1647-A National International Independent

PENDING OMB APPROVAL

No. 3206-0131

Combined Federal Campaign

2017 Application Instructions for

Independent Organizations and Members of Federations

Background

Enclosed is the model application for use by local, national/international, and international independent organizations to apply to participate in the Combined Federal Campaign (CFC) and for use by federation members to submit to the 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. The Office of Personnel Management (OPM) encourages organizations to apply early.

The application deadline for independent organizations and federations seeking eligibility is January 31, 2017.

All applications must be submitted electronically through the application module of the CFC Charity System (CFC-CS). Applications sent through any other means will not be processed.

OPM will not accept late applications. It is the applicant’s responsibility to ensure that its application and all required supplemental information and fees are received by the scheduled deadline. Requests for consideration after the deadline will not be granted.

All required documents and attachments must be complete and submitted before the application deadline. Documents that did not exist at the time of the application deadline will not be accepted during the appeals process. Organizations that are found ineligible have only one opportunity to appeal to the Director of OPM. The Director's decision is final for administrative purposes. Therefore, appellants should ensure that their appeals are complete and responsive to the actual reasons for the original denial decision.

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

Fees

A fee schedule is posted at www.opm.gov/cfc. All charities applying for participation in the CFC must pay a non-refundable Application Fee, which is due at the time the application is submitted. Applications that do not include payment at the time of submission will not be processed. Charities that are denied or withdraw will not have their fees refunded.

Charities that are approved for participation must pay a Listing Fee which is due no later than June 1, 2017. Approved organizations that have not paid the fee by that date will not be listed in the 2017 CFC Charity List. There are no waivers of the fee and requests for reconsideration will not be considered.

Taxonomy Codes

Each organization will be asked to identify up to three program categories, in priority order, which most closely identify the type of mission, services, and activities provided. The corresponding letters will be printed with your organization’s listing in the CFC charity list 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:

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 Unknown

DEFINITIONS

Organization Name of the applicant organization as it appears on the IRS Business Master File (BMF). If the name of the applicant organization differs from the name that appears in the IRS BMF, documentation from the IRS or state government authorizing this use of the name must accompany the application. The EIN must be included.

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

CFC Code The five-digit number assigned to the organization by the CFC. Organizations that did not previously participate in the CFC should leave this field blank.

Telephone Organization’s telephone number.

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. Links to social media pages are not accepted.

Organization Address The physical street address of the organization. Post Office Boxes or other mail service addresses may not be used.

Contact Person The individual to whom OPM will direct communications regarding the application. This may be any individual in the organization.

Contact Title Self-explanatory

Contact Address Contact person’s mailing address. Post Office Boxes may be used.

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

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. Participation decision letters and other CFC communications will be sent to this address.

INSTRUCTIONS

For details regarding CFC eligibility requirements, refer to CFC Guidance Memoranda on the CFC website at www.opm.gov/cfc.

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

Item 1
Check the one appropriate box and complete the schedule of services table listed as Attachment A.

National/International and International Organization Requirements - CFC eligibility requirements mandate that a national/international organization demonstrate it provided services in at least 15 different states or one foreign country over the three year period immediately preceding the start of the campaign’s application year (i.e., January 1, 2014 – December 31, 2016). A schedule listing a detailed description of the services in each state (minimum 15) or foreign country (minimum 1), including the year of service, must be included with the application. The schedule must make a clear showing of national and/or international presence. Simply providing a list of states or countries where an organization conducts or provides real services, benefits or program activities is not sufficient. An organization must provide a detailed description of the services and activities it provided, and the year in which those services were provided, in each state or foreign country. Applicants must document the dollar amounts of financial assistance (if applicable) and the number of beneficiaries of each service it lists in Attachment A.

The schedule must also include human health and welfare services that were provided in calendar year 2016 (see Certification #3).

This requirement cannot be met on the sole basis of services provided through an “800” telephone number or by disseminating information and publications via the U.S. Postal Service, the Internet, or a combination thereof. Broad descriptions of services and identical repetitive narratives will not be accepted at the sole discretion of OPM if they do not allow OPM to adequately determine that real services were provided or to accurately determine the individuals or entities who benefited. Providing listings of affiliated groups does not sufficiently demonstrate provision of real services by the applicant. Location of residence of organization members or location of residence of visitors to a facility does not substantiate provision of services in the location of residence. However, organizations that issue student scholarships or fellowships must indicate the state in which the recipient resides, not the state of the school or place of fellowship. Mere dissemination of information does not demonstrate provision of real services.

