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

2016 CFC Application, Page 3 of 3

%. This

I certify that the administrative and fundraising rate for the organization named in this application is

percentage has been computed from information on the IRS Form 990 (or Pro Forma 990) submitted with this

application by adding the amount spent on "management and general" to "fundraising" and dividing the resulting

total by "total revenue."

Please enter the following figures from your Form 990 (or Pro Forma 990). The resulting AFR percentage will

automatically populate above:

1. Enter Management and General Expenses: __________________

(Form 990, Page 10, Line 25, Column C)

2. Enter Fundraising Expenses:

__________________

(Form 990, Page 10, Line 25, Column D)

3. Enter Total Revenue:

__________________

(Form 990, Page 9, Line 12, Column A)

If you are completing this form by hand, to calculate the AFR percentage you must use the instructions below:

Add items 1 and 2 and divide the sum by 3 (total revenue). Multiply the result by 100 to obtain a percentage figure, then round to the

nearest tenth (one figure to the right of the decimal). For example, 15.44% rounds to 15.4%; 15.45% rounds to 15.5%; exactly 15%

should be written as 15.0%. No other method may be used to calculate this percentage.

I certify that an active and responsible governing body, whose members have no material conflict of interest and a

majority of which serve without compensation, directs the organization named in this application.

I certify that the organization named in this application prohibits the sale or lease of CFC contributor lists.

I certify that the organization named in this application conducts publicity and promotional activities based upon its

actual program 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 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. Department of the Treasury’s

Office of Foreign Assets Control. The organization named in this application is aware that a list of countries

subject to such sanctions, a list of Specially Designated Nationals and Blocked Persons subject to such

sanctions,

and

overviews

and

guidelines

for

each

such

sanctions

program

can

found

Should any change in circumstances pertaining to this certification occur at any time,

the organization will notify OPM's Office of CFC Operations immediately.

CERTIFYING OFFICIAL

I, _______________________________, am the duly appointed representative of _______________________________

(Print Name)

(Print Organization)

authorized to certify and affirm all statements 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 statement, I acknowledge and

agree to comply with that certification.

___________________________

_____________________________

(Signature)

(Title)

___________________________

_____________________________

(Typed or printed name)

(Date)

Please print this form and sign it with an original signature. You will need to upload a scanned copy of the

signed Certifying statements. Electronic signatures, stamps, or images are not acceptable.

Applicant Contact Information Page 3

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