Healthy Food Financing Initiative Questionnaire

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Overview

Contents
A
B1
B2
B3

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Sheet 1: Contents

HFFI-FA Data: Table of Contents
Chart	Description	Who Needs to Complete…
A	Matching Funds Summary	Optional for Applicants seeking HFFI- FA
B	Retained Earnings Calculator Charts * B1 for Non-Regulated CDFIs * B2 for Credit Unions * B3 for Banks, Thrifts, & Holding Companies	Optional for Applicants seeking HFFI-FA who are using Retained Earnings as Matching Funds.
	OMB No.: 1559-0040

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Sheet 2: A

A. Matching Funds Summary
Instructions: Detailed instructions and a sample chart can be found in the CDFI Program Guide to the Combined Application for Financial Assistance or Technical Assistance. Review those carefully and have Matching Funds documents available when completing this chart. Remember the following important points: 1) Fill in only one "Amount" column for each row. The date entry should correspond to the amount column and match status as explained in the Application instructions. 2) If the Matching Funds are from a state and/or local government agency, Applicants must provide the contact name, title, and phone number of the Matching Funds source in the far right column. Use same column for any additional comments relevant to the Matching Funds entry. 3) The appropriate Retained Earnings calculator (charts B1, B2, or B3) must be completed if the Applicant includes a Retained Earnings entry in this chart. 4) If additional rows are needed insert them in the middle of the table so that the "Total" formulas are automatically updated.
Type	Amount In-Hand	Amount Committed	Amount to be Raised	Date	Comments & Contact Data	Total
Equity Investment						$-
Grant						$-
Loan						$-
Secondary Capital						$-
Shares/Deposits						$-
Retained Earnings						$-
TOTALS	$-	$-	$-			$-
Equity Investment
Grant
Loan
Secondary Capital
Shares/Deposits
Retained Earnings

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Sheet 3: B1

	B1. Retained Earnings Calculator (Non-Regulated Entities)
	Instructions: This chart must be completed by any non-regulated (for- or non-profit) Applicant proposing to use retained earnings as a matching funds source. The Applicant must demonstrate in this chart that the proposed retained earnings meet the following criteria: (1) No federal funds are being proposed as part of the retained earnings. (2) Applicant is not double-counting match fund sources in Chart A (list of match fund sources). (3) Matching Funds meet applicable FY guidelines (see NOFA).
	The Applicant's electronic signature on SF-424 attests that all information reported in the Retained Earnings chart is accurate at the time of application. To the extent possible, the Fund will verify the table entries against the financial statements provided with the application. The information reported here is subject to audit; therefore, Applicant must be accurate in reporting Federal income and associated expenses.
	Non-regulated Applicants have two options for calculating Retained Earnings: (A) The increase in Retained Earnings over the Applicant's most recently completed fiscal year; or (B) The annual average increase in Retained Earnings over the Applicant's three most recently completed fiscal years.
	Fill out the data for each of the fiscal years.
		● Yellow cells automatically calculate based on entries made in the green cells. Complete green cells for each fiscal year using line items from the Applicant's financial statements and historical accounting records.
		● The chart assumes the Applicant's most recently completed fiscal year is 2009. If the most recently completed fiscal year is 2010, adjust the fiscal years by changing 2009 to 2010 – the other years will update automatically.
		● Rows A and E should be found on the Income Statements. Other rows may need to be calculated or researched from accounting records.
		● Itemize income associated with federal sources under Line B. Itemize income that the Applicant is also using as a source of match (as reported on Chart A) on line C. If additional rows are needed for reporting itemized data (Line B and Line C), add rows from middle of the section in order to maintain the sum formula on line B or C.
	A positive result in either of line J Col 3 or Line K Col 3 can be proposed as "Retained Earnings" match in Chart A.
		Col 1	Col 2	Col 3	Col 4
	Line	Financial Data	2007	2008	2009
	A	Total Operating Income/Revenue
	B	LESS Income from Federal Sources (Itemize source and amount in the lines below. Add additional lines as necessary)	$0	$0	$0
	C	LESS Income listed as Matching Funds on Chart A (Itemize source and amount in the lines below. Add additional lines as necessary)	$0	$0	$0
	D	Subtotal: Adjusted Operating Income/Revenue	$0	$0	$0
	E	Total Operating Expenses
	F	LESS Total Expenses Associated with Lines B and C (Itemize source and amount in the lines below. Add additional lines as necessary)	$0	$0	$0
	G	LESS Dividends Paid Out (For-profit CDFIs only)
	H	Subtotal: Adjusted Operating Expenses	$0	$0	$0
	I	TOTAL RETAINED EARNINGS (D-H)	$0	$0	$0
	Either Result Below Can Be Used for FY 2011 Application
	J	Retained Earnings Increase from Most Recent FYEnd		$0
	K	Three Year Average Retained Earnings Increase		$0

