Fillable Printable OPM Form 1647-A
Fillable Printable OPM Form 1647-A
OPM Form 1647-A
OPM Form 1647-A
Rev. September 2015
1
OMB APPROVED
No. 3206-0131
COMBINED FEDERAL CAMPAIGN
2016 Application Instructions for
National/International IndependentOrganizations And
Membersof Federations
BACKGROUND
Enclosed is the model application for useby
national/internationalindependentorganizations to
apply to participate in the Combined Federal
Campaign (CFC)and for use bynational/
international federation members to sub mit to the
national/international federations to which they
belong. The following instructions and form are
intended to assist charitable organizations in
applying for participation in the CFC. All aspects
of the CFC, including eligibility for participation,
are strictly governed by Federal regulation. The
current CFC regulations can be viewedon our
website at www.opm.gov/cfc
. Additional copies of
the application can also be downloaded from the
website. The Office of Personnel Management
(OPM) encourages organizations to apply early.
The application deadline for independent
organizations and federations seeking national
eligibility is 5:00 p.m. Eastern Standard Time,
Friday, January 15, 2016, but applications may
be sent to OPM’s Office of CFC as early as
Tuesday, December 1, 2015.A timely application
must be receivedb y the d ead line at th e following
address:
Office of Person nel Managemen t
Office of Combined Federal Campaign
ATTN: Charleese Scott
Room 6484
1900 E Street, NW
Washington, DC 20415
Do not send applications in binders or packets.
Also, do notsend multiple copies of your
application.
OPM will not accept late applications. It is the
applicant’s responsibility to ensure that its
application and all required supplemental
information isreceived at the aboveaddress by
the scheduled deadline. Requests for
consideration after the deadline will not be
considered.
Federation members must submit their applications
to the federation. Copies of these applications
should not be sent to OPM.
All requ ired documents and attachments mu st be
complete andsubmitted before the application
deadline. Documents that did not exist at the time
of the application deadlinewill not be accepted
during the appeals process. Organizations that
apply fornational/internationaleligibility and are
found ineligible haveonly oneopportunity to
appeal to the Director of OPM. The Director's
decision is final for administrative purposes.
Therefore, appellants should ensure that their
appeals are comp lete and responsive to th e actual
reasons for the original denial decision.
OPM will not accept applicationformswith
modifications toany ofthe certification
statements.
OPM Form 1647-A
Rev. September 2015
2
In order to determine whether an organizatio n may
participate in the campaign, OPM may request
evidence of corrective action regarding any prior
violation of regulation or directive, sanction, or
penalty, as appropriate. OPM will decide whether
the organization has demonstrated, to OPM’s
satisfaction, that the organization has taken
appropriate corrective action. Failure to
demonstrate satisfactory corrective action or to
respond to OP M’s req uest for information within
10 businessdays of the date of the request may
result in a determination that the organization will
not be included in theCharity List.
APPLICATION RECEIPT CONFIRMATION
When the application is entered into the CFC
database,an emailwill be sent to the contact
person’s email address(es) with instructions to use
an online system to enter the organization’s 25-
word statement and select up to three taxonomy
codes. This information will appear in the CFC
Charity List if the application is approved. Please
note that the email is not documentation of the
approval of the application.
Organization’s Program Description and
Taxonomy Codes
The organization will be given a Personal
Identification Number and be directed to a secure
website to register and verify the organization’s
information on file with OPM.All approved
organizations, regardless of past participation, must
register each year. During the registration process
applicants will be asked to verify contact
information on file with OPM and enter the 25-
word statement that will appear in the CFC charity
list.
In addition, the organization will be asked to
identify up to three program catego ries, in priority
order, which most closelyidentifythe type of
mission, services, and activities provided. The
corresponding letters will be printed with your
organization’s listing in the CFC charity listto
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 Envir onment
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 Emplo yment
K Food, Agriculture & Nutrition
L Housing& Shelter
M Public Safety, Disaster Preparedness & Relief
N Recreation & Sports
O Yo ut h Development
P Human Services
Q International, Foreign Affairs & National Security
R Civil Rights, Social Action & Advocacy
S Co mmunit y Improveme nt & Capacity Building
T P hilanthropy, Voluntarism &Grantmaking
Foundations
U Science & Technology
V Social Science
W Public& SocietalBenefit
X Religion-Related
Y Mutual& Membership Benefit
Z Unknown
DEFINITIONS
OrganizationName of the applicant org-
anizationas it appears on theIRS Business Master
File. If the name of the applicant organization
differs from the name that appears on the IRS
determination letter, the IRS Form 990, or audited
financial statements, documentation from the IRS
or state government authorizing use of thisname
must accompany the application. The EINmust be
included.
