Fillable 2013 CFC Independent Organization and Federation Member form

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2013 CFC Independent Organization and Federation Member form

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OPM Form 1647-A
Rev. September 2012
1
OMB APPROVED
No. 3206-0131
COMBINED FEDERAL CAMPAIGN
2013 Application Instructions for
National/International Independent Organizations And
Members of Federations
BACKGROUND
Enclosed is the model application for use by
national/international independent organizations to
apply to participate in the Combined Federal
Campaign (CFC) and for use by national/
international federation members to submit to the
national/international federations to which they
belong. The following instructions and form are
intended to assist charitable organizations in
applying for participation in the CFC. All aspects
of the CFC, including eligibility for participation,
are strictly governed by Federal regulation. The
current CFC regulations can be viewed on our
website at www.opm.gov/cfc. Additional copies of
the application can also be downloaded from the
website. The Office of Personnel Management
(OPM) encourages organizations to apply early.
The application deadline for independent
organizations and federations seeking national
eligibility is 5:00 p.m. Eastern Standard Time,
Tuesday, January 15, 2013, but applications may
be sent to OPM’s Office of CFC as early as
Monday, December 3, 2012. A timely application
must be received by the deadline at the following
address:
Office of Personnel Management
Office of Combined Federal Campaign
ATTN: Chimezie Ihuoma
Room 6484
1900 E Street, NW
Washington, DC 20415
OPM will not accept late applications. It is the
applicant’s responsibility to submit its application
and information by the scheduled deadline.
Requests for consideration after the deadline will
not be considered.
Federation members must submit their applications
to the federation. Copies of these applications
should not be sent to OPM.
All required documents and attachments must be
complete and submitted before the application
deadline. Documents that did not exist at the time
of the application deadline will not be accepted
during the appeals process. Organizations that
apply for national/international eligibility and are
found ineligible have only one opportunity to
appeal to the Director of OPM. The Director's
decision is final for administrative purposes.
Therefore, appellants should ensure that their
appeals are complete and responsive to the actual
reasons for the original denial decision.
OPM suggests that national/international
organizations use the model application provided
when applying to the CFC. Although not
required, submission of this form will expedite
the processing of individual applications. OPM
will not accept application forms with
modifications to any of the certification
statements.
In order to determine whether an organization may
OPM Form 1647-A
Rev. September 2012
2
participate in the campaign, OPM may request
evidence of corrective action regarding any prior
violation of regulation or directive, sanction, or
penalty, as appropriate. OPM will decide whether
the organization has demonstrated, to OPM’s
satisfaction, that the organization has taken
appropriate corrective action. Failure to
demonstrate satisfactory corrective action or to
respond to OPM’s request for information within
10 business days of the date of the request may
result in a determination that the organization will
not be included in the Charity List.
APPLICATION RECEIPT CONFIRMATION
When the application is entered into the CFC
database, an email will be sent to the contact
person’s email address(es) with instructions to use
an online system to enter the organization’s 25-
word statement and select up to three taxonomy
codes. This information will appear in the CFC
Charity List if the application is approved. Please
note that the email is not documentation of the
approval of the application.
Organization’s Program Description and
Taxonomy Codes
The organization will be given a Personal
Identification Number and be directed to a secure
website to register and verify the organization’s
information on file with OPM. All approved
organizations, regardless of past participation, must
register each year. During the registration process
applicants will be asked to verify contact
information on file with OPM and enter the 25-
word statement that will appear in the CFC charity
list.
In addition, the organization will be asked to
identify up to three program categories, in priority
order, which most closely identify the type of
mission, services, and activities provided. The
corresponding letters will be printed with your
organization’s listing in the CFC charity list to
assist donors in identifying charities by type of
service provided. Categories are derived from the
National Taxonomy of Exempt Entities (NTEE)
classification system developed by the National
Center for Charitable Statistics. The 26 categories
are:
A Arts, Culture, and Humanities
B Education
C Environment
D Animal Related
E Health Care
F Mental Health & Crisis Intervention
G Voluntary Health Associations & Medical
Disciplines
H Medical Research
I Crime & Legal Related
J Employment
K Food, Agriculture & Nutrition
L Housing & Shelter
M Public Safety, Disaster Preparedness & Relief
N Recreation & Sports
O Youth Development
P Human Services
Q International, Foreign Affairs & National Security
R Civil Rights, Social Action & Advocacy
S Community Improvement & Capacity Building
T Philanthropy, Voluntarism & Grantmaking
Foundations
U Science & Technology
V Social Science
W Public & Societal Benefit
X Religion-Related
Y Mutual & Membership Benefit
Z Unknown
DEFINITIONS
Organization Name of the applicant org-
anization as it appears on the IRS Business Master
File. If the name of the applicant organization
differs from the name that appears on the IRS
determination letter, the IRS Form 990, or audited
financial statements, documentation from the IRS
or state government authorizing use of this name
must accompany the application. The EIN must be
included.
