> ![](media/image1.png)Combined Federal Campaign

**2002 Application Instructions for**

**Local Unaffiliated Organizations**

### Background

Enclosed is the model application for participation by local
unaffiliated organizations in the Combined Federal Campaign. The
following instructions and form are intended to assist charitable
agencies applying for participation in the CFC. All aspects of the CFC,
including eligibility for participation, are strictly governed by
Federal regulation. Copies of current CFC regulations are available in
Adobe Acrobat PDF and Word on our website at www.opm.gov/cfc. Additional
copies of the application can also be downloaded from the website.

All required documents and attachments must be complete and submitted
before the application deadline. ***Applicants submitting missing,
incomplete or out of date documents will not be permitted to correct
their applications during the appeals process*.** All organizations that
apply for local eligibility and are found ineligible have ***one***
opportunity to appeal to the LFCC. If found ineligible on appeal by the
LFCC they will have ***one*** opportunity to appeal to the Director of
OPM. The Director\'s decision is final for administrative purposes.
Appellants must be complete and responsive to the actual reasons for the
LFCC denial.

If a local application form is available, OPM suggests that
organizations use the local application provided when applying to the
Combined Federal Campaign (CFC).

**Organizations that apply as a member of a federation must submit their
application through the auspices of the federation. All eligibility
decisions will be sent to the federation. Please be sure to check with
your federation directly about your status.** *If the organization is a
member of a federation this application must be kept on record by the
federation. This is an annual process. The LFCC or OPM may request the
full application of a member organization at anytime.* **Only
[unaffiliated]{.underline} organizations will be contacted directly by
the LFCC**. If you apply as a member of a federation, please ***[DO
NOT]{.underline}*** send the LFCC an unaffiliated application. If two
applications are received, the federation application will not be
considered.

**FAXES OR ELECTRONIC SUBMISSIONS OF APPLICATIONS ARE NOT ACCEPTED**

### Instructions

**Organization**

Legal name of the applicant organization. (If the name of the
organization is different from the name which appears on the IRS Form
990, official documentation authorizing this name change must accompany
the application. The Federal Tax ID Number must be included.)

**4 Digit CFC No**.

The number assigned to the organization in the previous year\'s
campaign, if applicable.

**Address**

Self-explanatory - Post Office Box addresses will not be accepted.

**Telephone**

Self-explanatory

**Contact Person**

Self-explanatory

**E-Mail Address**

Self-explanatory

**Address**

Contact person address if different than the organization\'s address.
Post Office Boxes may not be used.

**Telephone**

Of contact if different than organization.

**Home Page Address**

List the complete Internet address of the applicant organization. (no
e-mail)

Certifying Official Self-explanatory

**Item 1**

Check the one appropriate box. If applying for local or adjacent
eligibility make sure you include information on your local presence
such as office location, hours of operations, etc. **If applying for
statewide eligibility make sure to include proof of statewide coverage
as *Attachment A*.** Organizations applying for statewide eligibility
[must]{.underline} provide a [detailed description]{.underline} of the
services and activities they provided to 30 percent of their target
population in a given state population **or** in a geographic area 30
percent of the state\'s geographical boundaries.

#### Item 2 

**Include as *Attachment B* the most recent IRS determination letter.**
Also include a letter from the IRS or other state issued documentation
authorizing any legal name change. *Interim 501(c)(3) letters with
expiration dates beyond 12/31 will be accepted only with documentation
from the IRS showing the agency will continue its 501(c)(3) status.*)

**Item 3**

Check the one appropriate box.

**Item 4**

**Include as *Attachment C* a detailed description of the programs,
services, benefits, etc. provided by the organization and
[how]{.underline} those programs, services, benefits, etc. affect the
health and/or welfare of the target population.**

**Item 5**

If the agency is required to submit audited financial statements, the
certifying official must verify that the agency uses the accrual method
of accounting. ***A cash based accounting method will result in a
denial.*** Small agencies that are not required to submit audited
financial statements may use a cash or modified cash method of
accounting to prepare their IRS Form 990.

