolution or similar action authorized the filing of this
Application, including all understandings and assurances contained herein, and directed and authorized the person identified as the Authorized
Representative of the Applicant to act in connection with this Application and to provide such additional information as may be required;
18. The Applicant will comply with all applicable requirements of the Community Development Banking and Financial Institutions Act of 1994
(the Act) [12 U.S.C. 4701 et seq.], regulations implementing the Act and all other applicable Treasury regulations and implementing
procedures (and any regulations or procedures which are later promulgated to supplement or replace them);
19. The Applicant will comply, as applicable and appropriate, with the requirements of the Uniform Administrative Requirements, Cost
Principles, and Audit Requirements for Federal Awards (2 C.F.R. 200), any applicable OMB Circulars and any regulations and circulars which
are later promulgated to supplement or replace them, including standards for fund control and accountability;
20. The Applicant has not knowingly and willfully made or used a document or writing containing any false, fictitious or fraudulent statement or
entry as part of this Application or any related document, correspondence or communication (the Applicant and its Authorized Representative
should be aware that, under 18 U.S.C. 1001, whoever knowingly and willfully makes or uses such document or writing shall be fined or
imprisoned for not more than five years, or both);
21. The Applicant and its officers, directors, owners, and senior executives: (a) have not within a three-year period preceding the date of this
Application been convicted of or had a civil judgment rendered against them for commission of fraud; (b) have not within a three-year period
preceding the date of this Application been convicted of or had a civil judgment rendered against them for commission of a criminal offense,
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 4 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
which includes, but is not limited to, any felony criminal violation under any Federal law; (c) have not within a three-year period preceding the
date of this Application been convicted of or had a civil judgment rendered against them for violation of Federal or State antitrust statutes or
commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen
property; or (d) have not within the three-year period preceding the date of this Application been found liable in any civil legal action
involving creditor’s claims of greater than $500,000.
22. The Applicant and its officers, directors, owners, partners, and key employees: (a) have not within a three-year period preceding the date of
this Application been indicted for or charged with the commission of fraud or a criminal offense; (b) have not within a three-year period
preceding the date of this Application been indicted for or charged with the violation of Federal or State antitrust statutes or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) are not
presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of
the offenses enumerated in paragraphs 21(a), 21(b), or 21(c) of this certification; or (d) have not within the three-year period preceding the
date of this Application been the subject of any formal investigation or disciplinary proceeding by a government agency, regulatory body, or
professional association in connection with any matter which may have a material adverse effect on the Applicant or its financial condition or
the Applicant’s ability to carry out the activities associated with the Bond Guarantee Program.
23. Any other person or entity that Controls the Applicant (other than the Applicant’s officers, directors, owners, partners, and key employees):
(a) has not within a three-year period preceding the date of this Application been indicted, charged with, or convicted of, or had a civil
judgment rendered against it for commission of fraud; (b) has not within a three-year period preceding the date of this Application been
indicted, charged with, or convicted of, or had a civil judgment rendered against it for commission of a criminal offense, which includes, but is
not limited to, any felony criminal violation under any Federal law; (c) has not within a three-year period preceding the date of this
Application been indicted, charged with or convicted of, or had a civil judgment rendered against it for violation of Federal or State antitrust
statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving
stolen property; (d) is not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local)
with commission of any of the offenses enumerated in paragraphs 22(a) and 22(b) of this certification; (e) has not within the three-year period
preceding the date of this Application been the subject of any formal investigation or disciplinary proceeding by a government agency,
regulatory body, or professional association in connection with any matter which may have a material adverse effect on the Applicant or its
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 5 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
24.
25.
26.
27.
28.
29.
30.
31.
financial condition or the Applicant’s ability to carry out the activities associated with the CDFI Bond Guarantee Program; or (f) has not
within the three-year period preceding the date of this Application been found liable in any civil legal action involving creditor’s claims of
greater than $500,000.
The Applicant has never been delinquent on amounts due to the Internal Revenue Service or on any debts owed to Federal, State, or local
government.
Neither the Applicant, Controlling Entity (if applicable), nor any Affiliate has an unpaid Federal tax liability that has been assessed.
The Applicant has never filed for bankruptcy.
Neither the Applicant, Controlling Entity (if applicable), nor any Affiliate is a federally regulated financial institution currently under any
Enforcement Action from any federal regulator.