Employer Identification Number (EIN) The
nine-digit EIN assigned to the organization by the
IRS and appearing on the IRS Form 990 submitted
with the application.
5 Digit CFC Number The 5 digit number
assigned to the organization by the CFC.
Organizations that did not previously participate in
the CFC should leave this field blank.
Telephone Organization’s telephone number.
Website Address List the complete Internet
OPM Form 1647-A
Rev. September 2012
3
address of the applicant organization (no e-mail
addresses). This information is required, if the
organization has an Internet address.
Organization Address The physical street
address of the organization. Post Office Boxes
may not be used.
Contact Person The individual to whom OPM
will direct communications regarding the
application. This may be any individual in the
organization.
Contact Title Self-explanatory
Contact Address Contact person’s mailing
address. Post Office Boxes may be used.
Participation decision letters and other CFC
communications will be sent to the Contact Person
at this address.
Contact Telephone Contact person’s telephone
number, if different than the organization’s tele-
phone number.
Fax Contact person’s fax number.
Contact E-Mail Address(es) Contact person’s
electronic mail address. Applicants are en-
couraged to provide more than one email address.
INSTRUCTIONS
For details regarding CFC eligibility requirements
for national/international independent organ-
izations and federation members, refer to CFC
Guidance Memoranda on the CFC website at
www.opm.gov/cfc.
Applicants must check the box next to each
certification statement to demonstrate agreement to
comply with the statement and to certify that it
meets the requirement. Failure to provide a check
mark for each of the statements will be considered
as a refusal to certify and will result in the denial of
the application.
Item 1
Check the one appropriate box. Include Attach-
ment A. CFC eligibility requirements mandate
that a national/international organization demon-
strate it provided services in at least 15 different
states or one foreign country over the three year
period immediately preceding the start of the
campaign’s application year. A schedule listing a
detailed description of the services in each state
(minimum 15) or foreign country (minimum 1),
including the year of service, must be included
with the application. The schedule must make a
clear showing of national and/or international
presence. Simply providing a list of states or
countries where an organization conducts or
provides real services, benefits or program
activities is not sufficient. An organization must
provide a detailed description of the services and
activities it provided, and the year in which those
services were provided, in each state or foreign
country. Applicants must document the dollar
amounts of financial assistance (if applicable) and
the number of beneficiaries of each service it lists
in Attachment A. The schedule must also include
human health and welfare services that were
provided in calendar year 2012 (see Certification
#3).
A sample Attachment A format is included in these
instructions. OPM encourages applicants to use
this format, but it is not a requirement.
This requirement cannot be met on the sole basis
of services provided through an “800” telephone
number or by disseminating information and
publications via the U.S. Postal Service, the
Internet, or a combination thereof. Broad
descriptions of services and identical repetitive
narratives will not be accepted at the sole
discretion of OPM if they do not allow OPM to
adequately determine that real services were
provided or to accurately determine the individuals
or entities who benefited. Providing listings of
affiliated groups does not sufficiently demonstrate
provision of real services by the applicant.
Location of residence of organization members or
location of residence of visitors to a facility does
not substantiate provision of services in the
location of residence. However, organizations that
issue student scholarships or fellowships must
indicate the state in which the recipient resides, not
the state of the school or place of fellowship. Mere
dissemination of information does not demonstrate
provision of real services.
While it is not expected that an organization
maintain an office in each state or foreign country,
OPM Form 1647-A
Rev. September 2012
4
a clear showing must be made of the actual
services, benefits, assistance or program activities
provided in each state or foreign country. De
minimis services, benefits, assistance, or other
program activities in any state or foreign country
will not be accepted as a basis for qualification as a
national or international organization.
Item 2
Include as Attachment B a copy of the
organization’s most recent IRS determination
letter. If the name of the applicant organization
differs on the IRS determination letter, the IRS
Form 990, or audited financial statements,
documentation from the IRS or state government
authorizing this name change must accompany the
application.