While it is not expected that an organization maintain an office in each state or foreign country, a clear showing must be made of the actual services, benefits, assistance or program activities provided in each state or foreign country. De minimis services, benefits, assistance, or other program activities in any state or foreign country will not be accepted as a basis for qualification as a national or international organization.

Local Organization Requirements - Local charitable organizations are not required to have provided services in 15 states or a foreign country over the prior 3 years. The schedule for local organizations is only required to document services in their local area. Local organizations must also certify that the Organization Address submitted with the application is the primary location where the organization's services are rendered and/or its records are maintained. 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 CFC Zones can be found on the CFC website at www.opm.gov/cfc.)

Attachment A for local organizations must clearly describe a real service, benefit ,assistance, or program activity provided within the geographic area of the CFC zone where it is located with the 2015 calendar year. Broad descriptions or mission statements that do not include actual dates of service, location(s) and number of beneficiaries of each service will be denied.

Item 2

Check the one appropriate box. If the name of the applicant organization differs from the IRS BMF, documentation from the IRS or state government authorizing the use of the name must accompany the application.

If the organization does not appear in the BMF, one of the following must accompany the application:

(i) An affirmation letter from the IRS, dated on or after January 1 of the campaign year to which the organization is applying, that verifies the organization's current 501(c)(3) tax-exempt status.

(ii) 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 § 950.202 and § 950.203 to be included in the Charity List. A local affiliate of a national organization that is not separately incorporated must submit a certification from the Chief Executive Officer (CEO) or CEO equivalent of the national organization stating that it operates as a bonafide chapter or 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. The letter must be signed and dated on or after October 1 of the calendar year preceding the campaign year for which the organization is applying.

Listing of a local organization, as well as its satellite offices, is permitted, as long as there is no more than one location within a county or parish. Each office must individually meet all of the eligibility criteria and submit independent documentation as required in § 950.202 and § 950.203 to be included in the Charity List. However, a satellite office that is not separately incorporated, in lieu of its own 26 U.S.C. 501(c)(3) tax exemption letter and, to the extent required by § 950.203(a)(2), audited financial statements, may submit the local organization's 26 U.S.C. 501(c)(3) tax exemption letter and audited financial statements, but must provide its own pro forma IRS Form 990, as defined in § 950.203(a)(3), for CFC purposes. The satellite office must submit a certification from the Chief Executive Officer (CEO) or CEO equivalent of the local organization stating that it operates as a bonafide office in good standing and is covered by the local organization's 26 U.S.C. 501(c)(3) tax exemption, IRS Form 990 and audited financial statements.

(iii) For central organizations that are churches, the CFC will accept a copy of its most recently published listing (such as a church directory) of section 501(c)(3) organizations that are included in the group exemption held by the central organization. A subordinate may alternatively obtain a letter from the central organization affirming the subordinate's status as an organization exempt under section 501(c)(3) of the Internal Revenue Code that is included in the group exemption held by the central organization.

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

Self-explanatory. Human health and welfare services provided in calendar year 2016 must be reflected in Attachment A.

Item 4

Check the one appropriate box based on the organization’s total revenue as reported on the IRS Form 990.

If the organization has annual revenue of $250,000 or more, the certifying official must certify that the organization 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 by an independent certified public accountant annually in accordance with Generally Accepted Auditing Standards (GAAS). No other basis of accounting is acceptable under GAAP. The cash basis, modified cash basis, modified accrual basis, and any other methods are not acceptable.

Include as Attachment B a copy of the auditor’s report and the organization's complete audited annual financial statements. 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 2017 (i.e. ending on or after June 30, 2015).

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.

A copy of the organization's most recent annual audited financial statements must be included with the application. The statements must include all statements required for voluntary health and welfare organizations by the United States Financial Accounting Standards Board or the International Accounting Standards Board. The audited financial statements must cover the fiscal period ending not more than 18 months prior to the January of the year of the campaign for which the organization is applying. For example, the audited financial statements included in the 2017 application must cover the fiscal period ending on or after June 30, 2015.

