Fillable Printable OPM Form 1647-B
Fillable Printable OPM Form 1647-B
OPM Form 1647-B
OPM Form 1647-B
Rev. September 2015
1
OMB APPROVED
No. 3206-0131
COMBINED FEDERAL CAMPAIGN
2016 Application Instructions for
National/International Federations
BACKGROUND
Enclosed is the model application for use by
national/intern ational federations to particip ate 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 instru ctions and form are intended
to assist charitable federations in applying for
participation in the CFC. All aspects of the CFC,
including eligibility for participation, are strictly
governed by Federal regulation. The current CFC
regulations can be viewed on our website at
www.opm.gov/cfc
. Additional copies of the
application can also be downloaded from the
website. The Office of Personnel Management
(OPM) encourages federations to ap ply early.
The application deadline for national/international
federations seeking eligibility is 5:00 p.m. Eastern
Standard Time, Friday, January 15, 2016, but
applic ations may be sent to OPM ’s Office of CFC
as early as Tuesday, December 1, 2015. All
federation and federation member applications
must be submitted electronically on a CD-ROM or
USB flash drive by the application deadline. A
PDF copy of each member’s app lication must be
included, and. clearly marked with the name by
which the applicant wishes to be listed in the CFC
Charity List.
Applications must b e received by the application
deadline at the 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
OPM will not accept late applications. It is the
applicant’s responsibility that its application and
all required supplemental information is received
by the scheduled deadline. Requests for con-
sideration after the deadline will not be
considered.
All requ ired documents and attachments mu st be
complete and submitted before the application
deadline. Documents that did not exist at the time
of the application deadline will not be accepted
during the appeals process. Federations that
apply for national/international eligibility and are
found ineligible have only one opportunity 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 suggests that national/international
OMB Form 1647-B
Rev. September 2015
2
federations use the model application provided
when applying to the CFC. Although not
required, the submission of this form will
expedite the processing of individual appli-
cations. OPM will not accept application forms
with modifications to any of the certification
statements.
In order to determine whether a federation may
participate in the campaign, OPM may request
evidence of corrective action regarding any prior
violation of regulation or directive, sanction, or
penalty, as appropriate. OPM will decide whether
the federation has demonstrated, to OPM’s
satisfaction, that the federation has taken
appropriate corrective action. Failure to demon-
strate satisfactory corrective action or to respond to
OPM’s request for information within 10 business
days of the date of the request may result in a
determination that the federation will not be
included in the Charity List.
APPLICATION RECEIPT CONFIRMATION
When the application is entered into the CFC
database an email will be sent to the contact
person’s email address(es) with instructions to use
an online system to enter the organization’s 25-
word statement and select up to three taxonomy
codes. This information will appear in the CFC
Charity List if the application is approved. Please
note that the email is not documentation of the
approval of the application.
The federation will be given a Personal Identifi-
cation Number and be directed to a secure website
to register and verify the federat ion a nd its mem ber
organizations’ information on file with OPM. All
federations, 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.
Taxonomy Code s Each federation can identify
up to three categories, in priority order which most
closely identify th e type of mission, services, an d
activities provided. The corresponding letters will
be printed with the federation’s listing in the CFC
charity list to a ssist donors in identifying charities
by type of services provided. Categories were
derived from the National Taxonomy of Exempt
Entities classification system developed by the
National Cen ter 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 & Societal Benefit
X Religion Related
Y Mutual & Membership Benefit
Z Unknown
DEFINITIONS
Federation Name of the applicant f ederation, as it
appears in the IRS Business Master File. If the
name of the federation is differen t from the name
which appears on the IRS determination letter, I RS
Form 990, audited fin ancial statements, or annual
report, official documentation authorizing use of
this name must accompany the application. The
EIN must be included.
Em ploy er Identif ica tion N um ber (EIN ) The
nine-digit EIN assigned to the organization by the
IRS and appea ring on the IRS Form 990 submitted
with the application.
