201708 Annual Certification and Data Collection Report Form

CDFI Fund Certification and Data Collection Report Form

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OMB Approval No. 1559-0046
Paperwork Reduction Act Notice.
This submission requirements package is provided to Certified CDFIs to ensure they continue to remain
in compliance with CDFI certification requirements. Certified CDFIs are not required to respond to this
collection of information unless it displays a currently valid Office of Management and Budget (OMB)
control number. The estimated average burden associated with this collection of information is 8 hours
per CDFI. Comments concerning the accuracy of this burden estimate and suggestions for reducing this
burden should be directed to the Program Manager, Certification, Compliance, Monitoring and
Evaluation, Department of the Treasury, Community Development Financial Institutions Fund, 1500
Pennsylvania Avenue, Washington, D.C. 20220.

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CDFI Fund Annual Certification and Data Collection Report Form
Purpose:
The primary intent of the Annual Certification and Data Collection Report Form (the “Form”) is to ensure
that Community Development Financial Institutions (CDFI) continue to meet the requirements to be
certified CDFIs. 1 It is also a method to ensure that organizational information is updated annually. The
financial and portfolio data will be used by the CDFI Fund to gain insight on the CDFI industry.
Information provided in these sections will not impact a CDFI’s certification status or applications for CDFI
Fund programs.
Instructions:
Please complete the Form using data from your organization’s most recently completed fiscal year.
Please refer to the CDFI Fund Annual Certification and Data Collection Report Form Instructions for
detailed instructions on how to complete the Form. Definitions for the terms used in these materials
may be found in the CDFI Fund Glossary.
Documents needed to complete the Form (if applicable to your organization):
You should refer to the following documents for your organization when completing this report:
• Balance Sheet (Statement of Financial Position),
• Income Statement (Statement of Activities or Statement of Operations or Profit and Loss
Statement), and
• For Banks and Thrifts, Consolidated Reports of Condition and Income; or
• For Credit Unions, 5300 Call Report.
All financial statements should be the final, audited reports from your organization’s most recently
completed fiscal year. All data should be taken directly from these documents where possible.
Amendment to CDFI Certification Application Information:
There are four (4) parts to the Annual Certification and Data Collection Report Form: Part I. Organization
Information; Part II. Verification of CDFI Re-Certification Eligibility; Part III. Selected Financial Information;
and Part IV. Loan and Investment Portfolio Values. Part II requires the organization to confirm that it
continues to meet the CDFI certification eligibility criteria as outlined in the CDFI Certification Application.
Additional information will be required, as needed, to verify that the organization meets specific
requirements.
If your organization’s response to any of the Certification eligibility criteria questions in Part II is “No” or
if your organization’s EIN has changed, you must submit the “Certification Amendment” Form with the
updates in order for your organization to maintain the status as a certified CDFI.

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Emerging CDFIs are not required to complete the Form.

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Changes that require submission of a Certification Amendment
If any of the following information changed since your organization was last approved or recertified as a Certified CDFI, you are required to submit a Certification Amendment.
• EIN
• Articles of Incorporation
• Bylaws
• Charter
• Primary Mission
• Target Market
• Accountability Method
• Status as a Non-Government Entity
Please Note: Eligibility questions not answered in the affirmative will result in a review of CDFI
certification eligibility, which may result in revocation of CDFI certification if the Certification
Amendment form and necessary documentation are not submitted.

Part I. Organization and Management Change Information
Current Organization Information

Entry Type

Organization Identification Number
Autocomplete
Date
Autocomplete
1. Organization Information
1a.
Organization Name
Text Box
1b.
Employer Identification Number (EIN)
Text Box
1c.
Fiscal Year End
Month Day
1d.
Tax Status
Choose a response
1e.
Certified CDFI Serving Native Communities
Select a Response.
2. Organization Type - Select one of the following
☐ Bank or Thrift
☐ Venture Capital Fund
☐ Depository Institution
Holding Company
☐ Credit Union
☐ Loan Fund
2a.
FDIC Charter Number (Banks and Thrifts Only)
Text Box
2b.
Bank Holding Company Number
Text Box
(Banks and Thrifts Only)
2c.
Office of Thrift Supervision (OTS) Docket Number
Text Box
(Thrifts Only)
2d.
NCUA Number (Credit Unions Only)
Text Box
3. Line of Business
3a.
Primary Line of Business
Choose a business line.
3b.
Secondary Line of Business
Choose a business line.
4. Credit Union Membership (Credit Unions Only)
4a.
Total Number of Credit Union Members
Amount
4b.
Total Number of Credit Union Members in the Target Market(s)
Amount
5. Human Resources and Staffing
5a.
Percentage of FTE and contractor time dedicated to providing Financial
Amount
Products and/or Services (Unregulated Only)
5b.
Percentage of FTE and contractor time dedicated to providing
Amount
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Current Organization Information
5c.
5d.
5e
6.
6a.
7.
7a.
8.
8a.
8b.
9.
9a.
10.
10a.
11.
11a.
11b.

