Fillable Printable OPM Form 1647E
Fillable Printable OPM Form 1647E
OPM Form 1647E
OPM Form 1647-E
Rev. September 2015
1
OMB APPROVED
No. 3206-0131
COMBINED FEDERAL CAMPAIGN
2016 Application Instructions for
Family Support and Youth Activities
BACKGROUND
Enclosed is the model application for use Family
Support and Youth Activities (FSYA), also know n
as Morale, Welfare and Recreation (MWR)
organizations,applying to participate in the
Combined Federal Campaign (CFC). An FSYA is
an organization that operates on a military base for
the benefit of the members of the military who
work or live on that. The following instructions
and form are intended to assist an FSYAin
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
websiteat www.opm.gov/cfc. Additional copies of
the application can also be downloaded from the
website.
All requ ired documents and attachments mu st 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 andall required
information is received by the scheduled
deadline. Requests for consideration after the
deadline will not be considered.
Applicants whose applications do not contain
required documents or who submitincomplete or
out-of-date documents will not be permitted to
correct their applications during the appeals
process.Organizations that apply for local
eligibility and are found ineligible will havean
opportunity to appeal to the Local Federal
Coordinating Committee (LFCC) for reconsider-
ation. If found ineligible on appeal by the LFCC,
the organization may appeal the LFCC’s decision
to the Director of the Office of Personnel
Management (OPM). The Director's decision is
final for administrative purposes. Appellants
should ensure th at their ap peals are complete and
responsive to the actual reasons for the LFCC
denial decision.
Each LFCC determines the application deadline
for organizations seeking local eligibility. Since
local dates will vary, please check with the local
CFC for local application deadlines and filing
information. Local campaign contact information
can be found on the CFC website at
www.opm.gov/cfc/Search/Locator.asp.
If a local application form is available, OPM
suggests that organizations use the local
application provided when applying to the CFC.
The CFC will not accept applicationforms with
modifications to any ofthe certification statements.
In order to determine whether an organizatio n may
participate in the campaign, the L FCC ma y request
evidence of corrective action regarding any prior
violation of regulation or directive, sanction, or
penalty, as appropriate. The LFCC will decide
whether the organization has demonstrated, to the
LFCC’ssatisfaction, that the organization has
taken appropriate corrective action. Failure to
demonstrate satisfactory corrective action or to
respond to the LFCC’s request for information
within 10 businessdays of the date of the req u est
may result in a recommendation to OPM that the
organization will not be included in the Charity
List.The Director’s decision will be communi-
cated in writing to the organization .
OPM Form 1647-E
Rev. September 2015
2
DEFINITIONS
Organization Legal name of the applicant
organization.
Employer Identification Number (EIN) The
nine-digit EIN that has been assigned to the
organization by the IRS.
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.
Mailing Address A physical mailing address
mus t be pr ovi ded -Post Office Box addresses will
not be accepted.
Teleph one Organization’s t elephone number.
Con tact Person The contact p erson is the ind i-
vidual to whom the CFC will directcommunica-
tions. This may be any individual in the organi-
zation.
Contact TitleSelf-explanatory
Contact Address Contact person’s physical
mailing address if different than the organization's
address. Post Office Boxes may be used.
Participationdecision letters and other CFC
communications will be sent to the contact person
atthis ad dress.
Con tact T elep ho ne Contact person’ s tel ephone
number, if different than the organization’s tele-
phone number.
Fax Contact person’s fax number.
Contact E-Mail Contact person’s electronic mail
address.Applicants are encouraged to provide
more than one email address.
Website AddressList onecomplete Internet
address of the applicant organization (no e-mail
addresses).This information is required, if the
organization has an Internet address.
Disbursement AddressList 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) In formation
Lis t the Routing and Account numbers, along wi th
the name of the finan cial institution, where fund s
should be disbursed. This is an optional method
for receipt of CFC contributions.NOTE: Some
campaigns mayelect not to disburse funds
electronically.
Certifying Official The certify ing official is the
individ ual who has the au thority to affirm that all
statements in the application are accurate.For
FSYAs, the certifying official must be
commander of the military installation or the
head of the Federal facility where the
organization is located.