**Item 6**

**Include as *Attachment D* a copy of the organization\'s annual audit.
Compiled audits are not accepted because they do not break out
individual figures for the applicant organization.** Consolidated audits
must include a separate section on the applicant. *The audit must cover
the fiscal period ending not more than 18 months prior to the January of
the campaign year to which the organization is applying. The IRS Form
990 and audit must cover the same fiscal period. If revenue and expenses
on the two documents differ, these amounts must be reconciled by a
certified public accountant in either an accompanying signed statement
or in the IRS Form 990, Parts IV-A & IV-B.*) ***An audit is not required
for organizations with annual revenue of less than \$100,000 on line 12
of the IRS Form 990.***

**Item 7**

**Include as *Attachment E* a copy of the [most]{.underline}
[recently]{.underline} [completed]{.underline} signed IRS Form 990.**
The IRS Form 990 must be signed on page 6 in the block marked "Signature
of officer". **The preparer's signature alone is not sufficient.** A
complete Form 990 includes all supplemental statements, if applicable,
for the applicant organization. *A completed Form 990 is required to be
eligible for the CFC even if the Internal Revenue Service does not
require your organization to file the Form 990. IRS Forms 990EZ, 990PF,
and comparable forms will not be accepted. However, smaller
organizations that file Form 990EZ may submit it with pages 1 & 2 of the
Form 990 attached. The IRS Form and audit must cover the same period. If
the revenue and expenses on these two documents differ, a certified
public accountant must reconcile these amounts.*

**[IMPORTANT NOTES:]{.underline}**

For reconciliation, filling out Page 4 of the IRS Form 990 is preferred
by the LFCC. LFCC\'s will not do calculations to reconcile information
that must be complete on submission. All IRS Forms 990 MUST be signed on
page 6 in the block marked "Signature of officer". Several organizations
have used cash basis accounting for their IRS Forms 990 and accrual
basis of accounting for their audits. While these organizations may be
able to reconcile the differences, two different methods of accounting
will not be accepted.

**Item 8** Check the one appropriate box. The annual percentage for
administrative and fundraising expenses is computed ***only*** from IRS
Form 990 by adding the amount spent on \"management and general\" (line
14) to \"fundraising\" (line 15) and the dividing the resulting total by
\"total revenue\" (line 12). **If the annual percentage for
administrative and fundraising expenses is greater than 25.04%, include
as *Attachment F* a detailed justification of the organization\'s
administrative and fundraising expenses and a formal plan to reduce
expenses to 25% or less.** Failure to separately submit an acceptable
justification and plan for reducing expenses may result in a denial.

**Item 9**

Self-explanatory

**Item 10**

Self-explanatory

**Item 11**

Self-explanatory

**Item 12**

Self-explanatory

**Item 13**

Fill-in name of State or Entity.

**Item 14**

Organizations receiving over 80% of revenue from government sources are
not eligible to participate in the CFC. Sign only if revenue from
government sources, line 1c on IRS Form 990 is 80% or less of line 12 of
IRS Form 990. (Divide line 1c by line 12.) Medicare and Medicaid do not
apply.

**Item 15**

**Include as *Attachment G* a copy of the organization\'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
year to which the organization is applying or the preceding calendar
year**. It must contain a full description of the organization's
activities and supporting services and identify its directors and chief
administrative personnel**.) Attachment G should also include
information about the terms of office for the applicant's governing
board's officers and members and the dates, times and places of their
meetings over the past year.*

**Item 16**

**Include as *Attachment H*, a statement in 25-words or less that
describes real services, benefits or program activities the organization
provides.** The statement should not repeat the organization\'s name,
but must include the legal name as registered with the IRS if the
organization does business under a different name. All organizations
must include their IRS Employee Identification Number regardless of
whether or not they are operating under a \"dba\". The legal name
listing an EIN will NOT count as part of the 25-word statement. An
Internet web page address where information on the organization can be
obtained may be included and will not count towards the 25 words. (OPM
will not be responsible for incorrect web page addresses). E-Mail
addresses are not accepted.

Special design text used to draw attention to an organization, such as
special fonts, capitalization, quotations, and underlining, are not
accepted. **Any statement that uses special features, or exceeds 25
words will be edited by the LFCC.** Organizations will be listed by
their legal IRS recognized name as it appears on the IRS Form 990 only
unless the appropriate legal documentation permitting otherwise is
provided with the application. The appropriate format is as follows:

# 0000 Name of Organization 202-555-1234 www.opm.gov/cfc (Legal Name of Organization, if applicable) EIN 123456789 The description will contain no more than 25 words. It should be worded so the donor understands the program services provided. 4.2%

NOTE: All application information must be specific to the applicant
organization. Regional and/or national materials will not be accepted
for local chapters.