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Sheet 4: B2

B2. Retained Earnings (Credit Unions)
Overview: This chart must be completed by any credit union Applicant proposing to use retaining earnings as a source of matching funds. The Applicant's electronic signature provided upon submission of the SF-424 (application form) attests that all information reported in the Retained Earnings chart is accurate at the time of application. To the extent possible, the Fund will verify the table entries against the Applicant's 5300 Report data, including the PCA Net Worth Calculation Worksheet.
Options: Credit Unions have three options for calculating Retained Earnings: (A) The increase in Retained Earnings over the Applicant's most recently completed fiscal year; (B) The annual average increase in Retained Earnings over the Applicant's three most recently completed fiscal years; or (C) Retained Earnings accumulated since the Applicant's inception.
Eligibility: The Applicant must demonstrate in this chart that the proposed retained earnings meet the following criteria: (1) No federal funds are being proposed as part of the retained earnings. (2) Applicant is not double-counting match fund sources in Chart A (list of match fund sources). (3) Matching Funds meet applicable FY guidelines (see NOFA).
Tips on Filling out the Table
	● The chart assumes the Applicant's most recently completed fiscal year is 2009. If the most recently completed fiscal year is 2010, adjust the fiscal years by changing 2009 to 2010 – the other years will update automatically.
	● Complete green cells under each applicable column heading using line items from the Applicant's 5300 Call Reports and other historical accounting records. Yellow cells automatically calculate based on entries made in the green cells.
	● For options (A) or (B) fill in all four fiscal years of data (Col 2, 3, 4, and 5). For option (C), the "Since Inception" option, the Applicant need only complete column 5, the most recent FYEnd data to calculate the "Since Inception" amount.
	● Lines D and E are provided to help the Applicant back out the items mentioned in the Eligiblity section above. Itemize any federal sources on the lines below D. Itemize any funds that are reported on the Chart A Matching Funds request on lines below E. The entries will be totalled above. If additional rows are needed for reporting itemized data for Lines D and E, add rows from the middle of the section in order to maintain the sum formulas within the chart.
Additional Requirement for Option (C): For Insured Credit Unions using option (C), the Applicant must ALSO increase its member and/or non-member shares or total loans outstanding by an amount that is equal to the amount of Retained Earnings that is committed as Matching Funds by the end of the Awardee’s second performance period, as set forth in its Assistance Agreement. For example, if Retained Earnings since inception is equal to $50,000 and the Applicant designates the entire amount as match, the Applicant must increase its total member/non-member shares or loans outstanding by $50,000. Note the following:
	● The Fund will assess the likelihood of this increase during the application review process. An award will not be made to any Applicant that has not demonstrated that it has increased shares or loans by at least 25 percent of the requested FA award amount between December 31, 2008 and December 31, 2009, as demonstrated by the corresponding NCUA report.
	● An Applicant using option (C) must discuss its strategy for raising the required shares or loans in the Comprehensive Business Plan component of the FY 2011 application.
	Col 1	Col 2	Col 3	Col 4	Col 5
Line	Call Report and other Financial Data	2006	2007	2008	2009
A	Total Net Worth (from PCA Net Worth Calculation Worksheet)
B	LESS Uninsured Secondary Capital (from PCA…)
C	Subtotal Retained Earnings (A-B)	$0	$0	$0	$0
	Adjustments
D	LESS Federal Funds included in line C above. Itemize source and amount in the lines below. Add additional lines as necessary.	$0	$0	$0	$0
E	LESS Matching Funds on Chart A included in line C above. Itemize source and amount in the lines below. Add additional lines as necessary.	$0	$0	$0	$0
F	Subtotal of Adjustments (D+E)	$0	$0	$0	$0
G	Adjusted Retained Earnings (C-F)	$0	$0	$0	$0
H	Change Over Prior Year	N/A	$0	$0	$0
Any of the Results Below Can Be Used As Match:
I	Retained Earnings Increase from Most Recent FYEnd:			$0
J	Three Year Average Retained Earnings Increase:			$0
K	Retained Earnings Since Inception:			$0

