1b Guarantee Application - Appendix A-2C Assurances and Cer

Bond Guarantee Program

GA - Appendix A-2C Assurances and Certifications for Qualified Issuer and Guarantee Applications

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Organization Name: ____________________________________________________
EIN #: _______________________________________________________________
Certification Control # (if applicable): _______________________________________

CDFI Bond Guarantee Program: Assurances and Certifications for Qualified Issuer and
Guarantee Applications
Instructions: The term Applicant as used in these Assurances and Certifications includes all entities that
are proposed to participate in the Bond Issue including: the Qualified Issuer, Program Administrator,
Servicer, and Eligible CDFI(s). Each Applicant should submit a separate signed SF 424 and these
Assurances and Certifications as part of a Qualified Issuer and/or Guarantee Application. Signing the
certification on the SF 424 and initialing each page below certifies that the Applicant will comply with,
perform as described, and maintain compliance with the Assurances and Certifications in each section
listed below if its Application is approved. Certain of these Assurances and Certifications may not be
applicable to the Applicant. An Applicant may not modify any of the Assurances and Certifications.
A. General Assurances and Certifications
Instructions: Each Applicant (as that term is defined in this document) must review the following
assurances and certifications. With the exception of paragraphs 17, 18, 19, 20, 21, and 22 below, the
inability of the Applicant to provide the General Assurances and Certifications in section A below will
render the Applicant ineligible to participate in the CDFI Bond Guarantee Program. If the Applicant
cannot provide the General Assurances and Certifications in paragraphs 17, 18, 19, 20, 21, and 22, the
Applicant must submit a written explanation. The CDFI Fund will consider the explanation provided and
determine, in its sole discretion, whether the Applicant is eligible to participate in the CDFI Bond
Guarantee Program. If the Applicant cannot provide any of the other General Assurances and
Certifications, it should not submit, or be included in, a Qualified Issuer or Guarantee Application.
NOTE: Where the Applicant is unable to certify to paragraphs 17, 18, 19, 20, 21, and/or 22 of the
General Assurances and Certifications, the Applicant must attach a written explanation to this
Application.
____ Check here if the Applicant is submitting a written explanation.
As the Authorized Representative of the Applicant, I certify as follows:
1. The Applicant has the legal authority to apply for Federal assistance, and the institutional, managerial
and financial capability (including funds sufficient to pay the non-Federal share of project costs) to
ensure proper planning, management and completion of the project described in this Application.
2. The Applicant’s appropriate senior management, and its counsel, has read the Regulations set forth at
12 C.F.R. 1808, the CDFI certification regulations set forth at 12 C.F.R. 1805.201, as amended, and
the environmental quality regulations set forth at 12 C.F.R. 1815, as well as the template Bond
Documents and Bond Loan documents posted on the CDFI Fund’s website (www.cdfifund.gov/bond)
including, but not limited to, the following: Bond Trust Indenture, Bond Loan Agreement, Bond
Purchase Agreement, Collateral Assignment, Reimbursement Note, Opinion of Bond Counsel, and
Opinion of Counsel to the Borrower.
Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the
written explanations attached thereto are true, accurate, and complete to the best of the Applicant’s information, knowledge, and
belief.
Page 1 of 13