5 Digit CFC Number The 5 digit number
OMB Form 1647-B
Rev. September 2015
3
assigned to the federation by the CFC. Federations
that did not previously participate in the CFC
should leave th is field blank.
Federation Website Address List the complete
Internet add ress of th e app licant fed eration (no e-
mail addresses). This information is required, if
the federation has an Internet add ress.
Federa tion A ddress T he ph ysical street address
of the federation. Post Office Boxes may not be
used.
Con tact P erso n The contact person is the indi-
vidual to whom OPM will direct communications
regarding the fed eration application. T h is may be
any individual in the organization.
Contact Title Self-explanatory
Contact Address Contact Person’s mailing
address. Post Office Boxes may be used.
Participation decision letters and other CFC
communications will be sent to the Contact Person
at this ad dress.
Contact Telephone Contact Person’s telephone
number, if different than the organization’s
number.
Fax Contact Person’s fax number.
Contact E-Mail Address(es) Contact person’s
electronic mail address. Applicants are en-
couraged to provide more than one email address.
INSTRUCTIONS
For details regarding CFC eligibility requirements
for national/international federations, refer to CFC
Guidance Memoranda on the CFC website at
www.opm.gov/cfc
.
Applicants must check the box next to each
certification statement to demonstrate agreement to
comply with the statement and to certify that it
meets the requirement. Failure to provide a check
mark for each of the statements will be considered
as a refusal to certify and will result in the denial of
the application .
Item 1
Check the one appropriate box. Include as
Attachment A a list of all eligible member
organizations that meet all National/Inter-
national List eligibility criteria in 5 C.F.R. §§
950.202 and 950.203. Include their five-digit
CFC codes (if applicable), names as they
appear in the IRS Business Master File, “Doing
Busin ess As” names (if applica ble), EINs, and
administrative and fundraising rates. The
physical mailing address of each member must
also be included in Attachment A. The above
information must be sent as an Excel spread sheet
to cfc@opm.gov
in lieu of a paper copy in the
application. The subject line of the email must
read: “[F ederation Name] 2016 C FC Attach ment
A”. OPM will confirm receipt of the information.
A national/international federation must
demonstrate that it has 15 or more member
organizations that individually meet the eligibility
criteria for participation as national/international
organizations (real services, benefits, assistance, or
program activities in 15 or more different states or
one foreign country over the three year period
immediately preceding the start of the campaign
application year). An international federation must
demonstrate that it has 15 or more member
organizations that individually meet the eligibility
criteria for international organizations (real
services, benefits, assistance, or program activities
in a foreign country over the three-year period
immediately preceding th e start of the application
year). .
Item 2
Include as Attachment B a copy of the
federation’s most recent IRS determination
letter. If the name of the app licant differs on the
IRS determination letter, IRS Form 990, audited
financial statements, or annual report,
documentation from the IRS or state government
authorizing this name change must accompany the
application.
National/international organizations that are part of
an IRS group exemption must provide a copy of
the IRS letter granting the group exemption, as
well as the current list of subordinates that are
covered by the group exemption. The EIN on the
OMB Form 1647-B
Rev. September 2015
4
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 ex amples of
supporting 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 organi-
zations to verify their current tax-exempt status
prior to submitting a CFC application. This can be
done by contacting the IRS at (877) 829-5500.
Item 3
Self-explanatory
Item 4
Check the appropriate box. The certifying
official must certify that the federation
accounts for its funds on an accrual basis in
accordance with Generally Accepted
Accounting Principles (GAAP) and has an
audit of its fiscal operations completed annually
by an independent certified public accountant
in accordance with Generally Accepted
Auditing Standards (GAAS). No other basis of
accountin g is acceptable under GAAP. The cash
basis, modified cash basis, modified accrual basis,
and any other methods are not acceptable under
GAAP.
Include as Attachment C a copy of auditor’s
report and the federation's complete audited
annual financial statements. The audited
financial statements must cover the fiscal period
ending not more than 18 months prior to January
2016 (i.e., ending on or after June 30, 2014).
