Form CDFI Form 0037 CDFI Form 0037 Certification of Material Events Form

CERTIFICATION OF MATERIAL EVENTS FORM

Organization Name
EIN #:
Certification Control
number (if available):
Definition:
A “Material Event” is an occurrence that affects an organization’s strategic direction,
mission, or business operation and, thereby, its status as a certified Community
Development Entity (CDE) and/or Community Development Financial Institution
(CDFI), and/or its compliance with the terms and conditions of its assistance/allocation
agreement. For additional guidance on what constitutes a Material Event, refer to the
“Frequently Asked Questions (FAQ): Material Event Occurrence and Reporting”
document available on the Fund’s website.
Instructions:
This form is to be used by CDFI Fund Awardees, applicants, and certified CDEs and
CDFIs, to report potential Material Events to the CDFI Fund. The Certification of
Material Events form must be signed by the organization’s Authorized Representative.
The completed form should be addressed to the attention of the Certification, Compliance
Monitoring and Evaluation Manager and emailed to [email protected]. Please attach
additional pages if necessary.

-----------------------------------------------------------------------------------------------------------PAPERWORK REDUCTION ACT NOTICE
CDFI - 0036
OMB Control Number 1559-0037

This submission requirement is provided to CDFI Fund Awardees, applicants, and certified CDEs
and CDFIs, to report potential Material Events to the CDFI Fund. CDFI Fund Awardees,
applicants, and certified CDEs and CDFIs, are not required to respond to this collection of
information unless it displays a currently valid OMB number. The estimated average burden
associated with this collection of information is 0.25 hours. Comments concerning the accuracy of
this burden estimate and suggestions for reducing this burden should be directed to the CDFI
Fund, Department of the Treasury, Community Development Financial Institutions Fund, 1500
Pennsylvania Avenue, NW, Washington, DC 20220.

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Certification of Material Event Form: Revised May 2013

Please check the appropriate box for the reporting entity as of the date this form is
signed:
† I certify that no Material Event has occurred in the reporting entity since the date of its
most recent certification/re-certification and/or the most recent submission of a Material
Events Form.
† A Material Event(s) has (have) occurred in the above-named organization. I certify
that the event(s) listed below constitute all of such Material Events (attach additional
pages if needed).
Explanation of Material Event
Please provide a narrative explanation regarding the Material Event affecting the
organization including, a timeline and the name and contact information of key people
involved in the action.
Date of Material Event(s):
Explanation of Material Event(s):

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Certification of Material Event Form: Revised May 2013

Please answer the following questions with respect to the Material Event(s) affecting
the organization:
1. Will the event(s) have any effect on the key personnel (e.g., management team and/or
Governing Board) of the organization? †Yes †No
If yes, please describe:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
2. Could the event(s) have a materially adverse effect on the financial condition or business
operations of the organization?
If yes, please describe:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
3. Will the event(s) have any effect on the organization’s business strategy (e.g., project
selection criteria, product/investment criteria, investments in unrelated entities, etc.)? □
†Yes †No
If yes, please describe:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
4. Will the event(s) have any effect on the organization’s CDFI and/or CDE certification
status (e.g., Accountability, Target Market/Service Area, etc.)? †Yes †No
If yes, please describe:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
5. Will the event(s) have any effect on the organization’s ability to administer any current
or anticipated awards from one or more of the CDFI Fund’s award programs, including
drawing down undisbursed and/or raising additional Qualified Equity Investments
(QEIs)? †Yes †No
If yes, please describe:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
6. Will the event(s) result in any changes to one or more myCDFI Fund accounts (e.g.,
legal name, EIN, fiscal year, etc.)? †Yes †No
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If yes, please describe:
_______________________________________________________________________
_______________________________________________________________________

Certification of Material Event Form: Revised May 2013

7. If a prior awardee or allocatee, will the event(s) have any effect on the organization’s
ability to comply with the reporting requirements set forth in the organization’s award
agreement? †Yes †No
If yes, please describe:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
8. If a prior awardee or allocatee, will the event(s) cause the organization to be in noncompliance with an existing award agreement and/or necessitate the organization to seek
an amendment to its existing award agreement? †Yes †No
If yes, please describe:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
9. Will the event(s) have any effect on a pending application with one or more of the CDFI
Fund’s Programs? †Yes †No
If yes, please describe:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
To the best of my knowledge and belief, all information contained in this
certification statement is true and correct. My signature indicates authorization on
behalf of the organization’s governing body.

Authorized Representative Signature:
Title:
Date: