Certified for Opportunity Zone Preference Points

Certification for Opportunity Zone Preference Points
I certify that the information provided on this form and in any accompanying documentation is true and
accurate. (Type or clearly print the following information)
Applicant Organization:
Name of the Federal Program to which the applicant is applying:

Opportunity Zone Census Tract(s) which the proposed activities/projects will benefit:
Designated Opportunity Zone Census Tracts can be found at: https://www.cdfifund.gov/Pages/Opportunity-Zones.aspx using the “List
of designated Qualified Opportunity Zones”. Please provide the full 11-digit census tract number. (ex: 06067001101)

The application meets which of the following criteria (please select one):
The proposed activities/projects will occur solely within the Opportunity Zone Census Tract(s) listed
above.
The proposed activities/projects will occur within the Opportunity Zone Census Tract(s) listed above and
other communities.
The proposed activities/projects will occur outside Opportunity Zone Census Tracts, but substantial and
direct benefits will accrue within the Opportunity Zone Census Tracts listed above.
Note: Projects which substantially and directly benefit Opportunity Zone Census Tracts, but which do not consist of activities
delivered within Opportunity Zone Census Tracts may be considered for competitive preference. If applicable, the respective
Federal Agency will clearly define “substantially and directly” in the relevant funding announcement.

Estimated Funding Allocations
Estimate a percentage of the total dollar amount of awarded federal funding that would result in a direct benefit within the Opportunity
Zone Census Tracts listed above:

76% - 100%
51% - 75%
26% - 50%
11% - 25%
1% - 10%

Provide a narrative explaining and/or reference the section in the application that explains how the
project will support public and private investment in urban and economically distressed areas,
specifically qualified Opportunity Zones (300-word limit):
Example: “The Main Street project described in this application will stimulate economic opportunity and mobility, encourage
entrepreneurship, expand quality educational opportunities, and promote workforce development for those families residing within the
XYZ Opportunity Zone.”

Check the following boxes that accurately reflect the nature or purpose of the proposed project:
Access to Capital
Asset Building
Business Assistance
Community Capacity Building
Economic Development
Education
Healthy Food Access
Health
Housing

Workforce Development
Low Income Housing Tax Credit (LIHTC) or other
rent restricted housing
Market rate housing
Industrial development
Commercial or retail development
Other business development
“Above ground” infrastructure – streets,
sidewalks, lighting

Human Services and Family Support

“Below ground” infrastructure – water, sewer,
gas, electric

Community Infrastructure

Schools or other educational facilities

Public Safety

Hospitals or other health care facilities

Name:
Title:
Organization:
Signature:
Date (MM/DD/YYYY):

Public reporting burden for this collection of information is estimated to average 12 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. This agency may not collect this information, and you are not required to complete this form, unless it
displays a currently valid OMB control number. This information is being collected to determine preference points in certain
competitive federal grants and technical assistance applications. This information will be used to strategically target investment in
communities designated as Opportunity Zones. This information is required to obtain the benefit of the preference point. The
information collected is not confidential.