Employer Identification Number (EIN) The
nine-digit EIN assigned to the organization by the
IRS and appe aring o n the IRS Form 990 submitted
with the application.
5 Digit CFC NumberThe 5 digit number
assigned to the organizationby the CFC.
Organizations that did not previouslyparticipate in
the CFC should leave th is field blank.
TelephoneOrganization’s telephone number.
Website AddressList onecomplete Internet
OPM Form 1647-A
Rev. September 2015
3
address of the applicant organization (no e-mail
addresses).This information is required, if the
organization has an Internet address.
Organization AddressThe physical street
address of the organization. Post Office Boxes
may not be u sed.
Contact PersonThe individual to wh om OPM
will direct communicationsregarding the
application. This may be anyindividual in the
organization.
Contact TitleSelf-explanatory
Contact Address Contact person’s mailing
address. Post Office Boxes may be used.
Participationdecision letters and other CFC
communications will be sent to the Contact Person
at this ad dress.
Contact TelephoneContact person’s telephone
number, if different than the organization’s tele-
phone number.
FaxContact person ’s fax n umber.
Contact E-MailAddress(es)Contact person’s
electronic mail address. Applicants are en-
couraged to provide more than one email address.
INSTRUCTIONS
For details regarding CFC eligibility requirements
for national/international independentorgan-
izations and federationmembers, refer to CFC
Guidance Memoranda on the CFC website at
w
ww.opm.gov/cfc
.
Applicants must check the box next to each
certification statement to demonstrateagreementto
comply with the statement and to certify that it
meets the requirement. Failure to provide a check
mark for each of the statements will be considered
as a refusal to certify and will result in the denial of
the application .
Item 1
Check the one appropriate box. Include Attach-
ment A.CFC eligibility requirements mandate
that a national/international organization demon-
strate it provided services in at least 15 different
states or one foreign country over the three year
period immediately preceding the start of the
campaign’s application y ear(i .e., Januar y 1, 2013
– December 31, 2015). A schedule listing a
detailed description of the services in each state
(minimum 15) or foreign country(minimum 1),
including the year of service, must be included
with the application. Theschedule must make a
clear showing of national and/or international
presence.Simply providing a list of states or
countries where an organization conducts or
provides real services, benefits or program
activities is not sufficient. An organization must
provide a detailed description of th e services and
activities it provided, an d the yearin which those
services were provided, in eachstate or foreign
country. Applicants mustdocument the dollar
amounts of financial assistance (if applicable) and
the number of beneficiaries of each service it lists
in Attachment A. The schedule must also include
human health and welfare services that were
provided in calendar year 2015(see Certification
#3).
A sample Attachment A format is included in these
instructions. OPM encourages applicants to use
this format, but it is not a requirement.
This requirement can not be met on th e sole basis
of services provided through an “800” telephone
number or by disseminating information and
publications via the U.S. PostalService, the
Internet, or a combination thereof. Broad
descriptions of services and identical repetitive
narratives will not be acceptedat the sole
discretion of OPM if they do not allow OPM to
adequately determine that real services were
provided or toaccurately determine the individuals
or entities who benefited. Providing listings of
affiliated groups does not sufficiently demonstrate
provision of real services by the applicant.
Location of residence of organization members or
location of residenceof visitors to a facility does
not substantiate provision of services in the
location of residence. However, organizati ons that
issue student scholarships or fellowships must
indicate the state in which the recipient resides, not
the state of the school or place of fellowship. Mere
dissemination of information does notdemonstrate
provision of real services.
While it is not expected that an organization
OPM Form 1647-A
Rev. September 2015
4
maintain an office in each state or foreign country,
a clear showing must be made of the actual
services, benefits, assistance or program activities
provided in each state or foreign country. De
minimis services, benefits, assistance, or other
program activities in any state or foreign country
will not be accepted as a basis for qualifica tion as a
national or international organization.
Item 2
Include as Attachment Ba copy of the
orga nization’s most recen t IRS determinatio n
letter.If the name of the applicant organization
differs on the IRS determination letter, the IRS
Form 990, or audited financial statements,
documentation from the IRS or state government
authorizing this name change must accompany the
application.
