OPM Form 1647-C
Rev. September 2012
1
OMB APPROVED
No. 3206-0131
C
OMBINED FEDERAL CAMPAIGN
2013 Application Instructions for
Local Independent Organizations and
Members of Federations
BACKGROUND
Enclosed is the model application for use by local
independent organizations applying to participate
in the Combined Federal Campaign (CFC) and for
use by local federation members to submit to the
local 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.
All required documents and attachments must be
complete and submitted before the application
deadline each year. The CFC 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.
Documents that did not exist at the time of the
application deadline will not be accepted during
the appeals process. Organizations that apply for
local eligibility and are found ineligible will have
an opportunity to appeal to the Local Federal
Coordinating Committee (LFCC) for
reconsideration. If found ineligible on appeal by
the LFCC, the organization m ay appeal the
LFCC’s decision to the Director of the Office of
Personnel Management (OPM). The Director's
decision is final for adm inistrative purposes.
Appellants should ensure that their appeals are
complete and responsive to the actual reasons for
the LFCC denial decision.
Each LFCC determines the application deadline
for organizations seeking local eligibility. Since
local dates will vary, please check with the local
CFC for local application deadlines and filing
information. Local campaign contact information
can be found on the CFC website at
www.opm.gov/cfc/Search/Locator.asp.
If a local application form is available, OPM
suggests that organizations use the local
application provided when applying to the CFC.
The CFC will not accept application form s with
modifications to any of the certification
statements.
In order to determine whether an organization may
participate in the cam paign, the LFCC may
request evidence of corrective action regarding
any prior violation of regulation or directive,
sanction, or penalty, as appropriate. The LFCC
will decide whether the organization has
demonstrated, to the LFCC’s satisfaction, that the
organization has taken appropriate corrective
action. Failure to dem onstrate satisfactory
corrective action or to respond to the LFCC’s
request for information within 10 business days of
the date of the request m ay result in a
recommendation to OPM that the organization
will not be included in the Charity List. The
OPM Form 1647-C
Rev. September 2012
2
Director’s decision will be com municated in
writing to the organization.
DEFINITIONS
Organization Name of the applicant
organization, as it appears in the IRS Business
Master File. If the name of the organization differs
from the nam e that appears on the IRS
determination letter, IRS Form 990, or audited
financial statements, official 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 this application.
5 Digit CFC Number The 5 digit num ber
assigned to the organization by the CFC.
Organizations that did not previously participate in
the CFC should leave this field blank.
Organization Address A physical street address
must be provided - Post Office Box addresses will
not be accepted. This is the administrative office
address that will be used to assign a 5-digit CFC
code.
Check the box below the address to denote that it
is different from the address subm itted with the
2012 CFC application.
Service Office Address The location where
services are provided (if different from the
Organization Address).
Telephone Organization’s telephone number.
Contact Person The contact person is the indi-
vidual to whom the CFC will direct communica-
tions. This may be any individual in the organi-
zation.
Contact Title Self-explanatory
Contact Address Contact person’s m ailing
address if different than the organization's
address. Post Office Boxes m ay 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.
Website Address List the complete Internet
address of the applicant organization (no e-m ail
addresses). This information is required, if the
organization has an Internet address.
Disbursement Address List the address where
paper checks will be sent, if different from mailing
address. Post office boxes m ay be used for the
disbursement address.
Electronic Funds Transfer (EFT) Information
List the Routing and Account numbers, along with
the name of the financial institution, where funds
should be disbursed. This is an optional m ethod
for receipt of CFC contributions. NOTE: Some
campaigns may elect not to disburse funds
electronically.
INSTRUCTIONS
For details regarding CFC eligibility requirements
for local independent organizations 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
a refusal to certify and will result in the denial of
the application.
