Fillable Applicant Contact Information (Page 2 of 3) in pdf

2016 CFC Application, Page 2 of 3

CFC C

ERTIFYING

TATEMENTS

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 country over the three-year period immediately

preceding the start of the campaign application year. (Include as ATTACHMENT A, a schedule listing those

states or foreign countries where the program activities have been provided over the last three (3)

calendar years and a detailed description of the activities, including the year in which those services were

provided, in each state or foreign country listed.)

- 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 ATTACHMENT A, a schedule listing each country where program

activities have been provided over the last three (3) calendar years and a detailed description of the

program activities, including the year in which those services were provided in each country listed.)

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).

(Include as ATTACHMENT B a copy of the most recent IRS determination letter.)

I certify that the organization named in this application is a human health and welfare organization providing

services, benefits, or assistance to, or conducting activities affecting human health and welfare. The services,

benefits, assistance, or program activities affecting human health and welfare provided in 2015 are reflected in

ATTACHMENT A.

I certify that the organization named in the application accounts for its funds on an accrual basis in accordance

with generally accepted accounting principles (GAAP) and has an audit of its fiscal operations completed annually

by an independent certified public accountant in accordance with generally accepted auditing standards (GAAS).

(Include as ATTACHMENT C a copy of the organization's most recent audited financial statements for a

fiscal period ending on or after June 30, 2014.)

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. (Include as ATTACHMENT D a copy of the complete IRS Form 990 for a

period ending on or after June 30, 2014, including signatures in the box marked “Signature of Officer”. 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 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 page 1 and Part V only for a period

ending on or after June 30, 2014. IRS Forms 990 EZ, 990PF, and comparable forms are not acceptable

substitutes.)

Download Pro Forma 990

Template.

Applicant Contact Information Page 2