National/international organizations that are part of
an IRS group exemption must provide a copy of
the IRS letter granting the group exemption, as
well as the current list of subordinates that are
covered by the group exemption. The EIN on the
applicant’s Form 990 must match the EIN on the
current list of subordinates.
Bona-fide chapters or affiliates of a national
organization that do not have an IRS deter-
mination letter for the local organization must
provide a certification signed by either the Chief
Executive Officer (CEO) or CEO equivalent of the
national organization, dated on or after October 1,
2012, stating the local charitable organization
operates as a bona-fide chapter or affiliate in good
standing of the national organization and it is
covered by the national organization’s 501(c)(3)
tax-exemption, IRS Form 990 and audited
financial statements. A copy of the national
organization’s 501(c)(3) letter must accompany the
CEO’s certification.
Please review CFC Memorandum 2009-4 for more
information on this requirement and examples of
supporting documentation (www.opm.gov/cfc).
Each applicant’s 501(c)(3) status will be verified
with the IRS. Applicants whose current 501(c)(3)
status cannot be confirmed by the IRS will be
denied participation. OPM encourages
organizations to verify their current tax-exempt
status prior to submitting a CFC application. This
can be done by contacting the IRS at (877) 829-
5500.
Item 3
Self-explanatory. Human health and welfare
services provided in calendar year 2012 must be
reflected in Attachment A.
Item 4
The certifying official must certify that the
organization 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
by an independent certified public accountant
annually in accordance with Generally
Accepted Auditing Standards (GAAS). No
other basis of accounting is acceptable under
GAAP. The cash basis, modified cash basis,
modified accrual basis, and any other methods are
not acceptable.
Include as Attachment C a copy of the auditor’s
report and the organization's complete audited
annual financial statements. The audited
financial statements and IRS Form 990 must be
prepared using the accrual method of accounting
and cover the same fiscal period that ended not
more than 18 months prior to January 2013 (i.e.
ending on or after June 30, 2011).
The audited financial statements must include all
statements and audit notes as required by GAAP.
The Independent Auditor’s Report must include
the signature of the auditor or the auditing firm.
Item 5
Check the appropriate box. Include as
Attachment D a copy of the complete, signed
IRS Form 990 for a period ended not more
than 18 months prior to January 2013. The IRS
Form 990 must include a signature in the block
marked “Signature of officer”; the preparer’s
signature alone is not sufficient. Organizations
that file the IRS Form 990 electronically may
submit a signed copy of the IRS Form 8879-EO or
IRS Form 8453-EO in lieu of a signature on the
IRS Form 990.
The CFC will compare the number of voting
members disclosed in Part I, Line 3 with the
number of individuals that have the ‘individual
trustee or director’ or ‘institutional trustee’ position
OPM Form 1647-A
Rev. September 2012
5
selected in Part VII, Column C. If the number in
Part I is more than the number in Part VII, the
organization must provide an explanation for the
difference. Failure to clarify the difference or to
timely file an amended IRS Form 990 with the IRS
may result in the denial of the application. Please
review CFC Memoranda 2009-8 and 2010-5 for
additional information on the IRS Form 990
requirements, including the presentation of the
governing body and expenses.
A complete IRS Form 990 is required, including
all supplemental statements schedules, if
applicable, with the exception of Schedule B, to be
eligible for the CFC. If the IRS does not require
the organization to file the Form 990 (long form) it
must complete and submit a pro forma IRS Form
990 (see instructions below). IRS Forms 990EZ,
990PF, and comparable forms will not be accepted.
Organizations that file these forms must submit a
pro forma IRS Form 990 (see instructions below).
The audited financial statements and IRS Form
990 must be prepared using the accrual method of
accounting and cover the same fiscal period ended
not more than 18 months prior to January 2013
(i.e. ending on or after June 30, 2011).
Pro forma IRS Form 990 Instructions – The
IRS Form 990 can be downloaded from the IRS
website (www.irs.gov). The following sections
must be completed: Page 1, Items A-M, Part I
(Summary), Lines 1-4 only, Part II (Signature
Block), Part VII (Compensation - section A only);
Part VIII (Statement of Revenues), Part IX
(Statement of Functional Expenses), and Part XII
(Financial Statements and Reporting).
Item 6
Calculate and enter the organization’s annual
percentage for administrative and fundraising
expenses based on the formula below.
Add the amount in Part IX (Statement of
Functional Expenses), Line 25, Column C
(Management and General Expenses) to the
amount in Line 25, Column D (Fundraising
Expenses), and divide the sum by Part VIII
(Statement of Revenue), Line 12, Column A (Total
Revenue).
No other methods may be used to calculate this
percentage. All percentages must be listed to the
tenth of a percent (e.g. 15.7%).
Charities which do not reflect administrative and
fundraising expenses in the Statement of
Functional Expenses of the IRS Form 990,
resulting in a 0% rate, but show such expenses on
the audited financial statement will be denied
unless the audited financial statements specifically
state that these services were donated.
Item 7
Self-explanatory
Item 8
Self-explanatory
Item 9
Self-explanatory
Item 10
Self-explanatory
Item 11
Each federation and independent organization
applying to participate in the CFC must, as a
condition of participation, certify that it 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, and individuals subject to
economic sanctions administered by the U.S.
Department of the Treasury’s Office of Foreign
Assets Control (OFAC). The programs
administered by OFAC restrict or prohibit U.S.
persons from engaging in transactions and dealings
with targeted countries, entities, and individuals.
OFAC publishes a list of Specially Designated
Nationals and Blocked Persons (SDN List). The
persons on the SDN List are subject to economic
sanctions. The SDN List and additional
information relating to the economic sanctions
programs that OFAC administers are available at
http://www.treas.gov/ofac. A link to the SDN List
is available on the CFC website
(www.opm.gov/cfc). For further information,
please see CFC Memo 2005-13.
Certifying Official The certifying official is the
individual who has the authority to affirm that all
statements in the application are accurate. This
role cannot be delegated to the federation of which
OPM Form 1647-A
Rev. September 2012
6
the organization is a member.
IF THE ORGANIZATION IS DENIED
If your organization’s application is denied, it will
receive a certified letter stating the reason(s) for the
denial. If the organization wishes to appeal the
decision to the Director of OPM, the appeal must
be received by OPM within ten business days of
the receipt of the letter. The appeal should be
complete and respond to the reason(s) for the
original denial decision.
Additional information or a revision to a submitted
document will only be accepted if it existed prior
to the application deadline. The CFC will not
accept documents that did not exist or were not set
forth in final form prior to the application deadline.
REQUIRED ATTACHMENTS (failure to provide any of these documents may result in a denial)
Attachment A – Schedule of services by year and state and/or foreign country (See Items 1 & 3)
Attachment B – IRS determination letter (See Item 2)
Attachment C – Audited financial statements (See Item 4)
Attachment D – IRS Form 990 (See Item 5)
THE APPLICATION AND SUPPORTING DOCUMENTATION MUST BE RECEIVED BY THE
OFFICE OF PERSONNEL MANAGEMENT BY 5PM (EST), TUESDAY, JANUARY 15, 2013.
LATE APPLICATIONS WILL NOT BE ACCEPTED.
OPM Form 1647-A
Rev. September 2012
7
2013 CFC National/International Independent Organization and Federation Member
Attachment A Format
The use of this document is not required for Attachment A. If an applicant uses a different format,
it is encouraged to detail services it provided under the heading of each state or foreign country. A
minimum of 15 or more different states or one foreign country is required. This sample only lists 15
states, but applicants are encouraged to list, at least, a few more.
Several services can be described under any one state. Also, services that are provided in more than
one state can be described under the heading of each of those states. All dates must be within the
period of January 1, 2010 – December 31, 2012.
Foreign Country(ies)
Location
Date
Number of
Beneficiaries
State #1
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #2
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #3
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #4
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #5
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #6
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
OPM Form 1647-A
Rev. September 2012
8
State #7
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #8
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #9 ]
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #10
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #11
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #12
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #13
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #14
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
State #15
City
Date
Service Description (including who provided the
service)
Number of
Beneficiaries
OPM Form 1647-A
Rev. September 2012
9
OMB APPROVED
NO. 3206-0131
COMBINED FEDERAL CAMPAIGN
2013 APPLICATION FOR
NATIONAL/INTERNATIONAL INDEPENDENT ORGANIZATIONS
AND MEMBERS OF FEDERATIONS
(Federation members must complete this application to be kept on file by their federation.
This is an annual requirement. The application may be requested by OPM.)
Organization:
Employer Identification Number (EIN): __ __ - __ __ __ __ __ __ __
5 Digit CFC Number (If a previous participant in the CFC): ___ ___ ___ ___ ___
Telephone: Website Address: ____________________________
Organization Address: ___________________________________________________________
____________________________________________________________
(Post Office Box addresses are not accepted and may result in automatic disqualification.)
Contact Person: ____________________________________________________________
Contact Title: ____________________________________________________________
Contact Address:
(If different from the above address - Post Office Box Addresses are acceptable for the
Contact Ad
dress.. All OPM correspondence will be sent to this address.)
Contact Telephone: _________________ Fax: _____________________
Contact E-Mail Address(es): _________________________________________________________
OPM Form 1647-A
Rev. September 2012
10
SELECTION OF NATIONAL/INTERNATIONAL OR INTERNATIONAL:
A national/international organization may be listed in either the national/international part of
the Charity List or the International part of the Charity List. The organization will be listed
in the appropriate section based on the response to Item #1.
1) Place a check in the one appropriate box:
National/International Part
I certify that the organization named in this application provided or conducted real services,
benefits, assistance, or program activities in 15 or more different states or one foreign
country over the three-year period immediately preceding the start of the campaign
application year. (Include as ATTACHMENT A, a schedule listing those states or foreign
countries where the program activities have been provided within the 2010 -2012
period and a detailed description of the activities, including the year in which those
services were provided, in each state or foreign country listed. See recommended
format for Attachment A on page 6 of the application instructions.)
- OR -
International Part
I certify that the organization named in this application provided or conducted real services,
benefits, assistance, or program activities in a foreign country over the three-year period
immediately preceding the start of the campaign application year. (Include as
ATTACHMENT A, a schedule listing each country where program activities have been
provided within the 2010-2012 period and a detailed description of the program
activities, including the year in which those services were provided in each country
listed. See recommended format for Attachment A on page 6 of the instructions.)
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). (Include as ATTACHMENT B a copy of the
most recent IRS determination letter. See instructions for additional information.)
3) I certify that the organization named in this application is a human health and welfare organi-
zation 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 2012 are reflected in ATTACHMENT A.
4) I certify that the organization named in the application 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). (Include as ATTACH-
MENT C a copy of the auditor’s report and the complete audited financial statements
for a fiscal period ending not more than 18 months prior to January 2013. )
OPM Form 1647-A
Rev. September 2012
11
5) Place a check in the one appropriate box:
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 (long form). (Include as
ATTACHMENT D a copy of the complete IRS Form 990 for a period ending not more
than 18 months prior to January 2013, including signatures in the box marked “Signature of
Officer” or in IRS Forms 8879-EO or 8453-EO. The preparer’s signature alone is not
sufficient. IRS Forms 990EZ, 990PF, and comparable forms are not acceptable substitutes.)
- OR -
I certify that the organization named in this application is not required to prepare and submit
an IRS Form 990 (long form) to the IRS. (Include as ATTACHMENT D a pro forma IRS
Form 990 for a period ending not more than 18 months prior to January 2013. See
application instructions for pro forma IRS Form 990 requirements. IRS Forms 990 EZ,
990PF, and comparable forms are not acceptable substitutes.)
6) I certify that the administrative and fundraising rate for the organization named in this
application is __ __ . __%. This percentage has been computed from information on the IRS
Form 990 submitted with this application. See the instructions for information on the
formula.
7) 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, directs the
organization named in this application.
8) I certify that the organization named in this application prohibits the sale or lease of CFC
contributor lists.
9) 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.
10) I certify that the organization named in this application effectively uses the funds contributed
for its announced purposes.
11) 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 CFC Operations
immediately.
OPM Form 1647-A
Rev. September 2012
12
CERTIFYING OFFICIAL
I, ____________________________________, am the duly appointed representative
(Print Name)
of ____________________________________ authorized to certify and affirm all statements
(Print Organization)
enclosed in this application. I certify that I have read all the certifications set forth in this document
and affirm their accuracy. In addition, by checking the box next to the statement, I acknowledge and
agree to comply with that certification.
______________________________
(Signature)
______________________________
(Typed or Printed Name)
______________________________
(Title)
Date Completed ______________________
The application must be received by 5PM (EST) January 15, 2013. Send the application to:
Office of Personnel Management
Office of Combined Federal Campaign
ATTN: Chimezie Ihuoma
Room 6484
1900 E Street, NW
Washington, DC 20415
Public Burden Statement
We think this form takes an average of 3 hours to complete, including the time for getting the needed data and
reviewing both the instructions and completing the form. Send comments regarding our estimate or any other
aspects of this form, including suggestions for reducing completion time to Office of Personnel Management (OPM),
CFC Operations, (3206-0131), Washington, DC 20414-7900. The OMB number 3206-0131 is currently valid.
OPM may not collect this information, and you are not required to respond, unless this number is displayed.
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