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OPM Form 1647-D

Rev. September 2012

OMB APPROVED

No. 3206-0131

COMBINED FEDERAL CAMPAIGN

2013 Application Instructions for

Local Federations

BACKGROUND

Enclosed is the model application for use by local

federations applying 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.

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.

Federations 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 federation may appeal the

LFCC’s decision to the Director of the Office of

Personnel Management (OPM). The Director's

decision is final for administrative purposes.

Appellants should insure that their appeals are

complete and responsive to the actual reasons for

the LFCC denial decision.

Each LFCC determines the application deadline

for federations 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 sug-

gests that federations use the local application pro-

vided when applying to the Combined Federal

Campaign (CFC).

The CFC 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, the LFCC may request

evidence of corrective action regarding any prior

OPM Form 1647-D

Rev. September 2012

violation of regulation or directive, sanction, or

penalty, as appropriate. The LFCC will decide

whether the federation has demonstrated, to the

LFCC’s satisfaction, that the federation has taken

appropriate corrective action. Failure to demon-

strate satisfactory corrective action or to respond to

the LFCC’s request for information within 10

business days of the date of the request may result

in a recommendation that OPM withdraw

federation status. The Director’s decision will be

communicated in writing to the federation.

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 from the IRS or a

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 by the IRS and appearing

on the IRS Form 990 submitted with this

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.

Mailing Address A physical street address must

be provided - Post Office Box addresses will not

be accepted.

Check the box below the address to denote that it

is different from the address submitted with the

2012 CFC application.

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

mailing address if different than the organization's

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

encouraged to provide more than one email

address.

Federation Website Address List the complete

Internet address of the applicant federation (no e-

mail 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 may 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 method for

receipt of CFC contributions. NOTE: Some

campaigns may elect not to disburse funds

electronically.

Certifying Official The certifying official is the

individual who has the authority to affirm that all

statements in the application are accurate.

INSTRUCTIONS

For details regarding CFC eligibility requirements

for local 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 it meets

the requirement. Failure to provide a check mark

OPM Form 1647-D

Rev. September 2012

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 application, the complete applications of

all 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.

Item 1

Include as Attachment A a list of the federation

and all member organizations applying for

participation in the CFC which meet all local

eligibility criteria of 5 CFR §§§ 950.202, 950.203,

950.204, and 950.401(i) for participation.

The list must include the following information for

the federation and each of its member

organizations applying for participation in the

CFC: five-digit CFC code previously assigned to

the applicant (leave blank if the applicant is new);

legal name; telephone number; website address;

EIN; statement of 25 words or less that describe

the applicant organization’s program activities;

administrative fundraising rate; taxonomy codes

(see instructions below), and; the local presence

category under which each member organization is

eligible for participation in the local campaign (e.g.

Local, Adjacent, or Statewide). The federation is

not required to indicate a local, adjacent or

statewide presence.

The legal name that is registered with the IRS must

be provided for each applicant. If the applicant

solicits funds using a different name, it should

enter that name in the “DBA” (“Doing Business

As”) column. All applicants must include their

EIN regardless of whether or not they are operating

under a "DBA". See Item 2 for more information

on the requirements for “DBAs”.

The 25-word statement should not repeat the

applicant’s name. The legal name, DBA (if

applicable), telephone number, website address,

EIN, and taxonomy codes will NOT count toward

an applicant’s 25 words. OPM will not be

responsible for incorrect Internet addresses. E-mail

addresses are not accepted.

Special design text used to draw attention to a

federation or member organization’s title, such as

special fonts, capitalization, quotations, and

underlining, are not accepted. Any statement that

uses special features or exceeds 25 words will be

edited by the LFCC.

The physical mailing address of the federation and

each member organization applying for

participation in the CFC must also be included in

Attachment A.

All of the above information must be provided in

an Excel spreadsheet sent to the local CFC office

via email. A model spreadsheet and information

on where it should be sent can be obtained from

the local CFC office.

Taxonomy Codes The federation and each of its

member organizations applying for participation

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 the

organization’s listing in the CFC charity list to

assist donors in identifying charities by type of

service provided. Categories are derived from the

National Taxonomy of Exempt Entities (NTEE)

classification system developed by the National

Center for Charitable Statistics. The 26 categories

are:

A Arts, Culture, and Humanities

B Education

C Environment

D Animal Related

E Health Care

F Mental Health & Crisis Intervention

G Voluntary Health Associations & Medical

Disciplines

H Medical Research

I Crime & Legal Related

J Employment

K Food, Agriculture & Nutrition

L Housing & Shelter

OPM Form 1647-D

Rev. September 2012

M Public Safety, Disaster Preparedness & Relief

N Recreation & Sports

O Youth Development

P Human Services

Q International, Foreign Affairs, & National Security

R Civil Rights, Social Action & Advocacy

S Community Improvement & Capacity Building

T Philanthropy, Voluntarism & Grantmaking

Foundations

U Science & Technology

V Social Science

W Public, Societal Benefit

X Religion-Related

Y Mutual & Membership Benefit

Z Unknown

Special design text used to draw attention to a

federation 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.