INSTRUCTIONS
For details regarding CFC eligibility requirements
for FSYAs, refer to CFCregulations at 5 CFR §
950.204(c) on the CFC website at
www.opm.gov/cfc
.
Applicants must check the box next to cert ific at ion
statement #1 to demonstrat e agreementtocomply
withthe statement and to certifythat itmeets the
requirement. Failu re to provid e a check mark for
the statements will be considered a refusal to
certifyand will result in the denial of the
application.
Item 1
Each FSYAapplying 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 economic
OPM Form 1647-E
Rev. September 2015
3
sanctions.The SDN List and additional infor-
mation relating to the economic sanctions
programs that OF AC 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 C Memo 2005-13.
Item 2
Include as Attachment Aa copy of the letter
from the commanding officer of the military
installation certifyingthat the organization
meets the criteria in 5 C.F .R. §9 5 0 .2 04(d).
This certification letter must be completed
annually and dated on or after January 1 of the
campaign year to which the organization is
applying. The letter must certify that the organi-
zation meets the following criteria:
•The organization is a nonprofit, tax-exempt
organization that provides family service
programs or youth activity programs to
personnel in the Command or in the Federal
facility where the organization is located. The
activity does not receive a majority of its
financial support from appropriated fund s.
•The organization is a Non-Appro priat ed Fund
Instrumentality that supports the installation
MWR/FSYA p rogram.
•The organization has a high degree of integrity
and responsibility in the conduct of its affairs.
Contributions received are used effectiv ely for
the announced purposes of the organization.
•The organ izationis directed by the base Non-
Appropriated Fund Council or an active
voluntary board of directors which serves
without compensation and holds regular
meetings.
•The organization conducts its fiscal operations
in accordance with a detailed annual budget,
prepa red and appro ved at the beg inning o f the
fiscal year. Any significant variations from the
appro ved budget must have prior authorization
from the Non-Appropriated Fund Council or
the directors. The family support and youth
activities must have accounting procedures
available to an installation auditor and the
inspector general.
•The organ ization has a policy an dpractice of
nond iscrimination on th e basis of race, color,
religion, sex or national origin applicable to
persons served by the organization.
•The organization prepares an annual report
which includes a full description of the
organization’s activities andaccomplishments.
These reports are made available to the public
upon request.
Item 3
Include as Attachment B, a statement in 25
wo rds or less th at descri bes the organ izatio n’s
program activities. The statement should not
repeat the organ ization's name.The organization
must also provide the legal name as regist ered with
the IRS if th e organization does b usiness un der a
different name. All organizations must include
their IRS Employee Identification Nu mber (EIN)
regardless of whether or not they are operating
under a "dba" (“doing business as”). The
organization must also include a telephone number
that can b e reached from any location in the U.S .
and the organization’s administrative and
fundraising rate. The legal name, telephone
number, EIN, taxonomycodes (see below),and
administrative and fundraising rate will NOT count
as part of the 25-word statement. An Internet
address where information on the organization ca n
be obtained may be included and will not count
toward the 25 words. OPM will not be responsible
for incorrect Internet add resses. E-mail addresses
are not accepted.
Taxonomy Codes Each organization can
identify up to three categories, in priority order,
which most closely identify the type of mission,
services, and activities provided. The correspond-
ing letters will be printed in your organization’s
listing in the CFC charity list (see example below)
to assist don ors in id entifying charities by type of
service provided. Categories are derived from the
National Taxonomy of ExemptEntities (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
OPM Form 1647-E
Rev. September 2015
4
Disciplines
H Medical Research
I Crime & Legal Related
J Emplo yment
K Food, Agriculture & Nutrition
L Housing& Shelter
M Public Safety, Disaster Prepared ness & 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 &Grant making
Foundations
U Science & Technology Research Institutes,
Services
V Social Science Research Institutes, Services
W Public& SocietalBenefit
X Religion-Related
Y Mutual& Membership Benefit
Z Unknown
Special design text used to draw attention to an
organization 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 2 5 wo rds will be ed ited by the LF CC.