National/international organizations that are part of
an IRSgroup exemptionmust 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 EI N o n t he
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,
2015, stating the local charitable organization
operates as a bona-fide chapter or affiliate in good
standing of the national organization and it is
covered by the national organization’s 501(c)(3)
tax-exemption, IRS Form 990 and audited
financial statements. A copy of the national
organization’s 501(c)(3) letter must accompany the
CEO’s certification.
Please review CFC Memorandum 2009-4 for more
information on this requirement and examples of
supp orting documentation (www.opm.gov/cfc).
Each app licant’s 501(c)(3 ) status will be verified
with the IRS. Applicants whose current 501(c)(3)
status cannot be confirmed by the IRS will be
denied participation. OPM encourages
organizations to verifytheir currenttax-exempt
statusprior to submitting a CFC application. This
can be doneby contacting the IRS at (877) 829-
5500.
Item 3
Self-explanatory. Human health and welfare
services provided in calendar year 2015must be
reflected in Attachment A.
Item 4
The certifying official must certify that the
organization accounts for itsfunds on an
accrual basis in accordance with Generally
AcceptedAccountingPrinciples(GAAP)and
has an aud it of its f iscal operations com pleted
by an independent certified public accountant
annually in accordance with Generally
Accepted Auditing Standards (GAAS). No
other basis of accounting is acceptable under
GAAP. The cash basis, modified cash basis,
modified accrualbasis, and any o ther me thods are
not acceptable.
Include as Attachment Ca copy of the auditor’s
report and the organization'scomplete audited
annual financial statements.The audited
financial statements and IRS Form 990 must be
preparedusing the accrual method of accounting
and cover the same fiscal period that ended not
more than 18 months prior to January2016(i.e.
ending on or after June 30, 2014).
The audited financial statemen ts must includ e all
statements and audit n otesas required by GAAP.
The Independent Auditor’s Report must include
the signature of th e auditor or the aud iting firm.
Item 5
Check the appropriate box.Include as
Attachment Da copy of the complete, signed
IRS Form 990 for a period ended not more
than 18 months pri or to January2016. The IRS
Form 990must includea 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
subm it a s igned c opy of the IRS Fo rm 887 9-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
OPM Form 1647-A
Rev. September 2015
5
trustee or director’ or ‘institutional trustee’ position
selected in Part VII, Column C . If the numb er 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 for additional information
on the IRS Form 990 requirements, including the
presentation of the governing body and expenses.
A complete IRS Form 990is required, including
all supplemental statements schedules, if
applicable, with the exception of Schedule B, to be
eligible for the CFC . If the IRSdoes n ot require
theorganization to file the Form 990(long form)it
must complete and submit a pro forma IRS Form
990(see instru ctions below). IRS Forms 990EZ,
990PF, and comparable forms will not be accepted.
Organizations that file th ese forms must submit a
pro forma IRSForm 990 (see instructions below).
The audited financial statements and IRS Form
990 mus t be pre par ed u si ng t he a cc rua l m et hod o f
accounting and cover the same fiscal period ended
not more than 18 months prior to January2016
(i.e. end ing on or after June 30, 2014).
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, ItemsA-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 Fu n ctional E x pen ses) an d; Part XII
(Finan cial Statements and Reporting).
Item 6
Calcu late and enter the organiza tion’s annual
percentage for administrat i ve and fundraisi ng
expensesbased on the formula below.
Add the amount in Part IX (Statement of
Functional Expenses), Line 25, Column C
(Management and General Expenses) to the
amount in Line 25, Column D (Fundraising
Expenses), and divide the sum by Part VIII
(Statement of Revenue), Line 12, Column A (Total
Revenue).
No other methods may be used to calculate this
percentage.All percen tages 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,
res ulti ng i n a 0% rate , but sho w suc h expens es o n
the audited financial statement will be denied
unless the audited financial statements specifically
state that these services were donated.
Item 7
Self-explanatory
Item 8
Self-explanatory
Item 9
Self-explanatory
Item 10
Self-explanatory
Item 11
Each federation and independentorganization
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, en tities, and individuals.
OFAC publishes a list of Specially Designated
Nationals and Blocked Persons (SDN List).The
person s on the S DN List are su bject to econ omic
sanctions.The SDN List and additional
information relating to the economic sanctions
programs that OFAC administers are available at
//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 CF CMemo 2005-13.
