Fill - Free fillable Opm1647c (U.S. Office of Personnel Management) PDF form

OPM Form 1647-C

Rev. September 2012

OMB APPROVED

No. 3206-0131

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

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

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.

 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.

 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

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.

 Organizations with total revenue of at

least $100,000 but less than $250,000: the

OPM Form 1647-C

Rev. September 2012

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.

 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

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

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

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

OMB APPROVED

NO. 3206-0131

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

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

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.

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

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

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.)

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.

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.

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

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

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.

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