3. The Applicant will give U.S. Department of the Treasury (Treasury, as the awarding agency), the
Comptroller General of the United States, and if appropriate, the State, through any authorized
representative, access to and the right to examine all records, books, papers, or documents related to
the award; and will establish a proper accounting system in accordance with generally accepted
accounting standards or agency directives.
4. The Applicant will establish safeguards to prohibit employees from using their positions for a purpose
that constitutes or presents the appearance of personal or organizational conflict of interest, or
personal gain.
5. The Applicant will initiate and complete the work (the activities proposed in the Application) within
the applicable timeframe after receipt of approval of Treasury.
6. The Applicant will comply with all Federal statutes relating to nondiscrimination. These include, but
are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L.88-352) which prohibits
discrimination on the basis of race, color or national origin; (b) Title IX of the Education
Amendments of 1972, as amended (20 U.S.C.1681-1683, 1685-1686), which prohibits discrimination
on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C.794),
which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 U.S.C.6101-6107), which prohibits discrimination on the basis of age; (e) the Drug
Abuse Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on
the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment
and Rehabilitation Act of 1970 (P.L.91-616), as amended, relating to nondiscrimination on the basis
of alcohol abuse or alcoholism; (g) Sections 523 and 527 of the Public Health Service Act of 1912
(42 U.S.C. 290 dd-3 and 290 ee-3), as amended, relating to confidentiality of alcohol and drug abuse
patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C.3601 et seq.), as amended,
relating to nondiscrimination in the sale, rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s) under which Application for Federal assistance
is being made; and (j) the requirements of any other nondiscrimination statutes which may apply to
the Application.
7. The Applicant will comply, or has already complied, with the requirements of Titles II and III of the
Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646)
which provide for fair and equitable treatment of persons displaced or whose property is acquired as a
result of Federal or federally assisted programs. These requirements apply to all interests in real
property acquired for project purposes regardless of Federal participation in purchases.
8. The Applicant will comply with environmental standards which may be prescribed pursuant to the
following: (a) institution of environmental quality control measures under the National
Environmental Policy Act of 1969 (P.L.91-190) and Executive Order 11514; (b) notification of
violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d)
evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project
consistency with the approved State management program developed under the Coastal Zone
Management Act of 1972 (16 U.S.C. 1451et seq.); (f) conformity of Federal actions to State
Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C.
7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water

Authorized Representative Initials:___________
Signature: Initialing above and signing the certification on SF 424 certifies that the Assurances, Certifications, answers, and the
written explanations attached thereto are true, accurate, and complete to the best of the Applicant’s information, knowledge, and
belief.
Page 2 of 13

10.

11.
12.
13.
14.
15.

16.

17.

18.

19.

Act of 1974, as amended, (P.L.93-523); and (h) protection of endangered species under the
Endangered Species Act of 1973, as amended, (P.L.93-205).
The Applicant will assist Treasury in assuring compliance with Section 106 of the National Historic
Preservation Act of 1966, as amended (16 U.S.C. 470), EO 11593 (identification and protection of
historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a-1
et seq.).
Applicability of Federal Construction Requirements. The Secondary Borrower shall adhere to the
following Federal construction standards: (a) accessibility; (b) environmental impact; (c) safety; (d)
historical preservation; (e) seismic activity; and (f) metrification.
The Secondary Borrower shall ensure compliance with the provisions of the Americans with
Disabilities Act, to the extent codified in state and local building codes.
Seismic Safety. The Secondary Borrower shall ensure compliance with Executive Order 12699,
Seismic Safety of Federal and Federally Assisted or Regulated New Building Construction.
The Applicant will cause to be performed the required financial and compliance audits in accordance
with the Single Audit Act of 1984.
The Applicant will comply with all applicable requirements of all other Federal laws, executive
orders, regulations and policies governing the CDFI Bond Guarantee Program.
The Applicant will comply with the requirements of Section 106(g) of the Trafficking Victims
Protection Act (TVPA) of 2000, as amended (22 U.S.C. 7104) which prohibits grant award recipients
or a sub-recipient from: (a) engaging in severe forms of trafficking in persons during the period of
time that the CDFI Bond Guarantee Program award is in effect; (b) procuring a commercial sex act
during the period of time that the award is in effect; or (c) using forced labor in the performance of
the award or subawards under the award.
The Applicant is duly organized and validly existing under the laws of the jurisdiction in which it was
incorporated or otherwise established, and is (or within 30 days will be) authorized to do business in
any jurisdiction in which it proposes to undertake activities specified in this Application;
The Applicant’s Board of Directors (or similar governing body) has by proper resolution or similar
action authorized the filing of this Application, including all understandings and assurances contained
herein, and directed and authorized the person identified as the Authorized Representative of the
Applicant to act in connection with this Application and to provide such additional information as
may be required;
The Applicant will comply with all applicable requirements of the Community Development Banking
and Financial Institutions Act of 1994 (the Act) [12 U.S.C. 4701 et seq.], regulations implementing
the Act and all other applicable Treasury regulations and implementing procedures (and any
regulations or procedures which are later promulgated to supplement or replace them);
The Applicant will comply, as applicable and appropriate, with the requirements of the Uniform
Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (2 C.F.R.
Part 200), any applicable OMB Circulars and any regulations and circulars which are later
promulgated to supplement or replace them, including standards for fund control and accountability;