Entry Type

Development Services (Unregulated Only)
Total number of FTE staff dedicated to providing support toward CDFIrelated activities
Total Full Time Equivalent Staff Turnover
Has the organization seen the departure, replacement or change within
its senior leadership 2 team during the last fiscal year?
Strategic Plan
Did the organization adopt a new business/strategic plan during the last
fiscal year?
Governance
Has the organization’s governance structure 3 been changed during the
last fiscal year?
Management Information Systems
Has the organization implemented a new management information
system over the last fiscal year?
Does the CDFI’s information technology infrastructure support an
accounting system?
Legal
Has the organization been party to any adverse legal actions during the
last fiscal year?
Organizational Structure
Did the organization have any audit findings in the audit for its last
complete fiscal year?
Credit and Portfolio Management
Does the organization have a delinquent loan management policy?
In the last year, has the organization had one or more missed or
overdue payments to its creditors?

Amount
Amount
Choose a response
Choose a response
Choose a response
Choose a response
Choose a response
Choose a response
Choose a response
Choose a response
Choose a response

Part II. Verification of CDFI Re-Certification Eligibility
CDFI Certification Criteria

Entry Type

1. Legal Entity
1a.
The organization continues to be the same legal entity, duly formed and in
good standing, since it was certified by the CDFI Fund.

Choose a response

1b.

Choose a response

The organization has not amended its organizational documentation (e.g.,
articles of incorporation, bylaws, charter) since the organization’s CDFI
certification was last approved by the CDFI Fund.
2. Primary Mission

2

Senior leadership refers to the paid staff of the organization, excluding the board of directors. Senior leadership
may include but is not limited to the president, executive vice presidents, and senior vice presidents of the entity.
3
Changes in the governance structure of the CDFI refers to changes in the by-laws, charter of the organization, or
the roles and responsibilities of the board of directors or the senior leadership who are chartered with the
responsibility of governing the organization.

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CDFI Certification Criteria

The Primary Mission of the organization, as evidenced in board-approved
organizational documents, has not changed since the organization’s CDFI
certification was last approved by the CDFI Fund.

Entry Type

Choose a response

3. Financing Entity
3a.
The organization continues to be an entity whose predominant business
Choose a response
activity is the provision, in Arms-Length Transactions, of Financial Products,
as reflected on its financial statements and executed notes.
3b.
The organization continues to maintain Sufficient Capital to continue
Choose a response
Financing Activities that support the provision of Financial Products for at
least three months from the end of the organization’s fiscal year.
3c.

The organization continues to dedicate a Predominance of its Assets to
Financial Products.

3d.

The organization continues to dedicate a Predominance of staff time to the
provision to Financial Products.
4. Development Services
4a.
The organization, directly or through an Affiliate, or through a contract with
another provider, continues to meet the Development Services criteria
requirements.
4b.

Choose a response
Choose a response

Choose a response

Please identify the Development Services provided by the organization during the last fiscal year
and the associated Financial Products offered in conjunction with those services.
Development Services

Financial Product

Total Clients
Served

Target Market
Clients Served

Choose services.

Choose an associated product.

Amount

Amount

Choose services.

Choose an associated product.

Amount

Amount

Choose services.

Choose an associated product.

Amount

Amount

Choose services.

Choose an associated product.

Amount

Amount

Choose services.

Choose an associated product.

Amount

Amount

If “Other” is selected, enter a description of the Development Services.
5. Target Market
5a. At least 60% of the organization’s Transactions are directed towards serving
its approved Target Market(s).
5b. The organization reviewed its approved Target Market maps in CIMS and
verified that its Target Market(s) have not changed since its CDFI
certification was last approved by the CDFI Fund.
6. Accountability
6a. The organization continues to maintain Accountability to clients in its
approved Target Market through representation on its governing board, or
otherwise, since the Respondent’s CDFI certification was last approved by
the CDFI Fund.
6b. The organization maintained the same method or set of methods for
providing Accountability to the organization’s approved Target Market since
the organization’s CDFI certification was last approved by the CDFI Fund.