Organizations will be listed by their legal IRS
recognized name as it appears on the IRS
determination letter only unless the appropriate
legal documentation permitting otherwise is
provided with the application. See Item 2. The
format is as follows:
00000 Name of Organization (legal name of
organization, if applicable) (202)555-1234
www.opm.gov/cfc EIN#12-3456789 The
description will contain no more than 25 words. It
should be worded so the donor understands the
program services provided. B,V,O
Local CFC applications must be sent to the local campaignoffice.Do not send applications to the U.S.
Office of Personnel Management. Note that each campaign area sets its own application deadline. For
more information on the local application deadlines and addresses, please contact the Principal
Combined Fund Organization (PCFO) representative in your area. Contact information can be found
at
www.opm.gov/cfc/Search/Locator.asp.
OPM Form 1647-E
Rev. September 2015
5
OMBAPPROVED
NO.
3206-0131
COMBINED FEDERAL CAMPAIGN
2016APPLICATION FOR
FAMILY SUPPORT AND YOUTH ACTIVITIES
Organization:
Employer Identification Number (EIN): __ __ - __ __ __ __ __ __ __ __ __
5 Digit CFC Number (If a previous participant in the CFC): ___ ___ ___ ___ ___
Organization Address:
____________________________________________________________
(Pos t Off ice B ox addres se s are not acce pted and may r esul t i n aut omati c di squali fic ation.)
Telephone: ( ___ ) _________________________________________
Contact Person:
Contact Title:_________________________________________________________
Contact Address:
(If different from the above address – Post Office Boxes are acceptable for the Contact Address. All CFC
correspondence will be sent to this address.)
Contact Telephone: ( ___ )________________ Fax: ( ___)_____________________
Contact E-Mail Address:_________________________________________________________
Website Address(required, if available): ________________________________________
Disbursement A ddress:_________________________________________________________________
(This is the address where paper checks will be sent.)
Electronic Fu nds Tran sfer (EFT) information (O ptional):
Routing Number (9 digits): __ __ __ __ __ __ __ __ __
ACCT: ___________________________________________
Financial Institution: _________________________________
OPM Form 1647-E
Rev. September 2015
6
1) I certify that the organization named in this application is in compliance with all statutes,
Execu tive o rders, and regulations restricting or prohibiting U.S. persons from engaging in
transactions and dealings with countries, entities, or individuals subject to economic
sanctions administered by the U.S. Department of the Treasury’s Office of Foreign Assets
Control. The organization named in this application is 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 //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.
2) IncludeasATTACHMENT Athe letter from the comman der of the militar y insta llation or
the head of the Federal facility where the organization is located certifying that the
orga nizatio n mee ts the eligibility c rite ria outlin ed in 5 C.F.R. §950.204(d)(see application
instructions for a list of the eligibility criteria).
3) Include as ATTACHMENT Ba 25-word statement for listing in the campaign charity list.
(See I nstructions Item 3 for additional required information on the optional taxonomy codes.)
CERTIFYING OFFICIAL
I, ____________________________________, am the duly appointed representative
(Print Name)
of ____________________________________ authorized to certify and affirm all statements
(Print Organization Name)
enclosed in this application. I certify that I have read all the certifications set forth in this document
and affirm their accuracy . In addition, by checking the box next to the certification, the organization
named in this applicationacknowledgesand agrees to comply with that certification.
______________________________
(Signature)
______________________________
(Typed or Printed Name)
______________________________
(Title)
Date Completed ______________________ ______________________________
OPM Form 1647-E
Rev. September 2015
7
Public Burden Statement
We think this form
takes an av erage of 3 hours to complete, including the tim e for getting the n eeded data and re view in g
both the instructions and completing the form. Send comm ents regarding our estimate or any other aspects of this form,
including for reducing completion time to Office of Personnel Management (OPM), CFC Operations(3206-0131),
Washi ngton , DC 20415-7900. The OM B num ber 3206-0131 is currently valid. OPM may not collect this information,
and you are not required to respond, unless this number is displayed.