Not less than 100 percent of the principal amount of Bonds will be used to make Bond Loans for Eligible Purposes beginning on the Bond
Issue Date, and that Secondary Loans shall be made as set forth in the Regulations.
The Applicant has registered an Organization account with at least one User in MyCDFIFund and has established a System for Award
Management (SAM) account.
The Applicant has provided a valid and current Dun and Bradstreet Data Universal Numbering System (DUNS) number and has provided a
valid and current Employer Identification Number (EIN).
The information in this Application, and in these assurances and certifications in support of the Application, is true and correct to the best of
the Applicant’s knowledge and belief and the filing of this Application has been duly authorized.
[Remainder of this page left intentionally blank.]
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 6 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
B. Certification Regarding Debarment, Suspension, and Other Responsibility Matters -- Primary Covered Transactions
Instructions: The inability of a person to provide the certification required below will not necessarily result in the denial of participation in this
covered transaction. The prospective Applicant shall submit an explanation of why it cannot provide the certification set out below. The
certification or explanation will be considered in connection with Treasury’s approval of the proposed Application. However, failure of the
Applicant to furnish a certification or an explanation shall disqualify such person/entity from participation in this transaction. Please be advised of
the following:
• This certification is a material representation of fact upon which reliance is placed when Treasury determines to enter into this transaction.
If it is later determined that the Applicant knowingly rendered an erroneous certification, in addition to other remedies available to the
Federal government, Treasury may terminate this transaction for cause or default.
• The Applicant shall provide immediate written notice to the CDFI Fund if at any time the Applicant learns that its certification was
erroneous when submitted or has become erroneous by reason of changed circumstances.
• The terms “covered transactions,” “debarred,” “suspended,” “ineligible,” “lower tier covered transaction,” “participant,” “person,”
“primary covered transaction,” “principal,” “proposal”, and “voluntarily excluded,” as used in this clause (certification), have the
meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the CDFI
Fund for assistance in obtaining a copy of those regulations (31 CFR part 19).
• The Applicant agrees by submitting this Application that, should the proposed covered transaction be entered into, it shall not knowingly
enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the CDFI Fund.
• The Applicant further agrees by submitting this Application that it will include the clause titled “Certification Regarding Debarment,
Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,” to be provided by the CDFI Fund, without
modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions (see 31 CFR part 19,
Appendix B).
• A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is
not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 7 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
•
•
erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant
may, but is not required to, check the Nonprocurement List.
Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the
certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a
lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this
transaction, in addition to other remedies available to the Federal government, the CDFI Fund may terminate this transaction for cause or
default.
NOTE: Where the Applicant is unable to certify to one or more of the statements in the Certification Regarding Debarment, Suspension, and Other
Responsibility Matters, the Applicant must attach a written explanation to this Application.
By signing and submitting this Application, the prospective primary participants (the Applicant, as that term is defined above) is providing the
certification set out below.
The prospective primary participant (the Applicant) certifies to the best of its knowledge and belief, that it and its principals:
1. are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by
any Federal department or agency;
2. have not within a three-year period preceding this Application been convicted of or had a civil judgment rendered against them for
commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or
local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
3. are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission
of any of the offenses enumerated in paragraph (1)(b) of this certification; and
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 8 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
4. Have not within a three-year period preceding this Application had one or more public transactions (Federal, State or local) terminated for
cause or default.
Where the Applicant is unable to certify to any of the statements in this certification, such Applicant shall attach an explanation to this proposal.
____ Check here if the Applicant is submitting a written explanation.
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 9 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
C. Certification Regarding Drug-Free Workplace Requirements
The Applicant certifies that it will provide a drug-free workplace by:
1. publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled
substance is prohibited in the Applicant’s workplace and specifying the actions that will be taken against employee for violations of such
prohibition;
2. establishing a drug-free awareness program to inform employees about:
a. the dangers of drug abuse in the workplace;
b. the Applicant’s policy of maintaining a drug-free workplace;
c. any available drug counseling, rehabilitation, and employee assistance program;
d. the penalties that may be imposed upon employees for drug abuse violations occurring in the workplace
3. making it a requirement that each employee to be engaged in the performance of the award be given a copy of the statement required by
subparagraph (a);
4. notifying the employee in the statement required by subparagraph (a) that, as a condition of employment in such grant, the employee will:
a. abide by the terms of the statement; and
b. notify the employer of any criminal drug use statute conviction for a violation occurring in the workplace no later than five
calendar days after such conviction;
5. notifying the granting agency in writing, within ten calendar days after receiving notice of a conviction under subparagraph (d) (ii) from
an employee or otherwise receiving actual notice of such conviction;
6. taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(ii), with respect to any employee who is so
convicted:
a. taking appropriate personnel action against such an employee, up to and including termination, consistent with the
requirements of the Rehabilitation Act of 1973, as amended; or
b. requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such
purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; and
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 10 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
7. making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs 1 through 6 above.
