Fill - Free fillable Opm1647b COMBINED FEDERAL CAMPAIGN PDF form

OPM Form 1647-B

Rev. September 2012

OMB APPROVED

No. 3206-0131

COMBINED FEDERAL CAMPAIGN

2013 Application Instructions for

National/International Federations

BACKGROUND

Enclosed is the model application for use by

national/international federations to participate in

the Combined Federal Campaign (CFC). A

federation is a group of voluntary charitable human

health and welfare organizations created to supply

common fundraising, administrative, and

management services to its constituent members.

A federation must have at least 15 member

organizations, in addition to itself, that individually

meet all of the CFC eligibility criteria. If your

organization does not have 15 member

organizations that meet the CFC eligibility criteria,

it must apply as an independent organization using

the independent organization application.

The following instructions and form are intended

to assist charitable federations 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 federations to apply early.

NEW - The application deadline for

national/international federations seeking

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. All federation and

federation member applications must be submitted

electronically either via email or on a CD-ROM.

Applications submitted via email must be sent to

cfc@opm.gov. The subject line must read, “2012

[Federation Name] Application”. A PDF copy of

each member’s application must be attached. Each

file must be clearly marked with the name by

which the applicant wishes to be listed in the CFC

Charity List.

Federations may also submit the applications via

CD-ROMs. These must include a PDF copy of

each member’s application, clearly marked with

the name by which the applicant wishes to be listed

in the CFC Charity List. The CD-ROM must be

received by the application deadline at the fol-

lowing 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.

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. Federations that

apply for national/international eligibility and are

found in-eligible have only one opportunity to

OMB Form 1647-B

Rev. September 2012

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

federations use the model application provided

when applying to the CFC. Although not

required, the 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 a federation may

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 federation has demonstrated, to OPM’s

satisfaction, that the federation has taken

appropriate corrective action. Failure to demon-

strate 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 federation 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.

The federation will be given a Personal Identifi-

cation Number and be directed to a secure website

to register and verify the federation and its member

organizations’ information on file with OPM. All

federations, regardless of past participation, must

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.

Taxonomy Codes Each federation can identify

up to three categories, in priority order which most

closely identify the type of mission, services, and

activities provided. The corresponding letters will

be printed with the federation’s listing in the CFC

charity list to assist donors in identifying charities

by type of services provided. Categories were

derived from the National Taxonomy of Exempt

Entities 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 Unkown

DEFINITIONS

Federation Name of the applicant federation, as it

appears in the IRS Business Master File. If the

name of the federation is different from the name

which appears on the IRS determination letter, IRS

Form 990, audited financial statements, or annual

report, official documentation authorizing use of

this name must accompany the application. The

EIN must be included.

OMB Form 1647-B

Rev. September 2012

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 federation by the CFC. Federations

that did not previously participate in the CFC

should leave this field blank.

Federation Website Address List the complete

Internet address of the applicant federation (no e-

mail addresses). This information is required, if

the federation has an Internet address.

Federation Address The physical street address

of the federation. Post Office Boxes may not be

used.

Contact Person The contact person is the indi-

vidual to whom OPM will direct communications

regarding the federation 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

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 federations, 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.

A New Federation Applicant must submit, along

with its own application, the complete applications

of its member organizations.

A Currently Participating CFC Federation

Applicant must submit a complete application for

itself as well as each member that is new to the

federation (regardless of whether it participated as

an independent organization or member of another

federation in the 2012 CFC) and each member

denied participation in the 2012 CFC.

Federations may submit member applications in

PDF format via a CD-ROM included with the

federation application. Each file must be clearly

marked with the applicant’s name and include all

required attachments.

Item 1

Check the one appropriate box. Include as

Attachment A a list of all eligible member

organizations that meet all National/Inter-

national List eligibility criteria in 5 C.F.R. §§

950.202 and 950.203. Include their five-digit

CFC codes (if applicable), names as they

appear in the IRS Business Master File, “Doing

Business As” names (if applicable), EINs, and

administrative and fundraising rates. The

physical mailing address of each member must

also be included in Attachment A. The above

information must be sent as an Excel spreadsheet

to cfc@opm.gov in lieu of a paper copy in the

application. The subject line of the email must

read: “[Federation Name] 2013 CFC Attachment

A”. OPM will confirm receipt of the information.

A national/international federation must

demonstrate that it has 15 or more member

organizations that individually meet the eligibility

criteria for participation as national/international

organizations (real services, benefits, assistance, or

program activities in 15 or more different states or

one foreign country over the three year period

OMB Form 1647-B

Rev. September 2012

immediately preceding the start of the campaign

application year). An international federation must

demonstrate that it has 15 or more member

organizations that individually meet the eligibility

criteria for international organizations (real

services, benefits, assistance, or program activities

in a foreign country over the three-year period

immediately preceding the start of the application

year). .

Item 2

Include as Attachment B a copy of the

federation’s most recent IRS determination

letter. If the name of the applicant differs on the

IRS determination letter, IRS Form 990, audited

financial statements, or annual report,

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.

Attachment B must include the IRS determination

letter and/or other supporting documentation (e.g.

page from the Catholic Directory or letter from a

bona-fide chapter’s or affiliate’s national

organization stating that it is covered by the

national organization’s tax-exemption and is in

good standing with the national organization) that

verifies the tax-exempt status of the federation and

each of its member organizations as well as DBA

(“Doing Business As” documentation, if

applicable.

Item 3

Self-explanatory

Item 4

Check the appropriate box. The certifying

official must certify that the federation

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). 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 under

GAAP.

Include as Attachment C a copy of auditor’s

report and the federation's complete audited

annual financial statements. The audited

financial statements must cover the fiscal period

ending not more than 18 months prior to the

January of the campaign year to which the fed-

eration is applying (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.

OMB Form 1647-B

Rev. September 2012

The audited financial statements must verify

the federation is honoring designations made to

each member organization by distributing a

proportionate share of receipts based on donor

designations to each member. The IRS Form 990

and audited financial statements must cover the

same fiscal period and be prepared using the

accrual basis of accounting.

The audit requirement is waived for newly created

federations operating for less than a year as

determined from the date of its IRS tax-exemption

letter to the closing date of the CFC application

period.

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’ position 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 and Schedule A, if

applicable, for the applicant federation to be

eligible for the CFC. If the IRS does not require

the federation 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 use these forms must submit a

pro forma IRS Form 990.

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).

The IRS Form 990 and audited financial

statements 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).

Item 6

Calculate and enter the federation’s annual

percentage for administrative and fundraising

expenses based 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

Each federation must include as Attachment E

a complete listing of the federation’s board of

directors and the beginning and end dates of

each board member’s current term of office

OMB Form 1647-B

Rev. September 2012

(e.g. John Smith, 2009-2014). Attachment E

must also list the board’s meeting dates and

locations for the previous calendar year (2012).

The CFC uses Part VII of the IRS Form 990 to

verify that a majority of the governing body served

without compensation. The IRS Form 990

instructions define a director/trustee as member of

the governing body with voting rights. These are

the individuals that will be reviewed. Cases where

50% of the board received compensation and 50%

of the board was not compensated will be denied,

regardless of the amount of the compensation.

Item 8

Self-explanatory

Item 9

Self-explanatory

Item 10

Self-explanatory

Item 11

Self-explanatory

Item 12

Include as Attachment F a copy of the federa-

tion's most recently completed annual report.

The annual report must cover the fiscal year end-

ing not more than 18 months prior to January of

the campaign year to which the federation is

applying or the preceding calendar year. A more

frequently published document, such as a quarterly

newsletter, may be substituted as long as it meets

the requirements for an annual report. It must

contain a full description of the federation’s

activities and supporting services during the year

covered by the report and identify its directors and

chief administrative personnel.

The annual report or substitute must also include

an accurate description of the federation’s

membership dues and/or service charges received

by the federation from the charitable organizations

participating as members. The information must

clearly present the amounts raised, the sources of

contributions, the cost of fundraising, and how

costs are recovered from donations.

Reproductions of annual reports that are available

on a federation’s website are acceptable. The

annual report must be clearly marked as such on

the website and must include all of the criteria

outlined in the CFC regulations (describe the

organization's activities and identify the board of

directors and chief administrative personnel).

OPM will not accept miscellaneous pages from the

federation’s website that provide this information

in lieu of an annual report document. A printed

copy of the report must be included in the CFC

application.

Item 13

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.

IF THE FEDERATION IS DENIED

If the federation’s application is denied, it will

receive a certified letter stating the reason(s) for the

denial. If the federation 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

OMB Form 1647-B

Rev. September 2012

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 may result in a denial)

 Attachment A – List of eligible member organizations (include each organization’s IRS

Business Master File name (if applying under a DBA), EIN, and administrative and

fundraising rate) (See Item 1)

 Attachment B – IRS determination letter (See Item 2)

 Attachment C – Audited Financial Statements (See Item 4)

 Attachment D – IRS Form 990 (See Item 5)

 Attachment E – Board of Directors’ Current Terms of Office and Meeting Dates and Locations

(See Item 7)

 Attachment F – Annual Report (See Item 13)

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.

OMB Form 1647-B

Rev. September 2012

OMB APPROVED

No. 3205-0131

COMBINED FEDERAL CAMPAIGN

2013 APPLICATION FOR

NATIONAL/INTERNATIONAL FEDERATIONS

Federation:

Employer Identification Number (EIN): __ __ - __ __ __ __ __ __ __

5 Digit CFC Number (If a previous participant in the CFC): ___ ___ ___ ___ ___

Telephone: ____________________ Website Address: ___________________________

Federation 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 Boxes are acceptable for the Contact

Address. All OPM correspondence will be sent to this address.)

Contact Telephone: ____________ Fax: ____________________

Contact E-Mail Address(es): _________________________________________________________

OMB Form 1647-B

Rev. September 2012

SELECTION OF NATIONAL/INTERNATIONAL OR INTERNATIONAL:

A national/international federation may be listed in either the national/international part of the

Charity List or the international part of the Charity List. The federation 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 federation named in this application has _____ (enter number) member

organizations that individually meet the eligibility criteria for national/international

organizations in 5 C.F.R. §§ 950.202 and 950.203. Include as ATTACHMENT A, a list of

all member organizations that meet this requirement. The list must include each

organization with its five digit CFC code (if applicable), legal name in parentheses (if using a

“dba”), Employer Identification Number (EIN), administrative and fundraising rate, and

physical mailing address.

– OR –

International Part

I certify that the federation named in this application has _____ (enter number) member

organizations that individually meet the eligibility criteria for international organizations in 5

C.F.R. §§ 950.202 and 950.203 by providing real services, benefits, assistance, or program

activities in at least one foreign country over the previous three years. Include as

ATTACHMENT A, a list of all member organizations that meet this requirement. The

list must include each organization (with its legal name in parentheses if using a “dba”),

Employer Identification Number (EIN), administrative and fundraising rate, and physical

mailing address.

2) I certify that the Internal Revenue Service (IRS) recognizes the federation named in this

application as tax-exempt under 26 U.S.C. 501(c)(3) to which contributions are tax deducti-

ble pursuant to 26 U.S.C. 170(c)(2). (Include as ATTACHMENT B a copy of the

federation’s most recent IRS determination letter and the IRS determination letter

and/or other supporting documentation that verifies the tax-exempt status of its

member organizations. See instructions for additional information.)

3) I certify that the federation named in this application is a human health and welfare federa-

tion and either it or its member organizations provide services, benefits, or assistance to, or

conduct activities affecting, human health and welfare. Services, benefits, assistance, or

program activities affecting human health and welfare were provided in calendar year 2012.

4) Place a check in the one appropriate box:

I certify that the federation 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

OMB Form 1647-B

Rev. September 2012

accordance with generally accepted auditing standards (GAAS). (Include as

ATTACHMENT 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

which verifies that the federation is honoring designations made to each member

organization by distributing a proportionate share of receipts based on donor designations to

each member.)

- OR -

I certify that the federation named in the application accounts for its funds on an accrual basis

in accordance with generally accepted accounting principles (GAAP), but has been operating

for less than one year and therefore is not required to submit audited financial statements.

5) Place a check in the one appropriate box:

I certify that the federation named in this application prepares and submits to the IRS a

complete copy of the federation’s IRS Form 990. (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 federation named in this application is not required to prepare and submit an

IRS Form 990 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 federation named in this

application is __ __ . __%.This percentage is computed only from information on the IRS

Form 990 submitted with this application. See the instructions for more 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

federation named in this application. Include as ATTACHMENT E a complete list of the

federation’s board of directors with the beginning and end date of each board member’s

current term of office. ATTACHMENT E must also list the board’s meeting dates and

locations for calendar year 2012.

8) I certify that the federation named in this application prohibits the sale or lease of CFC

contributor lists.

9) I certify that the federation named in this application conducts publicity and promotional

activities based upon its actual program and operations, and that these activities are truthful

OMB Form 1647-B

Rev. September 2012

and non-deceptive, include all material facts, and make no exaggerated or misleading claims.

10) I certify that the federation named in this application effectively uses the funds contributed

for its announced purposes.

11) I certify that the federation named in this application does not employ, in its CFC operations,

the services of private consultants, consulting firms, advertising agencies or similar business

organizations to perform its policy-making or decision-making functions in the CFC.

12) I certify that the federation named in this application prepares and makes available to the

public an annual report that includes a full description of the federation's activities, sup-

porting services, member fees and/or service charges, and identifies its directors/ governing

body and chief administrative personnel. Include as ATTACHMENT F a copy of the most

recently completed annual report. See Instructions Item 12 for additional information.

13) I certify that the federation 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.

OMB Form 1647-B

Rev. September 2012

CERTIFYING OFFICIAL

I, ____________________________________, am the duly appointed representative

(Print Name)

of ____________________________________ authorized to certify and affirm all statements

(Print Federation Name)

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 certification, the federation

named in this application acknowledges and agrees to comply with that certification.

______________________________

(Signature)

______________________________

(Typed or Printed Name)

______________________________

(Title)

Date Completed ______________________

The application must be received by 5PM (EST) January 17, 2012. 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 20415-7900. 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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Fillable Opm1647b COMBINED FEDERAL CAMPAIGN

Fill Online, Printable, Fillable, Blank Opm1647b COMBINED FEDERAL CAMPAIGN Form

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