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Sheet 5: B3

B3. Retained Earnings (Banks, Thrifts, and Holding Companies)
Instructions: This chart must be completed by any bank, thrift, holding company Applicant proposing to use retained earnings as a matching funds source. The Applicant must demonstrate in this chart that the proposed retained earnings meet the following criteria: (1) No federal funds are being proposed as part of the retained earnings. (2) Applicant is not double-counting match fund sources in Chart A (list of match fund sources). (3) Matching Funds meet applicable FY guidelines (see NOFA).
The Applicant's electronic signature on SF-424 attests that all information reported in the Retained Earnings chart is accurate at the time of application. The Fund will verify the table entries against the financial statements provided with the application or data on the FFIEC website. The information reported here is subject to audit; therefore, Applicant must be accurate in reporting Federal income and associated expenses.
Bank, thrift, and holding company Applicants have two options for calculating Retained Earnings: (A) The increase in Retained Earnings over the Applicant's most recently completed fiscal year; or (B) The annual average increase in Retained Earnings over the Applicant's three most recently completed fiscal years.
Fill out the data for each of the fiscal years.
	Yellow cells automatically calculate based on entries made in the green cells. Complete green cells for each fiscal year using line items from the Applicant's financial statements and historical accounting records.
	The chart assumes the Applicant's most recently completed fiscal year is 2009. If the most recently completed fiscal year is 2010, adjust the fiscal years by changing 2009 to 2010 – the other years will update automatically.
	Rows A and E should be found on the Income Statements. Other rows may need to be calculated or researched from accounting records.
	Itemize income and expenses associated with federal sources under Line B. Itemize income that the Applicant is also using as a source of match (as reported on Chart A) on line A. If additional rows are needed for reporting itemized data (Line B and Line C), add rows from middle of the section in order to maintain the sum formula on line B or C.
	A positive result in either of line J Col 3 or Line K Col 3 can be proposed as "Retained Earnings" match in Chart A.
	Col 1	Col 2	Col 3	Col 4	Col 5
Line	Call Report Data	2006	2007	2008	2009
A	Retained earnings (Line 16c from Holding Company report FR Y-9SP; line 20d from FR Y-9LP; Schedule RC, line 26a from Bank Call Report)
B	Accumulated other comprehensive income (Line 16d from Holding Company report FR Y-9SP; line 20e from TFR Y-9LP; Schedule RC, line 26b from Bank Call Report)
C	Other noninterest income (Schedule RI, TFR, line 5l from Call Report)
D	LESS Income from Federal Sources (Itemize source and amount in the lines below. Add additional lines as necessary)	$0	$0	$0	$0
E	LESS Income listed as Matching Funds on Chart A (Itemize source and amount in the lines below. Add additional lines as necessary)	$0	$0	$0	$0
F	Eligible Retained earnings for purposes of CDFI Program matching funds calculation	$0	$0	$0	$0
Either Result Below Can Be Used
G	Retained Earnings Increase from Most Recent Fiscal Year		$0
H	Three Year Average Retained Earnings Increase		$0
OMB No. 1559-0040