Fillable Printable OPM Form 1647-D

OPM Form 1647-D

Rev. August 2015

OMB APPROVED

No. 3206-0131

COMBINED FEDERAL CAMPAIGN

2016 Application Instructions for

Local Federati ons

BACKGROUND

closed 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 fund-

raising, ad ministrative, an d 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.

e following in structions an d form are intend ed

to assist charitable federations in applying for

participation in the CF C. 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 appli-

cation can also be download ed from the website.

l 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

ensure that its application and all required

supplemental information is received by the

schedu led dead line. Req uests for consid eration

after the deadline w ill not be considered.

cuments that did not exist at the time of the

application deadline will not be accepted during

the appeals process.

derations th at app ly 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 t he

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 r esponsive to the actual reason s for

the LFC C deni al decision.

ch 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 infor-

mation. Local campaign contact in formation can

be found on the CFC website at

www.opm.gov/cfc/Search/Locator.asp.

a local application form is available, O PM sug-

gests that federations use the local application pro-

vided when applying to the Combined Federal

Campaign (CFC).

e CFC will not accept application forms with

modifications to any of the certification statements.

order to determine whether a federation may

participate in the campaign, the LFCC ma y request

evidence of corrective action regarding any prior

OPM Form 1647-D

Rev. August 2015

violation of regulation or directive, sanction, or

penalty, as appropriate. The LFCC will decide

whether the federation has demonstrated, to the

LFCC’ s satisfaction , th at th e 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 day s of the date of the request may result

in a recommendation that OPM withdraw

federation status. Th e Director’ s decision will be

communicated in writing to the federation.

DEFINITIONS

Federation Name of the applicant federation, as

it appears in the IRS Busin ess Master File. If the

name of the fed eration is differen t from the name

which appears on the IRS determination letter, IRS

Form 990, au dited 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 th is field blank.

Mailing Address A physical street address must

be provided - Post Office B ox add resses will not

be accepted.

Check the b ox b elow the ad d ress to den ote that it

is different from the address submitted with the

2015 CFC application.

Telephone Organization’s telephone number.

Con tact Person The contact p erson is the ind i-

vidual to whom the CFC will direct communica-

tions. This may be any individual in the organi-

zation.

Contact Title Self-explanatory

Con t act 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 ad dress.

Con tact T elep ho ne 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 encour-

aged to provid e more th an one email address.

Federation Website Address List one complete

Internet add ress of th e app licant fed eration (no e-

mail addresses). This information is required, if

the organization has an Internet add ress.

Disbursement Address List the address where

paper checks will be sent, if different from maili ng

address. Post office boxes may be used for the

disbursement address.

Electron ic Fu n ds T ran sfer (EF T ) Info rm a tion

Lis t the Routing and Account numbers , along with

the name of the finan cial institution, where fund s

should be disbursed. This i s an optional method for

receipt of CFC contributions. NOTE: Some

campaigns may elect not to disburse funds

electronically.

Certifying Official The certifying officia l is the

individ ual who has the au thority to affirm that all

statements in the appli cation 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 an d to certify it meets

the requirement. Failure to provide a check mark

for each of th e statements will be considered as a

OPM Form 1647-D

Rev. August 2015

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 2015 CFC) and each member

denied participation in the 2015 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 p articipation.

The list must include the following info rmat ion f or

the federation and each of its member

organizations applying for participation in the

CFC: five-digit CFC cod e 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

The federation is not required to indicate a local.

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 “DBA s”.

The 25-word statement should not repeat the

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

able), telephone number, website address, EIN,

and taxonomy codes will NOT count toward an

applicant’s 25 words. OPM will not be respons-

ible 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 under-

lining, 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 partici-

pation in the CFC must also be included in

Attachment A.

All of the ab ove information must be provided in

an Ex cel spreadsh eet sent to the local CF C office

via email. A model spreadsh eet 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 provid ed. Cat egories 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 Educatio n

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 Employment

K Food, Agricul t ure & Nutrition

L Housing & Shelter

M Public Safety, Disaster Prepared ness & Relief

N Recreation & Sports

O Yo ut h Devel opment

OPM Form 1647-D

Rev. August 2015

P Human Services

Q International, Foreign Affairs, & Natio nal Sec urity

R Civil Rights, Social Action & Advocacy

S Community Improvement & Capacity Building

T P hilanthropy, Voluntarism & Gra nt making

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-

tio n, quotations , and underli ning, are n ot acce pte d.