## 

## Combined Federal Campaign

**[2002 Application for]{.smallcaps}**

**[Local Unaffiliated Organizations]{.smallcaps}**

Organization:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(If the name of the organization is different from the name which
appears on the IRS*

*Form 990, official documentation authorizing this name change must
accompany the application.*

*The Federal Tax ID Number must be included.)*

4 Digit CFC Number (If a participant in the last year\'s CFC): **\_\_\_
\_\_\_ \_\_\_ \_\_\_**

Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> *(Post Office Box addresses are not accepted and may result in
> automatic disqualification)*

Telephone:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact Person:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

E-Mail:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(If different from the above address \-- All OPM correspondence will be
sent to this address)*

Telephone:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Internet Home Page Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Certifying Official]{.smallcaps}**

I,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
am the duly appointed representative

> *(Name)*

of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
authorized to certify and affirm all statements

> *(Organization)*

enclosed in this application.

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> *(Signature)*
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> *(Typed or Printed Name)*

Date Completed \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> *(Title)*

NOTE: All application information must be specific to the applicant
organization. Regional and/or national materials will not be accepted
for local chapters.

1\) Place a check in the ***one*** appropriate box:

I certify that the organization named in the application has a
substantial local presence in the geographical area covered by the local
campaign. *(Substantial local presence is defined as a staffed facility,
office or portion of a residence dedicated exclusively to that
organization, available to members of the public seeking its services or
benefits. The facility must be open at least 15 hours a week and have a
telephone dedicated exclusively to the organization.)*

Include as ATTACHMENT A supporting statements and/or documentation of
local presence.

-OR-

> I certify that the applicant organization named in the application has
> a substantial local presence in the geographical area covered by an
> adjacent local campaign. **Include as ATTACHMENT A supporting
> statements and/or documentation of adjacent presence.**

-OR-

> I certify that the organization named in the application has a
> substantial statewide presence. *(Substantial statewide presence is
> defined as providing or conducting real services, benefits, assistance
> or program activities covering 30 percent of the state's geographic
> boundaries* **or** *providing or conducting real services, benefits,
> assistance or program activities affecting 30 percent of the state's
> population targeted for services.)* **Include as *Attachment A*
> supporting statements of local statewide presence.**

2)  I certify that the Internal Revenue Service recognizes the
    organization 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. **Include a copy of the most recent IRS determination
    letter as *Attachment B*.** *(Interim 501(c)(3) letters with
    expiration dates beyond 12/31 will be accepted only with
    documentation from the IRS showing the organization will continue
    its 501(c)(3) status.)* If the name of the organization is different
    from the name which appears on the IRS Form 990, official
    documentation authorizing the name change must accompany the
    application. *The Federal Tax ID Number must be included.*

3\) Place a check in the ***one*** appropriate box:

> I certify that the expenses of the organization named in this
> application connected with lobbying and all attempts to influence
> voting or legislation at the local, State or Federal level would
> classify it as a tax-exempt agency under 26 U.S.C. 501(h).

\- OR -

I certify that the organization named in this application does not
engage in lobbying nor does it attempt to influence voting or
legislation at the local, State or Federal level.

4\) 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. **Include
> as *Attachment C* documentation describing the human health and
> welfare benefits.**

5)  I certify that the organization named in the application accounts
    for its funds in

accordance with generally accepted accounting principles (GAAP).

6)  I certify that the organization named in the application was audited
    in accordance with

generally accepted auditing standards (GAAS) by an independent certified
public accountant in the immediately preceding year. **Include a copy of
the organization\'s *most recently completed* audit as *Attachment D*.**
Compiled audits are not accepted. Consolidated audits must contain a
separate audited section on applicant. (*The audit must cover the fiscal
period ending not more than 18 months prior to the January of the
campaign year to which the organization is applying. The IRS Form 990
and audit must cover the same fiscal period. If revenue and expenses on
the two documents differ, these amounts must be reconciled by a
certified public accountant either in an accompanying signed statement
or IRS Form 990,*

*Parts IV-A & IV-B.*)

-OR-

I certify that the organization named in the application has annual
revenue less than \$100,000 and therefore is exempt from submitting an
audit in accordance with generally accepted auditing principles by an
independent certified public accountant. (Annual revenue is determined
by line 12 of the IRS Form 990).