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Text Box
Choose a response
Choose a response

Choose a response

Choose a response

CDFI Certification Criteria

7. Non-Governmental Entity
The organization continues to not be an agency or instrumentality of the
United States, or any state or political subdivision thereof, and that such has
not changed since the organization’s CDFI certification was last approved by
the CDFI Fund.

Entry Type
Choose a response

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

Value

Entry Type

1.

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

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Select a response.
Amount
Amount
Calculated
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Calculated
Amount
Amount

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

Value

Entry Type

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

Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount

Financing Capital Detail
Submit detailed Capital figures as of the most recent FYE, these values should equal the Total Capital
available for Financing Activities, the activities that support the provision of Financial Products.
7.
8.
9.
10.
11.
12.

Capital Category

Financing Debt
Government Grants
Equity Investments
Deposits
Secondary Capital, Uninsured (Credit Unions Only)
Net Assets or Retained Earnings
Total Financing Capital

Entry Type
Amount
Amount
Amount
Amount
Amount
Amount
Calculated

Part IV. Loan and Investment Portfolio Values
1. Loan and Investment Portfolio
Report total outstanding Loan and Investment portfolio information for the most recent FYE.
1a.
1b.
1c.
1d.
1e.
1f.
1g.

Value

Entry Type

Total Outstanding Loan Portfolio
Total Outstanding Investment Portfolio
Total Charge-Offs
Total Recoveries
Total Value of Non-performing Assets
Loans 90-Days or More Past Due
Other Real Estate Owned

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Amount
Amount
Amount
Amount
Amount
Amount
Amount

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2. Financial Products Portfolio Breakdown
Select all applicable Financial Products that are present in the organization’s outstanding portfolio:
☐
☐
☐

Loans (including loan acquisitions)
Equity Investments (including Equity Equivalent Investments)
Loan Guarantees

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

Loans
(If Selected)
☐
☐
☐

☐
☐
☐
☐
☐

Total Loan
Portfolio
(Count)

Business Loans
Amount
Commercial Real Estate Loans
Amount
Amount
Charter School
☐
Amount
Commercial
☐
Amount
Community Facility
☐
Amount
Health Care Facility
☐
Consumer Loans
Amount
Intermediary Loans
Amount
Microfinance Loans
Amount
Residential Real Estate Loans
Amount
Other (Please Describe)
Amount
Description:
Text Box

Total Loan
Portfolio
(Amount)

Target
Market
(Count)

Target
Market
(Amount)

Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount

Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount

Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount

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

Equity Investments
(If Selected)
☐
☐
☐

☐

Business Financing
Commercial Real Estate Financing
Charter School
☐
Commercial
☐
Community Facility
☐
Health Care Facility
☐
Consumer Financing

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Total
Portfolio
(Count)

Total
Portfolio
(Amount)

Target
Market
(Count)

Target
Market
(Amount)

Amount
Amount
Amount
Amount
Amount
Amount
Amount

Amount
Amount
Amount
Amount
Amount
Amount
Amount

Amount
Amount
Amount
Amount
Amount
Amount
Amount

Amount
Amount
Amount
Amount
Amount
Amount
Amount

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☐
☐
☐
☐

Intermediary Financing
Microfinance
Residential Real Estate Financing
Other (Please Describe)
Description:

Amount
Amount
Amount
Amount
Text Box

Amount
Amount
Amount
Amount

Amount
Amount
Amount
Amount

Amount
Amount
Amount
Amount

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

Loan Guarantees
(If Selected)
☐
☐
☐

☐
☐
☐
☐
☐

Business Financing
Commercial Real Estate Financing
Charter School
☐
Commercial
☐
Community Facility
☐
Health Care Facility
☐
Consumer Financing
Intermediary Financing
Microfinance
Residential Real Estate Financing
Other (Please Describe)
Description:

Total
Portfolio
(Count)
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Text Box

Total
Portfolio
(Amount)

Target
Market
(Count)

Target
Market
(Amount)

Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount

Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount

Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount

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

Authorized Representative Signature

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-----------------------------------------------------------------------------------------------------------PAPERWORK REDUCTION ACT NOTICE
OMB Control Number 1559-0046

Paperwork Reduction Act Notice
This submission requirement is provided to certified Community Development Financial Institutions to
annually report certain to the CDFI Fund information to maintain certification and other administrative
purposes. Certified 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 8.25 hours. Comments concerning the accuracy of this burden estimate and suggestions for reducing
this burden should be directed to the Department of the Treasury, Community Development Financial
Institutions Fund, 1500 Pennsylvania Ave., N.W., Washington, DC 20220.

The CDFI Fund is an equal opportunity provider.

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