The audited financial statemen ts must includ e all
statements and audit n otes as required by GAAP.
The Independent Auditor’s Report must include
the signature of th e auditor or the aud iting firm.
The audited financial statements must verify
the federation is honoring designat ions made to
each member organization by distributing a
proportionate share of receipts based on donor
desi gnations to each membe r. The IRS Form 990
and audited financial statements must cover the
same fiscal period and be prepared using the
accrual basis of accounting.
The audit requirement is waived for newly created
federations operating for less than a year as
determined from the date of its I RS tax-exemption
letter to the closing date of the CFC application
period.
Item 5
Check the appropriate box. Include as Attach-
ment D a copy of the complete, signed IRS
Form 990 for a peri od ende d not more t han 18
months prior to January 2016. The IRS Form
990 mu st inclu d e a signatu re in the b lock 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 I RS Form 8879-EO or IRS Form 8453-
EO in lieu of a signature on th e 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 res ult in the denial of
the application . Please review CFC Memorand a
for additional information on the IRS Form 990
requirements, including the presentation of the
governing body and expenses.
OMB Form 1647-B
Rev. September 2015
5
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 req uire
the federation to file the Form 99 0 (long form), it
must complete and submit a pro forma IRS Form
990 (see instructions below). IRS Forms 990EZ,
990PF, and comparable forms will not be accepted.
Organizations that use these forms must submit a
pro forma IRS Form 990 .
Pro forma IRS Form 990 Instructions – The
IRS Form 990 can be downloaded from the IRS
website (www.irs.gov
). The following sections
must be completed: Page 1, Items A-M; Part I
(Summary), Lines 1-4 only; Part II (Signature
Block); Part VII (Compensation section A only);
Part VIII (Statement of Revenues), Part IX
(Statement of Fu n ctional E x pen ses) an d; Part XII
(Finan cial Statements and Reporting).
The IRS Form 990 and audited financial
statements must be prepared using the accrual
method of accounting and cover the same fiscal
period ended not more than 18 months prior to
January 2016 (i.e. ending on or after June 30,
2014).
Item 6
Calculate and enter the federation’s annual
percentage for administrat i ve and fundraisi ng
expenses based the formula below.
Add the amount in Part IX (Statement of
Functional Expenses), Line 25, Column C
(Management and General Expenses) to the
amount in Line 25, Column D (Fundraising
Expenses), and divide the sum by Part VIII
(Statement of Revenue), Line 12, Column A (Total
Revenue).
No other methods may be used to calculate this
percentage. All p ercentages must be listed to the
tenth of a percent (e.g. 15.7%).
Charities wh ich d o not reflect administrative and
fundraising expenses in the Statement of
Functional Expenses of the IRS Form 990,
resulting in a 0% rate, but show such expenses on
the audited financial statement will be denied
unless the audited financial statements specifically
state that these services were donated.
Item 7
Each f ederatio n m ust includ e as Attachment E
a co mplete listin g of the federa tion’s boa rd of
directors and the beginning and end dates of
each board member’s current term of office
(e.g. John Smith, 2011-2016). Attachment E
must also list the board’s meeting dates and
locations for the previous calendar year (2015).
The CFC uses Part VII of the IRS Form 990 to
verify that a majority of the governing body s erved
without compensation. The IRS Form 990
instructions define a director/trustee as member of
the governin g b ody with voting rights. Th ese are
the individuals that will be reviewed. Cases where
50% of the boa rd rec eive d com pensa tion 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
S
elf-explanatory
Item 12
Include as Attachment F a co py of the federa-
tion's most recently completed annual report.
The annu al rep ort must cover th e fiscal year end-
ing not more than 18 months prior to January of
the campaign year to which the federation is
applying or the p receding calend ar year. A more
frequently published document, such as a quar terly
newsletter, may be substituted as lon g as it meets
the requirements for an annual report. It must
contain a full description of the federation’s
activities and supporting services during the year
covered by the report and identify its directors and
chief administrative personnel.