Certifying OfficialThe certifying official is the
individ ual who has the au thority to affirm that all
statements in the application are accurate.This
role cannot be delegated to the federation of which
OPM Form 1647-A
Rev. September 2015
6
the organization is a member.
IF THE ORGANIZATIONIS DENIED
If your organization’s application isdenied, it will
receive a certified letter stating the reason(s) for the
denial. If the organization wishes to appeal the
decision to the Director of OPM, the appeal must
be received by OPMwithin ten business days of
the receipt of the letter. The appeal should be
complete and respond to the reason(s) for the
original denial d ecision .
Additional information or a revision t o a subm itte d
document will only be accepted if it existed p rior
to the application deadline.The CFC will not
accept documents that did not exist or were not set
forth in final form prior to the application deadline .
REQUIRED ATTACHMENTS (fai lure to provide any of these docum ents may result in a denial)
Attachm ent A – Schedu l e of services by year a nd state and/or f oreign country (See Items 1 & 3)
Attachm ent B – IRS determination letter (See Item 2)
Attachm ent C – Au dited financial statements (See Item 4)
Attachm ent D – IRS Form 990 (See Item 5)
THE APPLICATION AND SUPPORTING DOCUMENTATION MUST BE RECEIVEDBY THE
OFFICE OF PERSONNEL MANAGEMENT BY 5PM (EST), FRIDAY, JANUARY 15, 2016.
LATE APPLICATIONS WILL NOT BE ACCEPTED.
OPM Form 1647-A
Rev. September 2015
7
2016 CFC National/International Independent Organization and Federation Member
Attachment A Format
The u se of t his document is not required for Attachment A. If an applicant uses a different format,
it is encouraged to detail services it p rovided under the heading of each state or foreign country. A
minimu m of 15 or more different states or o ne foreign country is required. This sample only lists 1 5
states, bu t applica nts are encouraged to list, at least, a few more.
Several services can be describ ed under any one state. Also, services th at are provid ed in more than
one state can be described under the heading of each of those states.A ll dates must be w ithin the
period of January 1, 2013 – Decemb er 31, 2015only.
Foreign Co untry( ies)
Location
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State # 1[enter sta te name]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State # 2[enter sta te name]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State # 3[enter sta te name]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State # 4[enter sta te name]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State #5[enter state name]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State # 6[enter sta te name]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
OPM Form 1647-A
Rev. September 2015
8
State # 7[enter state name]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State # 8[enter sta te name]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State # 9[enter sta te name]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State #10[enter state n ame]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State #11 [enter state name]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State #12[enter state n ame]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State #13[enter state n ame]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State #14[enter state n ame]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
State #15[enter state name]
City
Date
Service D escription(including who provided the
service)
Number o f
Beneficiaries
OPM Form 1647-A
Rev. September 2015
9
OMBAPPROVED
N
O.3206-0131
COMBINED FEDERAL CAMPAIGN
2016APPLICATION FOR
NATIONAL/INTERNATIONAL INDEPENDENTORGANIZATIONS
AND MEMBERS OFFEDERATIONS
(Federa tion members must complete this application to be kept o n file by their federatio n.)
Organization:
Employer Identification Number (EIN): __ __ - __ __ __ __ __ __ __
5 Digit CFC Number (If a previous participant in the CFC): ___ ___ ___ ___ ___
Telephone: ( )___________________ Website Address: ____________________________
Organization Address: ___________________________________________________________
____________________________________________________________
(Post Office Box addresses are not accepted and may result in automatic disqualification.)
Contact Person: ____________________________________________________________
Contact Title:____________________________________________________________
Contact Address:
(If different from the above address - Post Office Box Addresses are acceptable for the
Contact Address.. All OPM correspondence will be sent to this address.)
Contact Telephone: ( )_________________ Fax: ( )_____________________
Contact E-Mail Address(es): _________________________________________________________
OPM Form 1647-A
Rev. September 2015
10
SELECTION OF NATIONAL/INTERNATIONAL OR INTERNATIONAL:
A national/international organizationmay be listed in either the national/international part of
the Charity L ist or the Intern ational part o f the Charity L ist.The organiza tion will be listed
in the appropriate section based on the response to Item #1.