20. The Applicant has not knowingly and willfully made or used a document or writing containing any
false, fictitious or fraudulent statement or entry as part of this Application or any related document,
correspondence or communication (the Applicant and its Authorized Representative should be aware
that, under 18 U.S.C. 1001, whoever knowingly and willfully makes or uses such document or
writing shall be fined or imprisoned for not more than five years, or both);
21. The Applicant and its officers, directors, owners, and senior executives: (a) have not within a threeyear period preceding the date of this Application been convicted of or had a civil judgment rendered
against them for commission of fraud; (b) have not within a three-year period preceding the date of
this Application been convicted of or had a civil judgment rendered against them for commission of a
criminal offense, which includes, but is not limited to, any felony criminal violation under any
Federal law; (c) have not within a three-year period preceding the date of this Application been
convicted of or had a civil judgment rendered against them for violation of Federal or State antitrust
statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of
records, making false statements, or receiving stolen property; or (d) have not within the three-year
period preceding the date of this Application been found liable in any civil legal action involving
creditor’s claims of greater than $500,000.
22. The Applicant and its officers, directors, owners, partners, and key employees: (a) have not within a
three-year period preceding the date of this Application been indicted for or charged with the
commission of fraud or a criminal offense; (b) have not within a three-year period preceding the date
of this Application been indicted for or charged with the violation of Federal or State antitrust statutes
or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records,
making false statements, or receiving stolen property; (c) are not presently indicted for or otherwise
criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of
any of the offenses enumerated in paragraphs 21(a), 21(b), or 21(c) of this certification; or (d) have
not within the three-year period preceding the date of this Application been the subject of any formal
investigation or disciplinary proceeding by a government agency, regulatory body, or professional
association in connection with any matter which may have a material adverse effect on the Applicant
or its financial condition or the Applicant’s ability to carry out the activities associated with the Bond
Guarantee Program.
23. Any other person or entity that Controls the Applicant (other than the Applicant’s officers, directors,
owners, partners, and key employees): (a) has not within a three-year period preceding the date of this
Application been indicted, charged with, or convicted of, or had a civil judgment rendered against it
for commission of fraud; (b) has not within a three-year period preceding the date of this Application
been indicted, charged with, or convicted of, or had a civil judgment rendered against it for
commission of a criminal offense, which includes, but is not limited to, any felony criminal violation
under any Federal law; (c) has not within a three-year period preceding the date of this Application
been indicted, charged with or convicted of, or had a civil judgment rendered against it for violation
of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery,
falsification or destruction of records, making false statements, or receiving stolen property; (d) is not

24.
25.
26.
27.
28.

29.
30.
31.

presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal,
State, or local) with commission of any of the offenses enumerated in paragraphs 22(a) and 22(b) of
this certification; (e) has not within the three-year period preceding the date of this Application been
the subject of any formal investigation or disciplinary proceeding by a government agency, regulatory
body, or professional association in connection with any matter which may have a material adverse
effect on the Applicant or its financial condition or the Applicant’s ability to carry out the activities
associated with the CDFI Bond Guarantee Program; or (f) has not within the three-year period
preceding the date of this Application been found liable in any civil legal action involving creditor’s
claims of greater than $500,000.
The Applicant has never been delinquent on amounts due to the Internal Revenue Service or on any
debts owed to Federal, State, or local government.
Neither the Applicant, Controlling Entity (if applicable), nor any Affiliate has an unpaid Federal tax
liability that has been assessed.
The Applicant has never filed for bankruptcy.
Neither the Applicant, Controlling Entity (if applicable), nor any Affiliate is a federally regulated
financial institution currently under any Enforcement Action from any federal regulator.
Not less than 100 percent of the principal amount of Bonds will be used to make Bond Loans for
Eligible Purposes beginning on the Bond Issue Date, and that Secondary Loans shall be made as set
forth in the Regulations.
The Applicant has established a System for Award Management (SAM) account.
The Applicant has provided a valid and current Dun and Bradstreet Data Universal Numbering
System (DUNS) number and has provided a valid and current Employer Identification Number (EIN).
The information in this Application, and in these assurances and certifications in support of the
Application, is true and correct to the best of the Applicant’s knowledge and belief and the filing of
this Application has been duly authorized.
[Remainder of this page left intentionally blank.]

