Form OPM 1647 A OPM 1647 A Independent Members of Federations

OMB APPROVED
No. 3206-0269

COMBINED FEDERAL CAMPAIGN
2023 Application for
Independent Organizations and Members of Federations

2023 #00000 Independent Application Dashboard

You are providing a FULL APPLICATION this year.

Step 1: Charity Contact Information

Who You Are

Contact Person

Contact Title

Email Address(es) (Use semicolons to separate multiple addresses)

OPM will send the eligibility decision and other CFC communication
to the email address(es) on file. At least one email address is
required, however, applicants are highly encouraged to provide
more than one email address. For member organizations, the
Federation should enter its own email addresses if it wishes to
manage CFC communication on behalf of its member organizations.

Contact Address

P.O. Box Accepted.
Address Line 1

Address Line 2

City
Greenville
State

Zip

Phone Number

Optional Information

Organization's Website Address (Do not include "http://" in your website
address.)

Fax Number

Step 2: Application Type

Selected organization type
Local Charity
National/International Charity
International Charity

Selected federation membership or independent charity
This charity is part of a federation.
The parent federation code is

This charity is independent.

Check FSYA/FSYP/MWR if applicable
FSYA/FSYP/MWR
Indicate Military Installation

Step 3: Human Health & Welfare Services Verification Statement

Select “YES!” to certify the statement below.
Check box if applicable.
YES!
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 2021 are
reflected in the Area of Service submitted in the next step of this application, if applicable.

Step 4: Areas of Service(s)

Areas of Service(s) must be required.

Select “YES!” to certify the statement below

YES!
I certify that the organization named in the application has a
substantial local presence in the geographical area covered by the
local campaign.
#

Zone Name

Status

1 National Capital Area/Northern Virginia CFC Zone
Hours of Operation (limited to 256 characters)

Review Pending

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

Web-Based / Virtual Services
Were any of the above reported services web-based?

No

Yes

Note: Per 5 CFR §950.202(a)(1)(iii), for each web-based/virtual service that your
organization reported, it must submit:
Service log or other record indicating geographic distribution (i.e City/state
and/or country)
Scope of services received by users, in addition to
Two of the following:
Evidence of website registration;
Summary reports documenting customer feedback; and/or
Evidence that recipients of web-based services paid a fee.
Reports that reflect only the number of hits or visits to a website are not sufficient to
establish the provision of real services.
To submit the required documentation, upload a .pdf that lists information by
relevant geographic area based on CFC zone (i.e. local, National/International or
International), and year.
Choose File No file chosen
WebService File Uploaded

2023 Areas of Service - Local Charity
Service Office Address
Use existing charity address:
1199 North Fairfax Street
Suite 300
Alexandria, VA, 22314
Use new address

Schedule of Services

2022 Service Description
How: (Explain how the services were provided)

Who: (Benefited from the Service(s))

What: (Provide a description of the actual services, benefits, assistance, or program
activities provided)

Where: (Provide City, State and/or counties where the services were delivered)
Test

When: (Provide beginning and end dates of when the services were provided. If onetime
activities, end dates do not need to be selected)
One-time Check only if the reported service was a one-time activity. The “Start
date” will need to be entered but the “End date” will be disabled.
Start date End date:
Monetary Value of Benefit 3
OR Number of Beneficiaries

Step 5: Verification of 501(c)(3) Tax-Exempt Status
Select “YES!” to certify one of the statements below.

Option 1
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.

Option 2
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.
Organizations that are part of a group exemption are those recognized by the
IRS as affiliated with a central or parent organization that generally operates on
a state, regional, or national level. The IRS issues a group exemption letter that
includes the listing of central and subordinate organizations that are included in
the group ruling. In most cases, each central and subordinate organization will
have its own Employer Identification Number (EIN) which will be listed in the
group exemption letter and can be found in the IRS Business Master File.
Option 2-A Is your organization affiliated with a place of worship and/or religious
organization?
Yes
No
If Yes...For an organization that is affiliated with a place of worship such as a
church, it must submit the official and most recent subordinate listing approved
by the central organization (e.g. page from the US Catholic Directory that shows
the organization is listed in the church directory and is part of the group
exemption).
Upload

Option 3
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 taxexemption.

a letter from the central organization from the central/parent organization’s
headquarters, signed by the CEO or equivalent officer, is required. The
letter (referred to as the CEO letter) must certify that your local
organization (explicitly named in the letter) operates as a bona-fide chapter
or affiliate in good standing of the national, state, or regional organization
and it is covered by the national central/parent organization’s 501(c)(3) taxexemption, IRS Form 990 and audited financial statements. A copy of the l
central/parent organization’s 501(c)(3) determination or affirmation letter must
also be submitted along with the letter.

Step 6: IRS Determination or Affirmation Letter

Your organization’s EIN was not found in the IRS Business Master File. An IRS
determination or affirmation letter is required.