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 11 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
D. Certification Regarding Lobbying
The Applicant certifies, to the best of its knowledge and belief, that:
1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the Applicant, to any person for influencing or attempting
to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal
loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement;
2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence
an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this Application, the undersigned shall complete and submit Standard Form LLL, “Disclosure Form to Report
Lobbying, “ in accordance with its instructions; and
3. The Applicant shall require that the language of this certification be included in the award documents for all subawards of all tiers
(including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify
and disclose accordingly.
This certification is a material representation of fact upon which reliance is placed when this transaction is made or entered into. Submission of
this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails
to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 12 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
E. Environmental Review Form
Instructions: The CDFI Fund’s environmental review requirements are set forth in 12 CFR Part 1815. The Applicant should review such
regulations carefully before completing this section. In order to assure compliance with those regulations and other requirements related to the
environment, the Applicant shall provide the information below. If the Applicant answers YES to any of the below questions, the Applicant should
attach a detailed description of each action, clearly identifying the category in which the action falls:
____ Check here if the Applicant is submitting a written explanation.
YES
NO
1. Are there any actions proposed in the Application that do not constitute a “categorical
exclusion” as defined in 12 CFR 1815.110?
a. If YES, would any of these actions normally require an environmental impact
statement (see 12 CFR 1815.109)?
2. Are there any activities proposed in the Application that involve:
a. Historical or archeological sites listed on the National Register of Historic Places or
that may be eligible for such listing?
b.
c.
d.
e.
f.
g.
Wilderness areas designated or proposed under the Wilderness Act?
Wild or scenic rivers proposed or listed under the Wild and Scenic Rivers Act?
Critical habitats of endangered or threatened species?
Natural landmarks listed on the National Registry of Natural Landmarks?
Coastal barrier resource systems?
Coastal Zone Management Areas?
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
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Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
h.
i.
j.
k.
l.
Sole Source Aquifer Recharge Areas designated by EPA?
Wetlands?
Flood plains?
Prime and unique farmland?
Properties listed or under consideration for listing on the Environmental Protection
Agency’s List of Violating Facilities?
NOTIFICATION
As stated in 12 CFR 1815.105, if the CDFI Fund determines that the Application proposes actions which
require an environmental assessment or an environmental impact statement, any approval and funding of
the Application will be contingent upon:
1. The Applicant supplying to the CDFI Fund all information necessary for the CDFI Fund to perform or
have performed any required environmental review;
2. The Applicant not using any funds from the CDFI Bond Guarantee Program to perform any of the
proposed actions in the Application requiring an environmental review until approval is received from
the CDFI Fund; and
3. The outcome of the required environmental review.
In addition, as stated in 12 CFR 1815.106, if the CDFI Fund determines that an Application, or any part
thereof, is not sufficiently definite to perform a meaningful environmental review prior to approval of the
Application, final approval and funding of the Application shall require supplemental environmental review
prior to the taking of any action directly using funds from the CDFI Bond Guarantee Program for any
action that is not a categorical exclusion.6530430
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 14 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
[Remainder of this page left intentionally blank.]
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 15 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
F. 501(C)(4) Certification
Instructions: This questionnaire is necessary for the CDFI Fund to determine whether an Applicant with a 501(c)(4) designation from the IRS is
eligible to receive an award from the CDFI Fund (see 12 C.F.R. § 1805.200(a)(3)). Please read all definitions before responding to the questions
and continue to refer to such definitions in responding to this questionnaire. If the answer to any question is yes, please describe in detail the facts
and circumstances, subject matter, date(s), names and titles of all individuals and their employers and their organizations on a separate sheet(s) of
paper.