Certification Regarding Debarment, Suspension, and Other Responsibility Matters -- Primary
Covered Transactions

Instructions: The inability of a person to provide the certification required below will not necessarily
result in the denial of participation in this covered transaction. The prospective Applicant shall submit an
explanation of why it cannot provide the certification set out below. The certification or explanation will
be considered in connection with Treasury’s approval of the proposed Application. However, failure of
the Applicant to furnish a certification or an explanation shall disqualify such person/entity from
participation in this transaction. Please be advised of the following:
• This certification is a material representation of fact upon which reliance is placed when Treasury
determines to enter into this transaction. If it is later determined that the Applicant knowingly
rendered an erroneous certification, in addition to other remedies available to the Federal
government, Treasury may terminate this transaction for cause or default.
• The Applicant shall provide immediate written notice to the CDFI Fund if at any time the
Applicant learns that its certification was erroneous when submitted or has become erroneous by
reason of changed circumstances.
• The terms “covered transactions,” “debarred,” “suspended,” “ineligible,” “lower tier covered
transaction,” “participant,” “person,” “primary covered transaction,” “principal,” “proposal”, and
“voluntarily excluded,” as used in this clause (certification), have the meanings set out in the
Definitions and Coverage sections of the rules implementing Executive Order 12549. You may
contact the CDFI Fund for assistance in obtaining a copy of those regulations (31 C.F.R. Part 19).
• The Applicant agrees by submitting this Application that, should the proposed covered
transaction be entered into, it shall not knowingly enter into any lower tier covered transaction
with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the CDFI Fund.
• The Applicant further agrees by submitting this Application that it will include the clause titled
“Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower
Tier Covered Transaction,” to be provided by the CDFI Fund, without modification, in all lower
tier covered transactions and in all solicitations for lower tier covered transactions (see 31 C.F.R.
Part 19, Appendix B).
• A participant in a covered transaction may rely upon a certification of a prospective participant in
a lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily
excluded from the covered transaction, unless it knows that the certification is erroneous. A
participant may decide the method and frequency by which it determines the eligibility of its
principals. Each participant may, but is not required to, check the Nonprocurement List.
• Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render in good faith the certification required by this clause. The knowledge
and information of a participant is not required to exceed that which is normally possessed by a
prudent person in the ordinary course of business dealings.

•

Except for transactions authorized under paragraph 6 of these instructions, if a participant in a
covered transaction knowingly enters into a lower tier covered transaction with a person who is
suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in
addition to other remedies available to the Federal government, the CDFI Fund may terminate
this transaction for cause or default.

NOTE: Where the Applicant is unable to certify to one or more of the statements in the Certification
Regarding Debarment, Suspension, and Other Responsibility Matters, the Applicant must attach a written
explanation to this Application.
By signing and submitting this Application, the prospective primary participants (the Applicant, as that
term is defined above) is providing the certification set out below.
The prospective primary participant (the Applicant) certifies to the best of its knowledge and belief,
that it and its principals:
1. are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
2. have not within a three-year period preceding this Application been convicted of or had a civil
judgment rendered against them for commission of fraud or a criminal offense in connection with
obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or
contract under a public transaction; violation of Federal or State antitrust statutes or commission
of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. are not presently indicted for or otherwise criminally or civilly charged by a governmental entity
(Federal, State or local) with commission of any of the offenses enumerated in paragraph (1)(b)
of this certification; and
4. Have not within a three-year period preceding this Application had one or more public
transactions (Federal, State or local) terminated for cause or default.
Where the Applicant is unable to certify to any of the statements in this certification, such Applicant shall
attach an explanation to this proposal.
____ Check here if the Applicant is submitting a written explanation.