Item 1
Check the one appropriate box. Include as
Attachment A supporting statements and/or
documentation demonstrating to the satis-
faction of the LFCC that the organization has a
substantial local presence in the geographical
area covered by the local campaign, a
OPM Form 1647-C
Rev. September 2012
3
substantial local presence in the geographical
area covered by an adjacent local campaign, or
substantial statewide presence. Attachment A
must also include a description of the actual
services, benefits, assistance, or program
activities. provided by the organization in calendar
year 2012 and how those program s, services,
benefits, etc. affect human health and welfare of
the target population (see Certification #4).
Organizations are encouraged to list the number of
beneficiaries of each service and/or the value of
financial assistance provided in each location.
Substantial local presence is defined as a staffed
facility, office or portion of a residence dedicated
exclusively to that organization, available to
members of the public seeking its services or
benefits. The facility must be open at least 15
hours a week and have a telephone dedicated
exclusively to the organization. The office may be
staffed by volunteers. Substantial local presence
cannot be met on the basis of services provided
solely through an “800” telephone number or by
disseminating information or publications via the
U.S. Postal Service, the Internet, or a combination
thereof. (Information on the geographic
boundaries of local CFC Campaigns can be found
on the CFC website at
www.opm.gov/cfc/Search/Locator.asp.)
Substantial Local Presence in the Local
Campaign Area - provide the hours and days per
week of operation (a m inimum of 15 hours per
week is required), the organization’s dedicated
telephone number, and the county and state where
the applicant organization’s office is located. The
organization address or the service address must
be located in one of the counties served by the
local campaign.
If the office where the services are provided is
different from the organization’s main address (as
listed on page 8), enter the address of the location
where the services are provided.
OR
Substantial Local Presence in
the
geographical area covered by an adjacent
local campaign. An adjacent local cam paign is
defined as a local cam paign whose geographic
border touches the geographic border of another
local campaign. Provide the hours and day s per
week of operation (a m inimum of 15 hours per
week is required), the organization’s dedicated
telephone number, and the county and state where
the applicant organization’ s office is located.
Applicant organizations are responsible for
providing a complete application to each
campaign area in which it wishes to participate.
The organization address or the service address
must be located in one of the counties served by
an adjacent campaign area. Participation in a
local campaign via an adjacency determination
does not grant the organization a substantial local
presence in the adjacent local campaign and
participation via adjacency cannot be used to
establish adjacency to local campaigns bordering
the adjacent campaign area.
If the office where the services are provided (as
described in Attachment A) is different from the
organization’s main address (as listed on page 8),
enter the address of the location where the services
are provided.
OR
Substantial statewide presence is defined
as providing or conducting real services, benefits,
assistance or program activities in the previous
year (calendar year 2012) covering 30 percent of a
state’s geographic boundaries or providing or
conducting real services, benefits, assistance or
program activities affecting 30 percent of a state’s
population. Substantial statewide presence cannot
be met on the basis of services provided solely
through an “800” telephone number or by
disseminating information and publications via the
U.S. Postal Service, the Internet, or a combination
thereof. Applicant organizations are responsible
for providing a com plete application to each
campaign area in which it wishes to participate.
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 determ ination letter, the IRS
Form 990, or audited financial statem ents,
documentation from the IRS or state government
authorizing this name change must accompany the
application.
Organizations that are part of an IRS group
OPM Form 1647-C
Rev. September 2012
4
exemption must provide a copy of the IRS letter
granting the group exem ption, 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 a nd 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 c overed 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 m ust
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 confirm ed by the IRS will be
denied participation. OPM encourages
organizations to verify their current tax-exem pt
status prior to submitting a CFC application. This
can be done by contacting the IRS at (877) 829-
5500.
Item 3
Check the appropriate box.