An organization with annual revenue of at least $100,000 but less than $250,000 is not required to undergo an audit. The organization must certify that the organization accounts for its funds on an accrual basis in accordance with Generally Accepted Accounting Principles (GAAP) and its financial statements are reviewed by an independent certified public accountant on an annual basis or are audited by an independent public accountant on an annual basis. A copy of the reviewed or audited financial statements must be included with the application as Attachment B

An organization with annual revenue of less than $100,000 reported on its IRS Form 990 or pro forma IRS Form 990 submitted to the CFC is not required to undergo an audit, submit audited financial statements, or to account for its funds on an accrual basis in accordance with generally accepted accounting principles. Rather, the organization must certify that it has controls in place to ensure that funds are properly accounted for and that it can provide accurate and timely financial information to interested parties. Attachment B is not required for organizations with annual revenue less than $100,000.

Item 5

Check the appropriate box. Include as Attachment C a copy of the complete, signed IRS Form 990 for a period ended not more than 18 months prior to January 2017. 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.

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. (The IRS Form 990 instructions define a ‘director or trustee’ as a member of the organization’s governing body but only if the member has voting rights.) 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.

A complete IRS Form 990 is required, including all supplemental statements and Schedule A, if applicable, with the exception of Schedule B, to be eligible for the CFC. If the IRS 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 (see instructions below).

The audited financial statements and IRS Form 990 must be prepared using the accrual method of accounting (for organizations with revenues $100,000 or higher) and cover the same fiscal period ended not more than 18 months prior to January 2017 (i.e. ending on or after June 30, 2015).

Pro forma IRS Form 990 Instructions – The IRS Form 990 can be downloaded from the IRS website (www.irs.gov). The following sections must be completed: Page 1, Items A-M; 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 6

Calculate and enter the organization’s annual percentage for administrative and fundraising expenses based on the formula below.

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).

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.

Item 7

Self-explanatory

Item 8

Self-explanatory

Item 9

Self-explanatory

Item 10

Self-explanatory

Item 11

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.

Certifying Official The certifying official is the individual who has the authority to affirm that all state­ments in the application are accurate. This role cannot be delegated to the federation of which the organization is a member.

IF THE ORGANIZATION IS DENIED

If your organization’s application is denied, it will receive an email stating the reason(s) for the denial. If the organization wishes to appeal the decision to the Director of OPM, the appeal must be received by OPM within ten business days of the receipt of the email. The appeal should be complete and respond to the reason(s) for the original denial decision.

Additional information or a revision to a submitted document will only be accepted if it existed prior to the application deadline. The CFC will not accept documents that did not exist or were not set forth in final form prior to the application deadline.

APPLICANTS SHOULD BE AWARE THAT A FALSE RESPONSE TO ANY CERTIFICATION IN THIS APPLICATION MAY BE GROUNDS FOR DENIAL OF THE APPLICATION AND MAY BE PUNISHABLE BY FINE OR IMPRISONMENT (18 U.S.C. 1001).  ALL STATEMENTS AND INFORMATION PROVIDED ARE SUBJECT TO INVESTIGATION, INCLUDING CONFIRMATION THROUGH THIRD PARTIES AND OTHER GOVERNMENT AGENCIES.

Any information in your application may be subject to public disclosure under the Freedom of Information Act (FOIA). If your application is the subject of a FOIA request, you will be notified and given the opportunity to identify each item in the application that you believe is exempt from disclosure under the FOIA, specify which exemption you believe applies to that item, in accord with 5 U.S.C. Section 552, and give full justification for your belief that the justification(s) applies.  In making our decision on the disclosure, we will consider your justification for nondisclosure.  If we decide that an item of information that you believe is exempt is not exempt from disclosure, we will so inform you before it is disclosed.

REQUIRED ATTACHMENTS (failure to provide any of these documents may result in a denial)

• Attachment A – Schedule of services by year and state and/or foreign country (See Items 1 & 3)

• Attachment B – Audited financial statements (See Item 4)

• Attachment C – IRS Form 990 (See Item 5)

THE APPLICATION AND SUPPORTING DOCUMENTATION MUST BE SUBMITTED BY 11:59:59PM (EST), [TBD], 2017. LATE APPLICATIONS WILL NOT BE ACCEPTED.