C. Certification Regarding Drug-Free Workplace Requirements
The Applicant certifies that it will provide a drug-free workplace by:
1. publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the Applicant’s
workplace and specifying the actions that will be taken against employee for violations of such
prohibition;
2. establishing a drug-free awareness program to inform employees about:
a. the dangers of drug abuse in the workplace;
b. the Applicant’s policy of maintaining a drug-free workplace;
c. any available drug counseling, rehabilitation, and employee assistance program;
d. the penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;
3. making it a requirement that each employee to be engaged in the performance of the award be
given a copy of the statement required by subparagraph (a);
4. notifying the employee in the statement required by subparagraph (a) that, as a condition of
employment in such grant, the employee will:
a. abide by the terms of the statement; and
b. notify the employer of any criminal drug use statute conviction for a violation
occurring in the workplace no later than five calendar days after such conviction;
5. notifying the granting agency in writing, within ten calendar days after receiving notice of a
conviction under subparagraph (d) (ii) from an employee or otherwise receiving actual notice of
such conviction;
6. taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(ii),
with respect to any employee who is so convicted:
a. taking appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as
amended; or
b. requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local
health, law enforcement, or other appropriate agency; and
7. making a good faith effort to continue to maintain a drug-free workplace through implementation
of paragraphs 1 through 6 above.

D. Certification Regarding Lobbying
The Applicant certifies, to the best of its knowledge and belief, that:
1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the Applicant, to
any person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any Federal contract, the making of any Federal
grant, the making of any Federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any Federal contract, grant,
loan, or cooperative agreement;
2. If any funds other than Federal appropriated funds have been paid or will be paid to any person
for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with this Application, the undersigned shall complete and submit Standard Form LLL,
“Disclosure Form to Report Lobbying, “ in accordance with its instructions; and
3. The Applicant shall require that the language of this certification be included in the award
documents for all subawards of all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly.
This certification is a material representation of fact upon which reliance is placed when this transaction is
made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for
each such failure.

E. Environmental Review Form
Instructions: The CDFI Fund’s environmental review requirements are set forth in 12 C.F.R. Part 1815.
The Applicant should review such regulations carefully before completing this section. In order to assure
compliance with those regulations and other requirements related to the environment, the Applicant shall
provide the information below. If the Applicant answers YES to any of the below questions, the
Applicant should attach a detailed description of each action, clearly identifying the category in which the
action falls:
____ Check here if the Applicant is submitting a written explanation.
YES

1. Are there any actions proposed in the Application that do not constitute a
“categorical exclusion” as defined in 12 C.F.R. 1815.110?
a. If YES, would any of these actions normally require an environmental
impact statement (see 12 C.F.R. 1815.109)?
2. Are there any activities proposed in the Application that involve:
a. Historical or archeological sites listed on the National Register of Historic
Places or that may be eligible for such listing?
b. Wilderness areas designated or proposed under the Wilderness Act?
c. Wild or scenic rivers proposed or listed under the Wild and Scenic Rivers
Act?
d. Critical habitats of endangered or threatened species?
e. Natural landmarks listed on the National Registry of Natural Landmarks?
f. Coastal barrier resource systems?
g. Coastal Zone Management Areas?
h. Sole Source Aquifer Recharge Areas designated by EPA?
i. Wetlands?
j. Flood plains?
k. Prime and unique farmland?
l. Properties listed or under consideration for listing on the Environmental
Protection Agency’s List of Violating Facilities?
NOTIFICATION
As stated in 12 C.F.R. 1815.105, if the CDFI Fund determines that the Application proposes actions
which require an environmental assessment or an environmental impact statement, any approval and
funding of the Application will be contingent upon:

1. The Applicant supplying to the CDFI Fund all information necessary for the CDFI Fund to perform
or have performed any required environmental review;
2. The Applicant not using any funds from the CDFI Bond Guarantee Program to perform any of the
proposed actions in the Application requiring an environmental review until approval is received
from the CDFI Fund; and
3. The outcome of the required environmental review.
In addition, as stated in 12 C.F.R. 1815.106, if the CDFI Fund determines that an Application, or any
part thereof, is not sufficiently definite to perform a meaningful environmental review prior to approval
of the Application, final approval and funding of the Application shall require supplemental
environmental review prior to the taking of any action directly using funds from the CDFI Bond
Guarantee Program for any action that is not a categorical exclusion.
[Remainder of this page left intentionally blank.]