Listing of a national organization, as well as its
local affiliate organization, is perm itted. Each
national or local organization m ust individually
meet all of the eligibility criteria and submit
independent documentation as required in 5
C.F.R. §950.202, §950.203 or §950.204 to be
included in the Charity List, except that a local
affiliate of a national organization that is not
separately incorporated, in lieu of its own 26 USC
501(c)(3) tax exemption letter and, to the extent
required by §950.204(b)(2)(ii), audited financial
statements, may submit the national organization’s
26 USC 501(c)(3) tax exemption letter and audited
financial statements, but must provide its own pro
forma IRS Form 990 (see Item 6) for CFC
purposes.
A national organization m ay waive its listing in
the National/International or International parts of
the Charity List in favor of its local affiliate by
following the procedures set forth in 5 C.F.R.
§950.201(c).
Item 4
Self-explanatory. Human health and welfare
services provided in calendar y ear 2012 must be
reflected in Attachment A.
Item 5
Check the appropriate box.
Organizations with $250,000 or more in annual
revenue, as reported on the IRS Form 990, are
required to submit an annual audit of fiscal
operations by an independent certified public
accountant in accordance with Generally
Accepted Auditing Standards (GAAS). The
audited financial statem ents and IRS Form 990
must be prepared using the accrual method of
accounting and cover the sam e fiscal period that
ended not more than 18 months prior to January
2013 (i.e. ending on or after June 30, 2011).
Include as Attachment C a copy of the auditor’s
report and the organization’s complete audited
annual financial statements. The audited
financial statements must include all statements
and audit notes as required by GAAP. The
Independent Auditor’s Report m ust include the
signature of the auditor or the auditing firm.
The organization must certify that it accounts for
its funds in accordance with Generally Accepted
Accounting Principles (GAAP) and has an audit of
its fiscal operations com pleted annually by an
independent certified public accountant in
accordance with GAAS. Note that GAAP requires
the use of the accrual method of accounting. No
other basis of accounting is acceptable under
GAAP. The cash basis, m odified cash basis,
modified accrual, and any other methods are not
acceptable.
OR
Organizations with total revenue of at
least $100,000 but less than $250,000: the
OPM Form 1647-C
Rev. September 2012
5
certifying official must certify that the
organization accounts for its funds in
accordance with GAAP and has an audit of its
fiscal operations completed annually by an
independent certified public accountant in
accordance with GAAS. The organization is not
required to submit a copy of the audited financial
statements with the CFC application. However,
the information must be provided to OPM or the
LFCC upon request. Note that GAAP requires the
use of the accrual method of accounting. No other
basis of accounting is acceptable under GAAP.
The cash basis, m odified cash basis, modified
accrual, and any other methods are not acceptable.
OR
Organizations with total revenue of less
than $100,000: the certifying official must
certify the organization has controls in place to
ensure funds are properly accounted for and it
can provide accurate timely financial
information to interested parties. It is not
required to submit financial documentation with
the CFC application or m aintain its financial
records in accordance with GAAP.
Bona-fide chapters or local affiliates of a national
organization that are not separately incorporated
whose pro forma IRS Form 990 reports revenues
over $250,000 and whose financial operations are
covered by an audit of the national organization
may submit the national organization’s audited
financial statements together with a certification
from the national organization’s Chief Executive
Officer (CEO) or CEO equivalent stating that it
operates as a bona-fide affiliate in good standing
of the national organization and is covered by the
national organization’s 26 U.S.C. 501(c)(3) tax
exemption, IRS Form 990 and audited financial
statements. (See requirements under Item #2 for
bona-fide chapters or local affiliates.)
Bona-fide chapters of a national organization that
are not separately incorporated whose pro forma
IRS Form 990 reports revenues of at least
$100,000 but less than $250,000 and whose
financial operations are covered by an audit of the
national organization may certify it has an audit of
its fiscal operations completed annually if it, at the
time of the certification, is in good standing of the
national organization a nd is covered by the
national organization’s 26 U.S.C. 501(c)(3) tax
exemption, IRS Form 990 and audited financial
statements. This organization is not required to
submit with its application the national
organization’s audited financial statem ents.
However, it m ust be able to supply this
documentation to the LFCC or OPM upon request.
(See requirements under Item #2 for bona-fide
chapters or local affiliates.)
Item 6
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 (i.e. June
30, 2011). The IRS Form 990 must include a
signature in the block m arked “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 com pare the num ber 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 selected in Part VII, Colum n 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 inform ation 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 schedules, if
applicable, with the exception of Schedule B, to be
eligible for the CFC. If the Internal Revenue
Service 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.
Pro forma IRS Form 990 Instructions – The
IRS Form 990 (long form ) can be downloaded
OPM Form 1647-C
Rev. September 2012
6
from the IRS website (www.irs.gov). The
following sections m ust be com pleted: Page 1,
Items A-M; Part I (Summary and Part II, Signature
Block), Lines 1-4 only; Part VII (Com pensation
section A only); Part VIII (Statem ent of
Revenues); Part IX (Statem ent of Functional
Expenses), and; Part XII (Financial Statem ents
and Reporting).
The audited financial statem ents and IRS Form
990 must be prepared using the accrual method of
accounting and cover the same fiscal period ended
not more than 18 m onths prior to January 2013
(i.e. ending on or after June 30, 2011).
Organizations with total revenue of less than
$100,000 are not required to use the accrual
method of accounting.
Item 7
Calculate and enter the organization’s annual
percentage for administrative and fundraising
expenses. This percentage is computed from the
IRS Form 990 submitted with this application.
Add the am ount in Part IX (Statement of
Functional Expenses), Line 25, Column C
(Management and General Expenses) to the
amount in Line 25, Colum n D (Fundraising
Expenses), and divide the sum by Part VIII
(Statement of Revenue), Line 12, Colum n 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 Statem ent 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 8
The CFC uses Part VII of the IRS Form 990 to
verify that a m ajority 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 9
Self-explanatory
Item 10
Self-explanatory
Item 11
Self-explanatory
Item 12
Each federation and i ndependent 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 econom ic 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.
Item 13
Include as Attachment E, a statement in 25
words or less that describes the organization’s
program activities. The statem ent should not
repeat the organization's name. The organization
must also provide the legal nam e as registered
with the IRS if the organization does business
under a different name. All organizations m ust
include their IRS Employee Identification Number
(EIN) regardless of whether or not they are
operating under a "dba" (“doing business as”).
The organization m ust also include a telephone
number that can be reached from any location in
the U.S. and the organization’s administrative and
fundraising rate. The legal nam e, telephone
number, EIN, taxonomy codes (see below), and
OPM Form 1647-C
Rev. September 2012
7
administrative and fundraising rate will NOT
count as part of the 25-word statem ent. An
Internet address where inform ation on the
organization can be obtained may be included and
will not count toward the 25 words. OPM will not
be responsible for incorrect Internet addresses.
E-mail addresses are not accepted.
Taxonomy Codes Each organization 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 in y our
organization’s listing in the CFC charity list (see
example below) 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 Unkown
Special design text used to draw attention to an
organization title, such as special fonts, capitaliza-
tion, quotations, and underlining, are not accepted.
Any statement that uses special features, or
exceeds 25 words will be edited by the LFCC.
Organizations will be listed by their legal IRS
recognized name as it appears on the IRS
determination letter only unless the appropriate
legal documentation permitting otherwise is
provided with the application. See Item 2. The
format is as follows:
00000 Name of Organization (IRS BMF name
of organization, if applicable) (202)555-1234
www.opm.gov/cfc EIN#123456789 The
description will contain no more than 25 words. It
should be worded so the donor understands the
program services provided. 4.2% B,V,O
Certifying Official The certifying official is the
individual who has the authority to affirm that all
statements in the application are accurate.
OPM Form 1647-C
Rev. September 2012
8
Local CFC applications must be sent to the local campaign office. Do not send applications to the U.S.
Office of Personnel Management. Note that each campaign area sets its own application deadline. For
more information on the local application deadlines and addresses, please contact the Principal
Combined Fund Organization (PCFO) representative in your area.
Contact information can be found at www.opm.gov/cfc/Search/Locator.asp.
REQUIRED ATTACHMENTS (failure to provide any of these documents may result in a denial)
Attachment A – Documentation of local presence, adjacent presence, or statewide presence
(See Item 1)
Attachment B – IRS determination letter (See Item 2)
Attachment C – Audited Financial Statements (if total revenues are $250,000 or greater) (See
Item 5)
Attachment D – IRS Form 990 (See Item 6)
Attachment E – 25-word statement (See Item 13)
OPM Form 1647-C
Rev. September 2012
9
OMB APPROVED
NO. 3206-0131
C
OMBINED FEDERAL CAMPAIGN
2013 APPLICATION FOR LOCAL INDEPENDENT
ORGANIZATIONS AND MEMBERS OF FEDERATIONS
Organization:
Employer Identification Number (EIN): __ __ - __ __ __ __ __ __ __
5 Digit CFC Number (If a previous participant in the CFC): ___ ___ ___ ___ ___
Organization Address:
____________________________________________________________
(Post Office Box addresses are not accepted and may result in automatic disqualification.)
Check this box if the above address is different from the address submitted with the 2011 CFC application:
Telephone: ____________________________________________
Contact Person:
Contact Title: _________________________________________________________
Contact Address: _________________________________________________________
(If different from the above address – Post Office Boxes are acceptable for the Contact Address. All CFC
correspondence will be sent to this address.)
Contact Telephone: ____________ __ Fax: _______________________
Contact E-Mail Address(es): _________________________________________________________
Website Address (required, if available): ________________________________________
Disbursement Address: _________________________________________________________________
(This is the address where paper checks will be sent.)
Electronic Funds Transfer (EFT) information (Optional):
Routing Number (9 digits): __ __ __ __ __ __ __ __ __
ACCT: ___________________________________________
Financial Institution: _________________________________
OPM Form 1647-C
Rev. September 2012
10
1) Place a check in the one appropriate box:
I certify that the organization named in the application has a substantial local presence in the
geographical area covered by the local campaign. (Substantial local presence is defined in
the Instructions as Item 1.) Include as ATTACHMENT A supporting statements and/or
documentation of substantial local presence in the geographical area covered by the
local campaign and a description of
the programs, services, benefits, etc. provided by
the organization in calendar year 2012 and how those programs, services, benefits, etc.
affect human health and welfare of the target population.
Service Office Address (if different from Organization Address on previous page):
_____________________________________________________
_____________________________________________________
Hours of Operation Per Each Day of the Week (Example: Monday-Friday, 9AM-
5PM; Saturday, 10AM – 3PM; Sunday, Closed):
_____________________________________________________
_____________________________________________________
Organization’s Dedicated Phone Number: ____________________________
County and State Where Office is Located: __________________________________
-OR-
I certify that the applicant organization named in the application has a substantial local pres-
ence in the geographical area covered by an adjacent local campaign. (Substantial adjacent
presence is defined in the Instructions as Item 1.) Include as ATTACHMENT A
supporting statements and/or documentation of substantial presence in the
geographical area covered by an adjacent campaign and a description of the programs,
services, benefits, etc. provided by the organization in calendar year 2012 and how
those programs, services, benefits, etc. affect human health and welfare of the target
population.
Service Office Address (if different from Organization Address on previous page):
_____________________________________________________
_____________________________________________________
Hours of Operation Per Each Day of the Week (Example: Monday-Friday, 9AM-
5PM; Saturday, 10AM – 3PM; Sunday, Closed):
_____________________________________________________
_____________________________________________________
Organization’s Dedicated Phone Number: ____________________________
County and State Where Office is Located: __________________________________
-OR-
OPM Form 1647-C
Rev. September 2012
11
I certify that the organization named in the application has a substantial statewide presence.
