2016 COMBINED FEDERAL CAMPAIGN

LOCAL FEDERATION - APPLICATION CHECKLIST

Applying Federation:______

1stReviewer: ______2nd Reviewer: ______3rd Reviewer: ______

Application Accepted
Application Denied
Reason: ______
______
Signature Date / LFCC Appeal Appeal Received: Yes No
Approved
Denied
Reason:
Signature Date / OPM AppealAppeal Received: Yes No
Approved
Denied
Signature Date

COMPLETENESS REVIEW: Signature on application form All certifications checked

CERTIFICATION STATEMENT #1–Attachment A: Certification of Federation’s Members

At least 15 members Five digit codes Legal names DBA’s where applicable Telephone numbers
Website addresses EIN’s 25 Word Statements Administration & Fundraising percentages
Taxonomy codes Physical mailing addresses

CERTIFICATION STATEMENT #2 –Attachment B: IRS Determination Letter for the federation and each member

Recognized by IRS as a 501(c)(3) tax exempt organization. If name on the IRS letter differs from the Form 990
and/or the audit, official government documentation(State or Federal) is required at Attachment Bauthorizing name
change,or DBA name (if applicable)

IRS letter is for Applicant

IRS ltr is a Group Ruling (list of covered eligible agencies must be attached, or a CEO Ltr required)

IRS ltr is for an agency that is a Bona-Fide Chapter or Affiliate operating under a national organization’s single

corporation tax exemption (CEO Ltr required)

Note: CEO Ltr certifies that agency is in good standing and is covered by national organization’s tax-exempt status

Verified as currently holding 501(c)(3) status per OPM Charity Registry System

CERTIFICATION STATEMENT #3–Human Health and Welfare Certification

CERTIFICATION STATEMENT #4 –Attachment C: Audit, if required (year ending on or after June 30, 2014)

Verify audit signed by audit firm on audit firm letterhead:

GAAP/GAAS Yes / No (circle) Audit at Attachment C

Contains statement that Federation honors designations made to its members

or

Federation official certifies it is a newly created federation operating for less than one year (as determined from the

date of the IRS determination letter to the closing date of the CFC application period)

CERTIFICATION STATEMENT #5 –Attachment D: IRS Form 990 (year ending on or after June 30, 2014)

Organization submits an annual IRS Form 990 (Complete Form 990including all attachments at Attachment D)

If organization is not required to submit a Form 990 to IRS, must submit a pro-forma Form 990 at Attachment D

Name and EIN match IRS tax-exempt letter or DBA Yes / No (circle)

Dated same fiscal period as audit Yes / No (circle)

“Accrual” box in Form 990, Part XI, must be checked

Board of directors is listed in Part VII, number listed matches Part I Line 3 and a majority are not compensated

Form 990 includes signature of officer(tax preparer’s signature alone not sufficient)

Note: IRS Forms 990EZ, 990PF, and comparable forms are not acceptable substitutes for Federation application

CERTIFICATION STATEMENT #6 –Administration/Fundraising ExpensesVerify Federation’s calculation

Add management & general and ______
fundraising+______= ______Total
Enter total revenue ______
Divide total line by revenue line. The result is the percentage overhead: ______%(one digit after the decimal)

CERTIFICATION STATEMENT #7 – Attachment E: Board of DirectorsListing must show

Complete listing of board of directors includingbeginning and ending dates for term of office

Board meeting dates and locations for prior Calendar Year (CY)

CERTIFICATION STATEMENT #8 – Certification that sale or lease of donor list prohibited

CERTIFICATION STATEMENT #9 – Organization conducts truthful and non-deceptive practices

CERTIFICATION STATEMENT #10 – Organization effectively uses funds for its announced purposes

CERTIFICATION STATEMENT #11 – Organization does not use outside services in policy/decision-making functions

CERTIFICATION STATEMENT #12 –AttachmentF: Annual Report

Include most recent copy of Annual Report (AR) at Attachment F that describes:

Activities & services

Member fees and/or services charges levied on members

Identifies directors/governing body, and chief administrative personnel

or

If organization does not publish an AR, a more frequently published document, such as a quarterly newsletter, may

be substituted so long as it meets the requirements for the AR

CERTIFICATION STATEMENT #13 – Sanctions compliance

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NOTES