OMB Form 1647-B
Rev. September 2015
6
The ann ual report or substitute must also inclu de
an accurate description of the federation’s
membership du es and/or service charges received
by the federation from the charitable organizations
participating as members. The information must
clearly present the amounts raised , the sources of
contributions, the cost of fundraising, and how
costs are recovered from donations.
Reproductions of annual reports that are available
on a federation’s website are acceptable. The
annual report must be clearly marked as such on
the website and must include all of the criteria
outlined in the CFC regulations (describe the
organization's activities and identify the board of
directors and chief administrative personnel).
OPM will not accept miscellaneous pages f rom the
federation’s website that provid e this in formation
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, en tities, and in dividu als.
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
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 CF C Memo 2005-13.
Certifying Official The certify ing official is the
individu al who has the au thority to affirm that all
statements in the application are accurate.
IF THE FEDERATION IS DENIED
If the federation’s application is denied, it will
receive a certified letter stating the reason(s) for the
denial. If the federation wishes to appeal the
decision to the Director of OPM, the appeal must
be received by OPM within ten business days of
the receipt of the letter. The appeal should be
complete and respond to the reason(s) for the
original denial d ecision .
Additional information or a revision to a submitted
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 (failu re to provide any of these ma y result in a denial)
Attachment A – List of eligible member organizations (include each organization’s IRS
Business Master File name (if applying under a DBA), EIN, and administrative and
fundraising rate) (See Item 1)
Attachmen t B – IRS determination letter (See Item 2)
Attachmen t C – Audited Financial S tatemen ts (S ee Item 4)
Attachmen t D – IRS Form 990 (See Item 5)
Attachment E – Board of Directors’ Current Terms of Office and Meeting Dates and Locations
(See Item 7)
Attachmen t F – Annual Report (See Item 13 )
THE APPLICATION AND SUPPORT ING DOCUMENTATION MUST BE RECEIVED BY THE
OFFICE OF PERSONNEL MANAGEMENT BY 5PM (EST), FRIDAY, JANUARY 15, 2016. LATE
APPLICATIONS WILL NOT BE ACCEPTED.
OMB Form 1647-B
Rev. September 2015
7
OMB APPROVED
No. 3205-0131
COMBINED FEDERAL CAMPAIGN
2016
APPLICATION FOR
NATIONAL/INTERNATIONAL FEDERATIONS
Federation:
Employer Identification Number (EIN): __ __ - __ __ __ __ __ __ __
5 Digit CFC Number (If a previous participant in the CFC): ___ ___ ___ ___ ___
Telephone: ( )____________________ Website Address: ___________________________
Federa tion Address: _____________________________________________________________
_____________________________________________________________________________
(Post Office Box addresses are not accepted and may result in automatic disqualification.)
Contact Person: ____________________________________________________________
Contact Title: ____________________________________________________________
Contact Address: ____________________________________________________________
(If different from the above address – Post Office Boxes are acceptable for the Contact
Add ress. All OPM correspondence will be sent to this address.)
Contact Telephone: ( )____________ Fax: ( )____________________
Contact E-Mail Address(es): _________________________________________________________
OMB Form 1647-B
Rev. September 2015
8
SELECTION OF NATIONAL/INTERNATIONAL OR INTERNATIONAL:
A national/international federation may be listed in either the national/international part of the
Charity List or the international part of the Charity List. The federation will be listed in the
appropriate section based on the response to Item #1.
1) Place a check in the one appropriate box:
National/International Part
I certify that the federation named in this application has _____ (enter number) member
organizations that individually meet the eligibility criteria for national/international
organizations in 5 C.F.R. §§ 950.202 and 950.203. Include a s ATTACHMENT A, a list of
all member organizations that meet this requirement. The list must include each
organization with its five digit CFC code (if applicable), legal name in parentheses (if using a
“dba”), Employer Identification Number (EIN), administrative and fundraising rate, and
physical mailing address.
