1a Guarantee Application - Appendix A-2A Certification Rega

Appendix: Examples of Document and Chart Formatting
A-2A-No Material Change Certification

Certification Regarding Material Changes to the Qualified Issuer Application
Organization Name:
EIN #:
Certification Control # (if available):
Instructions: This form is to be used by Applicants (including Qualified Issuers, proposed Program
Administrators, Servicers, and Eligible CDFIs) to report potential Material Changes to Qualified Issuer
Applications to the CDFI Fund.
Definition: A Material Change to the Qualified Issuer Application is an occurrence that affects an
organization’s strategic direction, mission, or business operation, its status as a certified Community
Development Financial Institution (CDFI) if applicable, and/or its submitted Qualified Issuer Application,
including previously submitted Assurances and Certifications.
Please check the appropriate box for the reporting entity as of the date this form is signed:
□ I certify that no Material Change(s) has occurred in the reporting entity since the date of its most recent
Qualified Issuer Application.
□ A Material Change(s) has (have) occurred in the above-named organization. I certify that the event(s)
listed below constitute all of such Material Changes (attach additional pages if needed).
Explanation of Material Changes
Please provide a narrative explanation regarding the Material Change affecting the organization
including, a timeline and the name and contact information of key people involved in the action.
Date of Material Change(s):
Explanation of Material Change(s):

To the best of my knowledge and belief, all information contained in this certification statement is true
and correct. My signature also indicates authorization on behalf of the organization’s governing body.

Signature of Authorized Representative
Printed Name:
Title:
Date:

OMB Control Number: 1559-0044