ࡱ> \f[|U@ `fbjbj ^-****zzzD###b$<$\N,%%%%,%12 2DDDDIEI=N$OR:RaNzM4.L1M4M4aN**%,%o vN<<<M4(*8%z,%D<M4D<Z<>CbzfD,%$ t9-#u4T"D"DDN0NDD"R5RDfD****RzfD 22^<2LG3222aNaN$#<#OMB APPROVED No. 3206-0131 Combined Federal Campaign 2004 Application Instructions for United Way of Jefferson County, WV, Inc. Background Enclosed is the model application for participation by local unaffiliated organizations in the Combined Federal Campaign (CFC). The following instructions and form are intended to assist charitable organizations in 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 each year. Applicants submitting missing, incomplete or out of date documents will not be permitted to correct their applications during the appeals process.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 will have one opportunity to appeal to the Local Federal Coordinating Committee (LFCC) for reconsideration. If found ineligible on appeal by the LFCC, the organization may appeal to the Director of OPM. The Director's decision is final for administrative purposes. Appellants should insure that their appeals 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. If a local application form is available, OPM suggests that the organization use the local application provided when applying to the Combined Federal Campaign. FAXES OR ELECTRONIC SUBMISSIONS OF APPLICATIONS ARE NOT ACCEPTED DEFINITIONS 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, IRS determination letter, audited financial statements, or annual report, 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. Mailing Address A physical mailing address must be provided - Post Office Box addresses will not be accepted. Contact Person The contact person is the individual to whom the CFC will direct communications. This may be any individual in the organization. E-Mail Self-explanatory Contact Address Contact Persons physical mailing address if different than the organization's address. Post Office Boxes may not be used. Telephone Number (including area code) Contact Persons number, if different than the organizations number. Internet Address List the complete Internet address of the applicant organization (no e-mail addresses). Certifying Official The certifying official is the individual who has the authority to affirm that all statements in the application are accurate. Item 1 Check the one appropriate box. If applying for local or adjacent eligibility, make sure you include information on your local presence, or local presence through your member organizations, 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 provide either a detailed description of the services and activities they provided to 30 percent of their target population in a given state or a detailed description of those activities covering 30 percent of the state's geographical boundaries, either directly or indirectly through their member organizations. 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 IRS 501(c)(3) letters that have expired will be accepted only with proof of application to the IRS for permanent 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 or its member organizations and how those programs, services, benefits, etc. affect the health and/or welfare of the target population. Item 5 If the organization is required to submit audited financial statements, the certifying official must verify that the organization uses the accrual method of accounting. A cash based accounting method will result in a denial. Small organizations 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. Combined and consolidated audits are not accepted unless the applicants financial information is reflected in a separate audited combining or consolidating schedule. 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 either on the IRS Form 990, Parts IV-A and IV-B, or by the independent certified public accountant who completed the audit in an accompanying signed statement. 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 recently completed, signed IRS Form 990. The IRS Form 990 must be signed on page 6 in the block marked Signature of officer. The preparers signature alone is not sufficient. A complete form 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 revenue and expenses on the two documents differ, these amounts must be reconciled either on the IRS Form 990, Parts IV-A and IV-B, or by the independent certified public accountant who completed the audit in an accompanying signed statement. IMPORTANT NOTE: For reconciliation, filling out Page 4 of the IRS Form 990 is preferred by the LFCC. LFCC's will not reconcile information that must be complete on submission. All IRS Forms 990 MUST be signed by an official of the organization. Several organizations 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 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.) Medicaid and Medicare 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 organizations 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 applicants governing boards officers and members and the dates, times and places of their meetings over the past year. Item 16 All charities, including Organizations, which apply for participation in the CFC must now certify that they do not knowingly employ individuals or contribute funds to organizations found on terrorist related lists promulgated by the U.S. Government, the United Nations, or the European Union. Presently, these lists include the Department of Treasury's Office of Foreign Assets Control Specially Designated Nationals List, the Department of Justice's Terrorist Exclusion List, and the list annexed to Executive Order 13224. Should any change in circumstances occur during the year OPM will be notified within 15 days of such change. The Office of CFC Operations will make available links to all relevant websites and also make available for review each year an updated copy of the Department of the Treasury's Office of Foreign Assets Control - Specially Designated Nationals List. Item 17 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 (EIN) regardless of whether or not they are operating under a "dba" (doing business as). The legal name listing and EIN will NOT count as part of the 25-word statement. An Internet 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 Internet addresses. E-Mail addresses are not accepted. Include in this attachment the 25-word statements for all member organizations. Special design text used to draw attention to a organization title, 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% IMPORTANT: All application information must be specific to the applicant organization. Regional and/or national materials will not be accepted for local chapters. OMB APPROVED NO. 3206-0131 Combined Federal Campaign 2004 Application for United Way of Jefferson County, WV, Inc. 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): ___ ___ ___ ___ Mailing Address:  (Post Office Box addresses are not accepted and may result in automatic disqualification.) Telephone Number (including area code): ____________________________________________ Contact Person:  E-Mail: Contact Address: (If different from the above address -- All OPM correspondence will be sent to this address.) Telephone Number (including area code): _______________________________________ Internet Address: __________________________________________________________ Certifying Official 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 either itself or through its member organizations. (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 substantial 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 either itself or through its member organizations. 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 either itself or through its member organizations. (Substantial statewide presence is defined as providing or conducting real services, benefits, assistance or program activities covering 30 percent of the states geographic boundaries or providing or conducting real services, benefits, assistance or program activities affecting 30 percent of the target population in the given state.) Include as ATTACHMENT A supporting statements and/or documentation of statewide presence. 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 verification from the IRS that the organization will continue with a 501(c)(3) ruling.) If the name of the organization is different from the name which appears on the IRS Form 990, IRS determination letter, audited financial statements, or annual report, 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 that directly or indirectly affect, human health and welfare. If a organization claims direct services, it must include supporting information that describes the human and welfare benefits provided within the previous years. Include as ATTACHMENT C supporting information that describes the health and welfare benefits provided within the previous year. 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. Combined and consolidated audits are not accepted unless the applicants financial information is reflected in a separate audited combining or consolidating schedule. An audit is not required for organizations with annual revenue of less than $100,000 on line 12 of the IRS Form 990. (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 and Audit must cover the same period. If revenue and expenses on the two documents differ, these amounts must be reconciled either on the IRS Form 990, Parts IV-A and IV-B, or by the certified public accountant who completed the audit in an accompanying signed statement.) -OR- I certify that the organization named in the application is a newly created organization and therefore is exempt from submitting an audit in accordance with generally accepted auditing principles by an independent certified public accountant. 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 and Audit must cover the same period. If revenue and expenses on the two documents differ, these amounts must be reconciled either on the IRS Form 990, Parts IV-A and IV-B, or by the certified public accountant who completed the audit in an accompanying signed statement.) 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 administrative 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 __________________________________. 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. 16) I certify that, as of _____date the organization named in this application does not knowingly employ individuals or contribute funds to organizations found on the following terrorist related lists promulgated by the U.S. Government, the United Nations, or the European Union. Presently, these lists include the Department of Treasurys Office of Foreign Assets Control Specially Designated Nationals List, the Department of Justices Terrorist Exclusion List, and the list annexed to Executive Order 13224. Should any change in circumstances occur during the year OPM will be notified within 15 days of such change. 17) 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 fundraising. 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. 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 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. The 25-word information for each member organization should also be included with this attachment. 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 officials signature must be original. Automatic pens and/or signature stamps may not be used. PAGE  OPM Form 1647-D Rev. 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