Any statement that uses special features or

exceeds 25 wo rds w il l 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

supp orting 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 a nd

each of its member organ ization s as well as D BA

(“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 m atch the EI N 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 o f 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.

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

accord ance w ith G enerally Accepted Aud iting

Standards (GAAS). No other basis of accounting

is acceptable und er Generally Accepted A ccount-

ing Principles (GAAP). The cash basis, modified

cash basis, and modified accrual basis are not

acceptable meth ods of accounting un der GAAP.

Include as Attachment C a copy of the 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 the

OPM Form 1647-D

Rev. August 2015

January 2016 (i.e. ending on or after June 30,

2014). The audited financial statements must

verify the federation is honoring designations

made to each member organization by distri-

butin g a p rop o rtion a te sha re o f receip ts b ased

on donor desig natio ns to ea ch memb er.

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 auditing firm.

Newly created fed erations operating for less than

one year (as d etermined from the date of th e IRS

determination letter to the closing date of the CFC

application period) are not required to submit

audited finan ci al 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 pri or to January 2016. 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

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

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

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 d oes 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); P art VII (Compensation section A only);

Part VIII (Statement of Revenues); Part IX

(Statement of Functional Expenses), and; Part XII

(Finan cial Statements and Reporting).

The IRS Form 990 and audited financial state-

ments must be prepared using th e accrual method

of accounting and cover the same fiscal period

ended not more than 18 months prior to January

2016 (i.e. ended on or after June 30, 2014).

Item 6

Calculate and enter the federation’s annual

percentage for administrat i ve and fundraisi ng

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 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 specifica lly

state that these services were donated.

Item 7

Each f ederatio n m ust includ e as Attachment E

OPM Form 1647-D

Rev. August 2015

a co mplete 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, 2009-2016). Attachment E must

also list the board’s meeting dates and locations

for the p reviou s calend ar 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 den ied,

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 o f the f edera-

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 y ear to which the federation is applying

or the preceding calendar year. A more frequently

published document, such as a quarterly

newsletter, may be substitu ted so long as it meets

the requirements for the annu al report.

The annual report or more frequently published

document must contain a full description of the

federation’s activities and supporting services

durin g the year covered by the report and identify

its directors and ch ief ad min istrative p erson nel.

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 ch aritable 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 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. person s

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 admini-

stered 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

person s on the S DN List are su bject to econ omic

sanctions. The SDN List and additional infor-

mation 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.

OPM Form 1647-D

Rev. August 2015

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

www.opm.gov/cfc/Search/Locator.asp.

REQUIRED ATTACHMENTS (failure to provide any of these may result in a denial)

 Attachment A

– federation membersh ip listing ( See Item 1)

 Attachment B – IRS d etermina tion letter (See Item 2)

 Attachment C – Aud ited Financial S tatements (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. August 2015

OMB APPROVED

NO.

3206-0131

COMBINED FEDERAL CAMPAIGN

2016 APPLICATION FOR

LOCAL FEDERATIONS

Federation: _________________________________________________________________

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

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

Mailing Ad dress:

__________________________________________________________________

(Pos t Off ice B ox addres se s are not acce pted and may r esul t in aut omati c di squal ifi cation. )

Check this box if the above address is different from the addre ss submitted with the 2015 CFC application:

Telephone Number ( )_____________________________________________________________

Contact P erson:

Contact Title:

Contact A ddress:

__________________________________________________________________

(

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 Ad dress: _________________________________________________________________

(This is the ad dress wh ere pap er checks will b e sent.)

Electronic Fu nds Transfer (EFT) information (Option al):

RTN (9 digits): __ ___________________ ACCT: _____________________

Financial Institution: _________________________________

OPM Form 1647-D

Rev. August 2015

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 a

substantial local presence in the geographic area served by the local campaign. 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 e ither it or its membe r 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 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 financ ial state me nts

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 designa tions 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.)

OPM Form 1647-D

Rev. August 2015

- 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 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 perc entag e 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 beg inning and ending da te of each board member’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 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 fe de ra tion n ame d in this a pplic a tion effec tively 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 t he U.S. Department of the Treasury’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 guidelines for each such sanctions program can be found

at http://www.treas.gov/ofac. Should any change in circumstances pertaining to this

OPM Form 1647-D

Rev. August 2015

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 ac cur acy. 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 Stat e ment

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both the instructions and completing the form. Send comm ents regarding our estimate or any other aspects of this form,

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