– OR –
International Part
I certify that the federation named in this application has _____ (enter number) member
organizations that individually meet the eligibility criteria for international organizations in 5
C.F.R. §§ 950.202 and 950.203 by providing rea l services, bene fits, assistance, or prog ram
activities in at least one foreign country over the previous three years. Include as
ATTACHMENT A, a list of all member organizations that meet this requirement. The
list must include each organization (with its legal name in parentheses if using a “dba”),
Employer Identification Number (EIN), administrative and fundraising rate, and physical
mailing address.
2) I certify that the Internal Revenue Service (IRS) recognizes the federation named in this
application as tax-exempt under 26 U.S.C. 501(c)(3) to which contributions are tax deducti-
ble pursuant to 26 U.S.C. 170(c)(2). (Include as ATTACHMENT B a copy of the
federation’s most recent IRS determination letter. See instructions for additional
information.)
3) I certify that the federation named in this application is a human health and welfare fe dera-
tion a nd either it or its memb er org anizations provide services, benefits, or assistance to, or
conduct activities affecting, human health and welfare. Services, benefits, assistance, or
program activities affecting human health and welfare were provided in calendar year 2015.
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 wi th generally accepted aud iting standard s (GAAS). (Include as ATTACH-
MENT C a copy of the auditor’s report and the complete audited financial statements
OMB Form 1647-B
Rev. September 2015
9
for a fiscal period ending not more than 18 months prior to January 2016 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 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 federation named in this application is not required to prepare and submit an
I RS Form 990 to the I RS. (Include as ATT ACHMENT D a pro forma IRS Form 990 for
a period ending not more than 18 months prior to January 2016. See application
instructions for pro forma IRS Form 990 requirements. IRS Forms 990 EZ, 990PF, and
comparable forms are not acceptable substitutes.)
6) I certify that the administrative and fundraising rate for the federation named in this
application is __ __ . __%.This percentage is computed only from information on the IRS
Form 990 submitted w ith this applic ation. See the instructions for more information on the
formula.
7) I certify that an active and responsible governing body, whose members have no material
conflict of interest and a majority of whom serves without compensation, directs the
federation named in this applica tion. Include as ATTACHMENT E a complete list of the
federation’s board of directors with the beginning and end date of each board membe r’s
current term of office and the board’s meeting dates and locations for calendar year 2015.
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 progr am and operations, and that these ac tivities are truthf ul
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 c ontributed
for its announced purposes.
OMB Form 1647-B
Rev. September 2015
10
11) I certify that the federation named in this application does not employ, in its CFC operations,
the services of private consultants, consulting firms, advertising agencies or similar business
organizations to perform its policy-making or decision-making functions in the CFC.
12) I certify th at the federation named in thi s applicatio n prepares and mak es available to the
public an annual report that includes a full description of the federation's activities, sup-
porting services, member fees and/or service charges, and identifies its directors/ governing
body and chief administrative personnel. Include as ATTACHMENT F a copy of the most
recently completed annual report. See Instructions Item 12 for additional information.
13) I certify that the federation named in this application is in compliance with all statutes,
Executive orders, and regul ations 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 n amed in this app lication is awa re that a list o f countries subject
to such sanctions, a list of S pecially 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 Name)
enclosed in this application. I certify that I have read all the certifications set forth in this document
and affirm their ac cur acy. I n 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)
OMB Form 1647-B
Rev. September 2015
11
Date Completed ______________________ ______________________________
The application must be received by 5PM (EST) January 15, 2016. Send the application to:
Office of Person nel Managemen t
Office of Combined Federal Campaign
ATTN: Charleese Scott
Room 6484
1900 E Street, NW
Washington, DC 20415
Public Burden Statement
We think this form takes an average of 3 hours to complete, including the t ime for get ting the ne eded data and
reviewing both the instructions and completi ng the for m. Send comments regarding our est imate or any other
aspects of this form, including suggestions for reducing completion time to Office of Personnel Management (OPM),
CFC Operations (3206-0131), Washington, DC 20415-7900. The OMB number 3206-0131 is currently valid. OPM
may not collect this information, and you are not required to respond, unless this number is displayed.