1) Place a check in the one appropriate box:
National/International Part
I certify that the organization named in this application provided or conducted real services,
benefits, assistance, or program activities in 15 or more different states or one foreign
countryover the three-year period immediately preceding the start of the campaign
application year. (Include as ATTACHMENT A, a schedulelisting those statesor foreign
countrieswhere the program activities have been provided withinthe 2013-2015period
only and a detailed description of the activities, including the year in which those
services were provided, in eachstate or foreign country listed.See recommended
format for Attachment A on page 6 of the application instructions.)
- OR -
International Part
I certify that the organization named in this application provided or conducted real services,
benefits, assistance, or program activities in a foreign country over the three-year period
immediately preceding the start of the campaign application year. (Include as
ATTACHMENTA, a schedulelistingeach country where program activities have been
provided withinthe 2013-2015 period only and a det ai le d des c ri ptio n of t he pr o gr am
activities, including the yearin which those services were provided in eachcountry
listed.See recommended format for Attachment A on page 6 of the instructions.)
2) I certify that the Internal Revenue Service (IRS) recognizes the organization named in this
application as tax-exempt under 26 U.S.C. 501(c)(3) to which contributions are tax
deductible pursuant to 26 U.S.C. 170(c)(2).
(Includeas ATT ACHMENT Ba copy of the
most recent IRS determination letter.See instructions for additional information.)
3) I certify that the organization named in this application is a human health and welfare organi-
zation providing services, benefits, or assistance to, or conducting activities affectinghuman
health and welfare. The services, benefits, assistance, or program activities affecting human
health and welfare provided in calendar year 2015 are reflected in ATTACHMENT A.
4) I certify that the organization named in the application accounts for its funds on an accrual
basis inaccordancewith generally accepted accounting principles (GAAP) andhas an audit
of its fiscal operations completed annua lly by a n independent certified public accountant in
accordance with generally accepted auditing standards (GAAS). (Include as ATTACH-
MENT Ca copy of the auditor’s report and the complete auditedfinancial statements
for a fiscal period ending not more than 18 months prior to January 2016. )
OPM Form 1647-A
Rev. September 2015
11
5) Place a check in the one appropriate box:
I certify that the organization named in this application prepares and submits to the IRS a
complete copy of the organization’s IRS Form 990(long form). (Include as
ATTACHMENT Da copy of th e complete IRS Form 990for a period ending not more
than 18 months prior to January 2016, including signatures in the box marked “Signature of
Officer”or in IRS Forms 8879-EO or 8453-EO. The preparer’s signature alone is not
sufficient. IRS Forms 990EZ, 990PF, and comparable forms are not acceptable substitutes.)
- OR -
I certify that the organization named in this applicationis not required to prepare and submit
an IRS Form 990 (long form) to the IRS. (Include as ATTACHMENT Da pro forma IRS
Form 990 for a period ending not morethan 18 months prior to January2016. See
application instructions for pro forma IRS Form 990 requirements. IRS Forms 990 EZ,
990PF, and comparable forms are not acceptable substitutes.)
6) I certify that the administrative and fundraising rate for the organization named in this
application is __ __ . __%.This percentage has been computed from information on the I RS
Form 990 submitted with this application.See the instructions for information on the
formula.
7) I certify that an active and responsible governing body, whose members have no material
conflict of interest and a majority of whom serves without compensation, directs the
organization named in this application.
8) I certifythat the organization named in this application prohibits the sale or lease of CFC
contributor lists.
9) I certify that the organization named in this application conducts publicity and promotional
activities based upon its actual progr am and operations, and tha t these activities a re truthful
and non-deceptive, include all material facts, andmake no exaggerated or misleading claims.
10)I certify that the organization named in this application effectively uses the funds contributed
for its announced purposes.
11)I certify that the organization named in this application is in compliance with all statutes,
Executive orders, and regulations restricting or prohibiting U.S. persons from engaging in
transactions and dealings with countries, entities, or individuals subject to economic
sanctions administered by the U.S. Depart men t o f th e Treas ury’s Office of Foreign Assets
Control. The organization named in this application is awar e that a list of countries subject
to such sanctions, a list of S pecially Designated Nationals and Blocked Persons subject to
such sanctions, and overviews and g uidelines for each such sanctions program can be found
at //www.treas.gov/ofac. Should any change in circumstances pertaining to this
certification occur at any time, the organization will notify OPM's Office of CFC
immediately.
