CDFI Fund Title VI Compliance Worksheet

OMB Control Number 1559-XXXX

Form Expiration Date: xx/xx/xxxx

Community Development Financial Institutions Fund Title VI Compliance Worksheet PAPERWORK REDUCTION ACT NOTICE Public reporting burden for this collection of information is estimated to average thirty (30) minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information to the Community Development Financial Institutions Fund, 1500 Pennsylvania Ave, NW, Washington, DC 20220. Applicant Name:
Employer Identification Number:
DUNS or SAM Number:
Submitted by:
Title:
Date Submitted:
Signature:

The United States Department of the Treasury regulations implementing Title VI of the Civil Rights Act (Title VI), are set forth in 31 C.F.R. Part 22. The Applicant should review such regulations carefully before completing this section. Please note that these regulations apply to Applicants as well as their prospective subrecipients that are not direct beneficiaries of Federal Financial Assistance (e.g., Depository Institution Holding Company and their Subsidiary Depository Institutions). In order to assure compliance with those regulations, and other requirements related to compliance with Title VI, the Applicant shall provide the following information:

TITLE VI COMPLIANCE REQUIREMENTS	YES	NO
Civil Rights Complaint Information: Has the Applicant had legal findings that they violated civil rights laws or civil rights complaints that resulted in any settlements in the last two years? If Yes, provide information on lawsuits and/or complaints such as case name, number, specific complaint, and date of case. Does the Applicant have any pending civil rights investigations, complaints, and/or lawsuits filed against them that pertain to allegations of discrimination on the basis of race, color, and/or national origin? If Yes, provide information on the investigations, complaints, and/or lawsuits such as case name, number, date of case, and status of case (e.g., discovery). Has the Applicant ever been found to be noncompliant with civil rights requirements for any Federal Financial Assistance in the last two years? If Yes, provide the Federal Awarding Agency, program name, findings, corrective actions, status of corrective actions, agency point of contact, and attach a copy of the Title VI compliance review issued by the federal agency. Does the Applicant have any pending applications or current awards of Federal Financial Assistance with other federal awarding agencies? If Yes, please select the applicable federal agency(ies), enter the associated program name(s), and award amount.
Notice of Rights and Program Location: Does the Applicant post signs in its offices to inform persons of their rights under Title VI and other civil rights requirements? If No, please describe the Applicant’s plan to post this information. Does the Applicant post information on their website informing persons of their rights under Title VI and other civil rights requirements? If No, please describe the Applicant’s plan to post this information. If the Applicant provides services directly to customers, do they make efforts to ensure that facilities are accessible to the communities they serve? If No, describe why and how the Applicant mitigates this issue. If an Applicant does not provide direct services to customers answer “Yes.”
Language Assistance Plan: Does the Applicant have a Language Assistance Plan (LAP) or process in place to support persons with limited English proficiency (LEP)? If No, describe how the Applicant will meet this requirement. Does the LAP or process to support LEP persons take into consideration the volume, proportion, or frequency of LEP persons that the Applicant serves in determining the appropriate language assistance? If No, describe how the Applicant determines what LEP services they provide. Does the Applicant display notices in appropriate languages in intake areas or initial points of contact on how to access language services? If No, describe how the Applicant meets this requirement or will meet this requirement. Does the Applicant provide language interpreter services or translated materials to LEP persons? If No, describe why not or how the Applicant plans to meet this requirement.
4. Sub-recipient Communication: If the Applicant has sub-recipients, do they have established measures to communicate civil rights compliance requirements to their sub-recipients? If No, describe how the Applicant meets this requirement or will meet this requirement. If the Applicant does not have sub-recipients answer “Yes.” If the Applicant has sub-recipients, do they inform sub-recipients about how to provide notice to the public about their right to file a complaint of discrimination? If No, describe how the Applicant meets this requirement or will meet this requirement. If the Applicant does not have sub-recipients answer “Yes.” If the Applicant has sub-recipients, do they conduct periodic review checks of sub-recipient compliance with Title VI requirements? If No, describe how the Applicant meets this requirement or will meet this requirement. If the Applicant does not have sub-recipients answer “Yes.”