F. 501(C)(4) Certification
Instructions: This questionnaire is necessary for the CDFI Fund to determine whether an Applicant with
a 501(c)(4) designation from the IRS is eligible to receive an award from the CDFI Fund (see 12 C.F.R. §
1805.200(a)(3)). Please read all definitions before responding to the questions and continue to refer to
such definitions in responding to this questionnaire. If the answer to any question is yes, please describe
in detail the facts and circumstances, subject matter, date(s), names and titles of all individuals and their
employers and their organizations on a separate sheet(s) of paper.
The CDFI Fund reserves the right to seek follow-up responses from an Applicant. Failure to complete
this questionnaire and, if applicable, respond timely to follow-up questions, will delay the CDFI Fund’s
processing of the Application, and may result in the disqualification of the Application from further
consideration.
After submitting responses to this questionnaire, the Applicant is under a continuing obligation to: (1)
supplement its responses upon a change in circumstances; and (2) revise or modify its responses within
10 business days of having actual or constructive knowledge that the responses previously submitted and
certified are no longer complete, accurate, or true.
Scope: The scope of this questionnaire is limited to activities on or after January 1, 1996.
____ Check here if the Applicant is submitting a written explanation.
Questions
1. Does the Applicant have an IRS 501(c)(4) designation?
If no, STOP NOW. Questions 2 through 11 are not applicable.
2. Has any officer, employee, director, partner, proprietor, or board member contacted1 a Covered
Executive Branch Official2 with regard to the formulation, modification, or adoption of Federal
legislation (including legislative proposals)

 Yes
 No
 Yes
 No


3. Has any officer, employee, director, partner, proprietor, or board member contacted a Covered

Executive Branch Official with regard to the formulation, modification, or adoption of a Federal rule,
regulation, Executive Order, or any other program, policy, or position of the United States
Government?

4. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered

Executive Branch Official with regard to the administration or execution of a Federal program or
policy (including the negotiation, award, or administration or a Federal contract, grant, loan, permit,
or license)?

Yes
No

5. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered
Executive Branch Official with regard to the nomination or confirmation of a person for a position
subject to confirmation by the United States Senate?
6. Has any officer, employee, director, partner, proprietor, or Board member engaged in efforts
supporting and coordinating the contact by others of a Covered Executive Branch Official including
preparation and planning activities, research and other background work that was intended, at the
time performed, for a purpose described in Questions 1-4?
7. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered
Legislative Branch Official3 with regard to the formulation, modification, or adoption of Federal
legislation (including legislative proposals)?
8. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered
Legislative Branch Official with regard to the formulation, modification, or adoption of a Federal
rule, regulation, Executive Order, or any other program, policy, or position of the United States
Government?
9. Has any officer employee, director, partner, proprietor, or Board member contacted a Covered
Legislative Branch Official with regard to the administration or execution of a Federal program or
policy (including the negotiation, award, or administration of a Federal contract, grant, loan, permit,
or license)?
10. Has any officer, employee, director, partner, proprietor, or Board member contacted a Covered
Legislative Branch Official with regard to the nomination or confirmation of a person for a position
subject to confirmation by the United States Senate?

 Yes
 No
 Yes
 No

 Yes
 No

 Yes
11. Has any officer, employee, director, partner, proprietor, or Board member engaged in efforts
 No
supporting and coordinating the contact by others of a Covered Legislative Branch Official including
preparation and planning activities, research and other background work that was intended, at the
time performed, for a purpose described in Questions 6-9?

“Contacted” means any oral or written communication including an electronic communication.
“Covered Executive Branch Official” means: (a) the President; (b) the Vice President; (c) any officer or employee,
or any other individual functioning in the capacity of such an officer or employee, in the Executive Office of the
President; (d) any officer or employee serving in an Executive Level I-V position, a “Schedule C” position, or any
official in a Senior Executive Service position; (e) any member of the uniformed services serving at grade O-7 or
above; or (f) any officer or employee serving in a position of a confidential, policy-determining, policy-making, or
policy-advocating character described in section 7511(b)(2) of title 5, United States Code.
3
“Covered Legislative Branch Official” means: (a) a member of Congress; (b) an elected officer of either House of
Congress; and (c) any employee of the House or Senate, including employees of Members, committees, leadership
and working groups or caucuses organized to provide legislative services or other assistance to Members of
Congress; and any other legislative branch employee serving in a position described under section 109(13) of the
Ethics in Government Act of 1978 (5 U.S.C. App.).
2

File Type	application/pdf
Author	Denise N. Noel
File Modified	2021-02-03
File Created	2021-02-03