7\) **Include as *Attachment E* a copy of the *most recently completed*
IRS Form 990, *including signature*.** (***NOTE:** If the Internal
Revenue Service does not require your organization to file the Form 990,
you **must still complete** one in accordance with IRS regulations to be
eligible for the CFC. IRS Forms 990 EZ, 990PF, and comparable forms are
not accepted. However, smaller organizations that file Form 990EZ may
submit it with pages 1 & 2 of the Form 990 attached. The IRS Form 990
and audit must cover the same period. If the revenue and expenses on
these two documents differ, the reconciliation must be included in the
IRS Form 990 itself or include a letter of reconciliation submitted by
the CPA who completed the audit.*)

8\) Place a check in ***one*** appropriate box:

I certify that the organization named in this application in the
immediately preceding year has spent 25% or less of its total support
and revenue on administrative and fund-raising expenses. The actual
percentage of administrative and fund-raising expenses is \_\_\_\_\_\_%.
This percentage must be computed from information on the IRS Form 990 by
adding the amount spent on \"management and general\" (line 14) to
\"fundraising\" (line 15) and dividing the resulting total by \"total
revenue\" (line 12).

OR --

I certify that the organization named in this application in the
immediately preceding year has spent in excess of 25% of its total
support and revenue on administrative and fund-raising expenses. The
actual percentage of administrative and fund-raising expenses is
\_\_\_\_\_\_\_ % and this percentage is reasonable under the
circumstances. **Include as *Attachment F* a detailed justification of
the organization\'s management, general and fundraising**

**expenses and a formal plan to reduce expenses to 25%.**

9\) I certify that an active and responsible governing body directs the
organization named in this application whose members have no material
conflict of interest and a majority of which serve without compensation.

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

11) I certify that the organization named in this application conducts
    publicity and promotional activities based upon its actual programs
    and operations, that these publicity and promotional activities are
    truthful and non-deceptive, include all material facts, and make no
    exaggerated

> or misleading claims.

12\) I certify that the organization named in this application
effectively uses the funds contributed by Federal personnel for its
announced purposes.

13\) I certify that the organization named in this application is
chartered/incorporated under a governmental entity. This entity or State
is \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

14\) I certify that the organization named in this application has in
the preceding year received no more than 80 percent of its total support
and revenues from government sources. (Revenue from government sources
must be computed from the IRS Form 990 by dividing line 1c by line 12.)

15\) I certify that the organization named in this application prepares
and makes available to the public an annual report that includes a full
description of the organization\'s activities and supporting services
and identifies its directors/governing body and chief administrative
personnel. **Include as *Attachment G* a copy of the 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
year to which the organization is applying or the preceding calendar
year*.) *Attachment G should also include information about the terms of
office for the applicant's governing board's officers and members and
the dates, times and places of their meetings over the past year.*

16) 25-Word Statement for listing in the campaign brochure. **Include as
    *Attachment H* a**

**statement of *25 words or less* describing the program of the
organization and the percentage of its total support and revenue that
goes to administration and fund-raising.** Also, provide a telephone
number that can be reached from any location in the U.S. The 25-word
statement should describe real services, benefits or program activities
the organization provides. The organization\'s ratio of total support
and revenue to administration and fundraising also will appear in the
25-word statement, but does not count toward the 25-word limit. The
statement provided by the organization should not repeat the
organization\'s name, but must include the legal name as registered with
the IRS [if the organization does business under a different
name]{.underline}. This will **NOT** count as part of the 25-word
statement. The statement must include the IRS Employee Identification
Number, which will not count as part of the 25 words. An Internet web
page address where information on the organization can be obtained may
be included and will not count toward the 25 words. E-Mail addresses are
not accepted. Please see the local unaffiliated application instructions
for a sample 25-word statement.

I CERTIFY THAT I HAVE READ ALL THE CERTIFICATIONS SET FORTH IN THS
DOCUMENT AND THAT MY SIGNATURE BELOW SIGNIFIES THAT I ACKNOWLEDGE AND
AGREE WITH SUCH CERTIFICATIONS.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# Certifying Official\'s Signature & Title

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# Date

**NOTE:**

**Applications will not be accepted if submitted electronically or by
facsimile.**

**The certifying official's signature must be original.**

**Automatic pens and/or signature stamps may not be used.**

**Public Burden Statement**

We think this form takes an average of 3 hours to complete, including
the time for getting the needed data and reviewing both the instructions
and completing the form. Send comments regarding our estimate or any
other aspects of this form, including suggestions for reducing
completion time to Office of Personnel Management (OPM), Reports and
Forms Manager, Paperwork Reduction Project (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.