The CDFI Fund reserves the right to seek follow-up responses from an Applicant. Failure to complete this questionnaire and, if applicable,
respond timely to follow-up questions, will delay the CDFI Fund’s processing of the Application, and may result in the disqualification of the
Application from further consideration.
After submitting responses to this questionnaire, the Applicant is under a continuing obligation to: (1) supplement its responses upon a change in
circumstances; and (2) revise or modify its responses within 10 business days of having actual or constructive knowledge that the responses
previously submitted and certified are no longer complete, accurate, or true.
Scope: The scope of this questionnaire is limited to activities on or after January 1, 1996.
____ Check here if the Applicant is submitting a written explanation.
Questions
1. Does the Applicant have an IRS 501(c)(4) designation?
Yes
No
If no, STOP NOW. Questions 2 through 11 are not applicable.
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 16 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
2. Has any officer, employee, director, partner, proprietor, or board member contacted1 a Covered
Executive Branch Official2 with regard to the formulation, modification, or adoption of Federal
legislation (including legislative proposals)
Yes
No
3. Has any officer, employee, director, partner, proprietor, or board member contacted a Covered
Executive Branch Official with regard to the formulation, modification, or adoption of a Federal rule,
regulation, Executive Order, or any other program, policy, or position of the United States
Government?
4. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered
Executive Branch Official with regard to the administration or execution of a Federal program or
policy (including the negotiation, award, or administration or a Federal contract, grant, loan, permit,
or license)?
5. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered
Executive Branch Official with regard to the nomination or confirmation of a person for a position
subject to confirmation by the United States Senate?
6. Has any officer, employee, director, partner, proprietor, or Board member engaged in efforts
supporting and coordinating the contact by others of a Covered Executive Branch Official including
preparation and planning activities, research and other background work that was intended, at the
time performed, for a purpose described in Questions 1-4?
7. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered
3
Legislative Branch Official with regard to the formulation, modification, or adoption of Federal
legislation (including legislative proposals)?
8. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered
Legislative Branch Official with regard to the formulation, modification, or adoption of a Federal
rule, regulation, Executive Order, or any other program, policy, or position of the United States
Government?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 17 of 18
Appendix: Examples of Document and Chart Formatting
A-2C-Federal Assurances and Certifications
B-1D-2B –Federal Assurances and Certifications
Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________
9. Has any officer employee, director, partner, proprietor, or Board member contacted a Covered
Legislative Branch Official with regard to the administration or execution of a Federal program or
policy (including the negotiation, award, or administration of a Federal contract, grant, loan, permit,
or license)?
10. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered
Legislative Branch Official with regard to the nomination or confirmation of a person for a position
subject to confirmation by the United States Senate?
Yes
No
Yes
No
Yes
11. Has any officer, employee, director, partner, proprietor, or Board member engaged in efforts
No
supporting and coordinating the contact by others of a Covered Legislative Branch Official including
preparation and planning activities, research and other background work that was intended, at the
time performed, for a purpose described in Questions 6-9?
1
“Contacted” means any oral or written communication including an electronic communication.
“Covered Executive Branch Official” means: (a) the President; (b) the Vice President; (c) any officer or employee, or any other individual functioning in the
capacity of such an officer or employee, in the Executive Office of the President; (d) any officer or employee serving in an Executive Level I-V position, a
“Schedule C” position, or any official in a Senior Executive Service position; (e) any member of the uniformed services serving at grade O-7 or above; or (f) any
officer or employee serving in a position of a confidential, policy-determining, policy-making, or policy-advocating character described in section 7511(b)(2) of
title 5, United States Code.
3
“Covered Legislative Branch Official” means: (a) a member of Congress; (b) an elected officer of either House of Congress; and (c) any employee of the House
or Senate, including employees of Members, committees, leadership and working groups or caucuses organized to provide legislative services or other assistance
to Members of Congress; and any other legislative branch employee serving in a position described under section 109(13) of the Ethics in Government Act of
1978 (5 U.S.C. App.).
2
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the written explanations attached thereto are true,
accurate, and complete to the best of the Applicant’s information, knowledge, and belief.
Page 18 of 18
| File Type | application/pdf |
| Author | Denise N. Noel |
| File Modified | 2017-11-13 |
| File Created | 2017-10-27 |