PENDING OMB APPROVAL

No. 3206-0131

Combined Federal Campaign

2017 Application for

Independent Organizations

and Members of Federations

(Federation members must complete this application to be kept on file by their federation.)

CFC Application System Account Registration:

Name:

Email Address:

CFC Charity Application:

Organization:

Employer Identification Number (EIN): ___ ___ - ___ ___ ___ ___ ___ ___ ___

CFC Code (If a previous participant in the CFC): ___ ___ ___ ___ ___

Telephone: ( )___________________ Website Address:

Organization Address:

(PO Box addresses are not accepted and may result in automatic disqualification.)

Contact Person:

Contact Title:

Contact Address:

(If different from the above address - Post Office Box Addresses are acceptable for the Contact Address.. All OPM correspondence will be sent to this address.)

Contact Telephone: ( )_________________ Fax: ( )_____________________

Contact Email Address(es):

Disbursement Address: _________________________________________________________________

(This is the address where paper checks will be sent.)

Electronic Fund Transfer (EFT):

Financial Institution:

Routing Number (nine digits): ___ ___ - ___ ___ ___ ___ ___ ___ ___

Account Number:

CFC Auto-Response Element (CARE) Statement:

The CFC Pledge System will immediately acknowledge donors’ gifts with a statement expressing thanks and an organization-specific explanation of what the donors’ gift will be used to fund. You may enter that statement here (optional; limited to 1,000 characters, including spaces, carriage returns, and line breaks.)

CFC Volunteerism:

Yes No

  Please indicate if your organization provides volunteer opportunities.

  If “yes”, please indicate if your organization would like to solicit volunteer time from federal employees.

$ . If yes, what is the estimated monetary value to your organization per hour of volunteer time.

Schedule of Services (Attachment A):

National/International organizations are required to enter descriptions of real services, benefits, assistance, or program activities (hereafter listed as “services”) 15 or more different states or a minimum of one foreign country. Several services can be described under any one state or foreign country. Also, services that are provided in more than one state or foreign country can be described under the heading of each of those states or foreign countries. All dates must be within the period of January 1, 2014 – December 31, 2016 only.

International organizations are required to enter descriptions of services in a minimum of one foreign country. Several services can be described under any one foreign country. Also, services that are provided in more than one foreign country can be described under the heading of each of those foreign countries. All dates must be within the period of January 1, 2014 – December 31, 2016 only.

Local organizations must enter descriptions of services physically provided to or conducted in the geographic campaign zone to which they are applying. Several services can be described, but local organizations may describe services under only one state’s heading. That state must correspond to the state certified as the Service Office Address in first certification statement below. All dates must be within calendar year 2016 only.

For each state or foreign country submitted:

State or Foreign Country:

Date:

Service Description (including who provided the service; limited to 256 characters):

Number of Beneficiaries:

- OR -

Monetary Value of Benefit:

1) Place a check in the one appropriate box:

Local Part

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, a description of the programs, services, benefits, etc. provided by the organization in calendar year 2016 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):

Name of Campaign Zone Where Service Office is Located:

Hours of Operation Per Each Day of the Week (Example: Monday-Friday, 9AM-5PM; Saturday, 10AM – 3PM; Sunday, Closed):

Organization’s Dedicated Phone Number:

County and State Where Office is Located:

– OR –

National/International Part

I certify that the organization named in this application provided or conducted real ser­vices, benefits, assistance, or program activities in 15 or more different states or one foreign country over the three-year period immediately preceding the start of the campaign application year. (Include as ATTACHMENT A, a schedule listing those states or foreign countries where the program activities have been provided within the 2014-2016 period only and a detailed description of the activities, including the year in which those services were provided, in each state or foreign country listed. See recommended format for Attachment A on page 6 of the application instructions.)

– OR –

International Part

I certify that the organization named in this application provided or conducted real ser­vices, benefits, assistance, or program activities in a foreign country over the three-year period immediately preceding the start of the campaign application year. (Include as ATTACHMENT A, a schedule listing each country where program activities have been pro­vided within the 2014-2016 period only and a detailed description of the program activities, including the year in which those services were provided in each country listed. See recommended format for Attachment A on page 6 of the instructions.)