Item 2

Include as Attachment B a copy of the

federation’s most recent IRS determination

letter. If the name of the applicant organization

differs on the IRS determination letter, the IRS

Form 990, or audited financial statements,

documentation from the IRS or state government

authorizing this name change must accompany the

application.

Please review CFC Memorandum 2009-4 for more

information on this requirement and examples of

supporting documentation (www.opm.gov/cfc).

Each local federation and federation member’s

501(c)(3) status will be verified with the IRS.

Federation applicants and federation members

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 by done 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.

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.

Item 3

Self-explanatory

Item 4

Check the appropriate box. The federation’s

certifying official must certify 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 by an

independent certified public accountant in

accordance with Generally Accepted Auditing

Standards (GAAS). No other basis of accounting

is acceptable under Generally Accepted

Accounting Principles (GAAP). The cash basis,

modified cash basis, and modified accrual basis are

not acceptable methods of accounting under

GAAP.

Include as Attachment C a copy of the auditor’s

OPM Form 1647-D

Rev. September 2012

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 2013 (i.e. ending on or after June 30,

2011). 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 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.

Newly created federations operating for less than

one year (as determined from the date of the IRS

determination letter to the closing date of the CFC

application period) are not required to submit

audited financial statements.

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 a Form 990 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 not required to file the IRS Form

990 (long form) 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 state-

ments 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. ended on or after June 30, 2011).

Item 6

Calculate and enter the federation’s annual

percentage for administrative and fundraising

expenses. This percentage is computed from the

IRS Form 990 submitted with this application.

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

OPM Form 1647-D

Rev. September 2012

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 individual’s current term of office (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 ending

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 so long as it meets

the requirements for the annual report.

The annual report or more frequently published

document 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 more frequently published

document 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 (see above). 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.

OPM Form 1647-D

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 may result in a denial)

 Attachment A – federation membership listing (See Item 1)

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

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

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

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

(See Item 7)

 Attachment F – Annual Report (See Item 12)

OPM Form 1647-D

Rev. September 2012

OMB APPROVED

NO. 3206-0131

COMBINED FEDERAL CAMPAIGN

2013 APPLICATION FOR

LOCAL FEDERATIONS

Federation: _________________________________________________________________

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

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

Mailing 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 Number

Contact Person:

Contact Title:

Contact Address:

__________________________________________________________________

(If different from the above address – Post Office Box Addresses are acceptable for the

Contact Address. All CFC correspondence will be sent to this address.)

Contact Telephone: Fax:

Contact E-Mail Address: _________________________________________________________

Federation Website Address (required, if available): ______________________________________

Disbursement Address: _________________________________________________________________

(This is the address where paper checks will be sent.)

Electronic Funds Transfer (EFT) information (Optional):

RTN (9 digits): _____________________ ACCT: _____________________

Financial Institution: _________________________________

OPM Form 1647-D

Rev. September 2012

1) I certify that the federation named in the application has ________ (enter number)

member organizations that individually meet all local eligibility criteria of 5 CFR §§§

950.202, 950.203, 950.204, and 950.401(i) for participation in this campaign by having

either a substantial local presence in the geographic are served by the local campaign, a

substantial local presence in the geographic area served by an adjacent local campaign, or

a substantial statewide presence. Include as ATTACHMENT A a list of the federation

and all member organizations that meet this requirement. See instructions for

additional information.

2) I certify that the Internal Revenue Service recognizes the federation 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 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

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

to, or conduct activities that directly or indirectly affect, human health and welfare. The

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

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

MENT C a copy of the auditor’s report and the complete audited financial statements

for a fiscal period ending not more than 18 months prior to January 2013 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

OPM Form 1647-D

Rev. September 2012

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 from the IRS Form 990 submitted

with this application. See the application instructions for 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 list of the federation’s

board of directors with the beginning and ending 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 programs and operations, and that these activities are truthful

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

10) I certify that the 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 the 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 and

supporting 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 organization named in this application is in compliance with all statutes,

Executive orders, and regulations restricting or prohibiting U.S. persons from engaging in

transactions and dealings with countries, entities, or individuals subject to economic

sanctions administered by the U.S. Department of the Treasury’s Office of Foreign Assets

Control. The organization named in this application is aware that a list of countries subject

OPM Form 1647-D

Rev. September 2012

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

CERTIFYING OFFICIAL

I, ____________________________________, am the duly appointed representative

(Print Name)

of ____________________________________ authorized to certify and affirm all statements

(Print Federation certification)

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 ______________________

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), OPM Forms Officer,

Paperwork Reduction Project (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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