(Substantial statewide presence is defined in the Instructions as Item 1.) Include as
ATTACHMENT A supporting statements and/or documentation of substantial
statewide presence and a description of the programs, services, benefits, etc. provided
by the organization in calendar year 2012 and how those programs, services, benefits,
etc. affect human health and welfare of the target population.
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) and 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) Place a check in the one appropriate box:
I certify that the organization named in this application is not part of a group exemption.
- OR -
I certify that the organization named in this application is part of a group exemption.
- OR -
I certify that the organization named in this application is a bona-fide chapter or affiliate that
operates under a national organization’s single corporation tax-exemption.
4) 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 2012 are reflected in ATTACHMENT
A.
5) Place a check in the one appropriate box:
I certify that the organization named in this application reports total revenue of $250,000 or
more on its IRS Form 990 (or pro forma IRS Form 990) covering a period ending not more
than 18 months prior to January 2013 and meets both of the following two conditions:
accounts for its funds on the accrual basis in accordance with generally accepted
accounting principles (GAAP); and,
has an audit of its fiscal operations co mpleted annually by an independent certified
public accountant in 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.)
- OR -
I certify that the organization nam ed in this application reports total revenue of at least
$100,000 but less than $250,000 on its IRS Form 990 (or pro forma IRS Form 990) covering
OPM Form 1647-C
Rev. September 2012
12
a period ending not m ore than 18 m onths prior to January 2013 and m eets both of the
following two conditions:
accounts for its funds on an accrual basis in accordance with generally accepted
accounting principles (GAAP); and,
has an audit of its fiscal operations co mpleted annually by an independent certified
public accountant in accordance with generally accepted auditing standards (GAAS).
- OR -
I certify that the organization nam ed in this application reports total revenue of less than
$100,000 on its IRS Form 990 (or pro forma IRS Form 990) covering a period ending not
more than 18 months prior to January 2013 and has controls in place to ensure funds are
properly accounted for and that it can provide accurate timely financial information to
interested parties.
6) Check 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. (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 m arked “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 to the IRS. (Include as ATTACHMENT D a pro forma IRS Form 990
for a period ending not m ore than 18 m onths prior to January 2013. See application
instructions for pro form a IRS Form 990 requirements. IRS Forms 990 EZ, 990PF, and
comparable forms are not acceptable substitutes.)
7)
I certify that the administrative and fundraising rate for the organization named in this
application is __ __.__%. This percentage is computed from the IRS Form 990 submitted
with this application.
8)
I certify that an active and responsible governing body, whose members have no material
conflict of interest and a m ajority of whom serves without com pensation, directs the
organization named in this application.
9)
I certify that the organization named in this application prohibits the sale or lease of CFC
contributor lists.
10)
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.
OPM Form 1647-C
Rev. September 2012
13
11) I certify that the organization named in this application effectively uses the funds contributed
for its announced purposes.
12) 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 econom ic
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 circum stances pertaining to this
certification occur at any tim e, the orga nization will notif y OPM's CFC Operations
immediately.
13) Include as ATTACHMENT E a 25-word statement for listing in the campaign charity list.
(See Instructions Item 13 for additional required information on the optional taxonomy
codes.)
CERTIFYING OFFICIAL
I, ____________________________________, am the duly appointed representative
(Print Name)
of ____________________________________ authorized to certify and affirm all statements
(Print Organization 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 organization
named in this application acknowledges and agrees to comply with that certification.
______________________________
(Signature)
______________________________
(Typed or Printed Name)
______________________________
(Title)
Date Completed ______________________
Send the application to the appropriate local CFC office. For contact information, visit
www.opm.gov/cfc.
OPM Form 1647-C
Rev. September 2012
14
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 num ber 3206-0131 is currently valid. OPM m ay not collect this
information, and you are not required to respond, unless this number is displayed.