2) Place a check in the one appropriate box:

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) to which contributions are tax deductible pursuant to 26 U.S.C. 170(c)(2) and it is not part of a group exemption. (See instructions for additional information.)

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) to which contributions are tax deductible pursuant to 26 U.S.C. 170(c)(2) and it is part of a group exemption. (See instructions for additional information.)

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) to which contributions are tax deductible pursuant to 26 U.S.C. 170(c)(2) and it is a bona-fide chapter or affiliate that operates under a national organization’s single corporation tax-exemption. (See instructions for additional information.)

3) 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 2016 are reflected in ATTACHMENT A.

4) Place a check in the one appropriate box:

I certify that the organization named in the application has annual revenue of $250,000 or more as reported on the IRS Form 990 (Attachment C), 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). (Include as ATTACH-MENT B 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 2016. )

– OR –

I certify that the organization named in the application has annual revenue of at least $100,000 but less than $250,000 as reported on the IRS Form 990 (Attachment C), accounts for its funds on an accrual basis in accordance with generally accepted accounting principles (GAAP) and has either an audit or a review of its fiscal operations completed annually by an independent certified public accountant. (Include as ATTACHMENT B a copy of the auditor’s report and the complete audited financial statements or review for a fiscal period ending not more than 18 months prior to January 2017.)

– OR –

I certify that the organization named in the application has annual revenue of less than $100,000 as reported on the IRS Form 990 (Attachment C). The organization has controls in place to ensure that funds are properly accounted for and is able to provide accurate and timely financial information to interested parties. (ATTACHMENT B is not required.)

5) Place a check in 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 (long form). (Include as ATTACHMENT C a copy of the complete IRS Form 990 for a period ending not more than 18 months prior to January 2016, including signatures in the box marked “Signature of Officer” or in either IRS Form 8879-EO or IRS Form 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 (long form) to the IRS. (Include as ATTACHMENT C a pro forma IRS Form 990 for a period ending not more than 18 months prior to January 2016. See application instructions for pro forma IRS Form 990 requirements. IRS Forms 990 EZ, 990PF, and comparable forms are not acceptable substitutes.)

6) I certify that the administrative and fundraising rate (AFR) for the organization named in this application is __ __ . __%. This percentage has been computed from information on the IRS Form 990 submitted with this application. See the instructions for information on how to calculate the AFR.

7) 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.

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

9) 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.

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

11) 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 Office of CFC immediately.

Certifying Official

I, ____________________________________, am the duly appointed representative

(Print Name)

of ____________________________________ authorized to certify and affirm all statements

(Print Organization)

included in this application. I certify that I have read all the certifications set forth in this document and affirm their accuracy. In addition, by checking the boxes next to the certification statements above, I acknowledge and agree to comply with that certification, Federal regulations pertaining to the CFC, and the directions of the Director of the Office of Personnel Management.

______________________________

(Typed or Printed Name)

______________________________

(Title)

Date Completed ______________________ ______________________________

The application must be submitted through the online CFC application module by 11:59:59PM (EST) [TBD], 2017. Applications submitted after that date, or sent via any means other than the online application module, will not be accepted.

APPLICANTS SHOULD BE AWARE THAT A FALSE RESPONSE TO ANY CERTIFICATION IN THIS APPLICATION MAY BE GROUNDS FOR DENIAL OF THE APPLICATION AND MAY BE PUNISHABLE BY FINE OR IMPRISONMENT (18 U.S.C. 1001).  ALL STATEMENTS AND INFORMATION PROVIDED ARE SUBJECT TO INVESTIGATION, INCLUDING CONFIRMATION THROUGH THIRD PARTIES AND OTHER GOVERNMENT AGENCIES.

Any information in your application may be subject to public disclosure under the Freedom of Information Act (FOIA). If your application is the subject of a FOIA request, you will be notified and given the opportunity to identify each item in the application that you believe is exempt from disclosure under the FOIA, specify which exemption you believe applies to that item, in accord with 5 U.S.C. Section 552, and give full justification for your belief that the justification(s) applies.  In making our decision on the disclosure, we will consider your justification for nondisclosure.  If we decide that an item of information that you believe is exempt is not exempt from disclosure, we will so inform you before it is disclosed.

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, (3206-0131), Washington, DC 20414-7900. 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.

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OPM Form 1647-A

Rev. February 2016