Select “YES!” to certify statement below.
YES!
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) and to which contributions
are tax deductible pursuant to 26 U.S.C. 170(c)(2).
IRS determination or affirmation letter uploaded

Doing Business As (DBA)/Listing Name

Test Ind 2
Annual CFC charity lists are obligated to list the legal names of the charitable organizations
that are approved to participate in the campaign. The legal name of the organization is
associated with the CFC applicant’s EIN which both can be found in the IRS Business Master
File. A DBA (doing business as) name is any organization name other than its legal name.
DBA names may also be known as fictitious names or assumed business names.
An organization may submit a request to be listed with a DBA name along with its legal name
if it submits documentation issued by a state or other government entity that approved the
organization to use a DBA (e.g. fictitious, assumed business, trade, etc.) name. Organizations
are encouraged to submit DBA name requests with acceptable documentation with the CFC
application to resolve discrepancies in the legal name of the organization listed on the CFC
application, financial statements and/or IRS Form 990 or pro forma IRS form 990.
Discrepancies found with the organization’s legal name and with the financial statements and
tax return is a deficiency and may result in an adverse eligibility determination.
The documentation must bear both the legal name (as recognized by the IRS and shown
below) and the DBA name, and expressly state the DBA name is registered or otherwise
approved for use. Such documentation that presents an expiration date must not have
expired. Acceptable documentation may include IRS-issued group exemption, determination
and/or affirmation letters, a filed IRS Form 990 that lists the DBA name, and CEO letter for
organizations that are chapters/affiliates.
DBA Name:
Legal name of the organization: Test Ind 2

Step 7: Financial Statements

Select “YES!” to certify one of the statements below.

Based on the organization’s total revenue (Part VIII, Line 12, Column A) reported in
the IRS Form 990, verify that the correct certification was selected on Step 7 and if
the appropriate financial statements were submitted. If not, the application should
be a "Fail".

Option 1
I certify that the organization named in the application has annual
revenue of $250,000 or more as reported on the IRS Form 990 (/tep
8) and 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).
Audited Financial Statement Uploaded
Fiscal period end date:

Option 2
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 (Step 8), 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.

Option 3
I certify that the organization named in the application has annual
revenue of less than $100,000 as reported on the IRS Form 990 (Step
8). 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. (Financial statements are not
required.)

Step 8: IRS Form 990 or Pro Forma IRS Form 990

Select “YES!” to certify one of the statements below.

Option 1

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.
IRS Form 990 Uploaded

PLEASE ENTER DETAILS FOR THE CURRENT
FORM 990
Please enter details for the current Form 990
Fiscal period start

date:

Fiscal period end

date:

Accounting Method: Cash
Is the uploaded tax return signed and dated by an Officer at the
Organization?

Yes
No

Electronic Signature of Officer
The IRS Form must be signed and dated by an officer at the organization. The
document can be electronically signed on this step of the CFC application.

YES!
Under penalties of perjury, I declare that I have examined this
return, including accompanying schedules and statements, and
to the best of my knowledge and belief, it is true, correct, and
complete.
An officer who is authorized to sign the organization’s tax
document may be the organization’s president, vice president,
treasurer, assistant treasurer, chief accounting officer or other
corporate or association officer, such as a tax officer.
Please note: The tax preparer’s signature will not be accepted
in lieu of a signature from an officer at the organization.

Full Name
John Doe
Title
Director
Initials
JD

Option 2
I certify that the organization named in this application is not
required to prepare and submit an IRS Form 990 to the IRS.

Step 9: Administrative and Fundraising Rate (AFR)

Based on the organization’s total revenue (Part VIII, Line 12, Column A) reported
in the IRS Form 990 or pro forma IRS Form 990, verify that the correct certification
was selected on Step 7 and if the appropriate financial statements were
submitted. If not, the application should be a "Fail".

Fill in the required fields with information from the IRS Form 990 or pro forma
IRS Form 990 and confirm the AFR.
NOTE: When entering the organization’s total revenue (Part VIII, Line 12), General and
Management Expenses (Part IX, Line 25, Column C), and Fundraising expenses (Part
IX, Line 25, Column D), round up to the nearest dollar. The system does not accept
decimals.

Management & General Expenses
Fundraising Expenses
Total Revenue

Your AFR is: 59.1%
AFR = total expenses divided by total revenue X 100

Confirm organization’s AFR and select “YES!” to certify the statement below.

YES!
I certify that the administrative and fundraising rate (AFR) for the
organization named in this application is the AFR Calculated from
entry above. This percentage has been computed from information
on the IRS Form 990 or pro forma IRS Form 990 submitted with this
application.

Step 10: Governing Body

Select “YES!” to certify the statement below.
YES!
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,

For the majority of the board to be considered uncompensated, less than 50% of the
people marked as either Institutional trustee or Individual trustee or director in column
C of Part VII may have any compensation showing in columns D, E or F. If 50% or

more have any compensation in those columns, the majority of the board is not
considered uncompensated.
Enter number of Individual and/or Institutional Trustees
reported on Part VII, Column C of the IRS Form 990 or pro
forma IRS Form 990 submitted on Step 8.

Enter Number of Voting Members of the Board reported on
Part I, Line 3 of the submitted IRS Form 990 or pro forma
IRS Form 990 submitted on Step 8.

If the number of individual and/or or institutional trustees is fewer than the number of voting
members, an explanation for the discrepancy must be provided below. If the organization is
required to submit an IRS Form 990 to the IRS, the organization may need to make the
corrections in the document and then amend it with the IRS before submission with the CFC
application. A previously filed tax return that was edited but not amended with the IRS will
not be accepted.

Explanation of discrepancy (1000 characters max)

1000 characters remaining

Step 11: Verification Statements

“YES!” to certify the statements below.
YES!
I certify that the organization named in this application prohibits the sale or lease of CFC
contributor lists.
YES!
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.
YES!
I certify that the organization named in this application effectively uses the funds
contributed for its announced purposes.

YES!
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.