Form CDFI-0019 CDFI Fund Community Development Entity Certification App
New Markets Tax Credit (NMTC) Program--Community Development Entity (CDE) Certification Application
1559-0014 - New Markets Tax Credit Program Community Development Entity Certification Application
New Markets Tax Credit (NMTC) Program - Community Development Entity (CDE) Certification Application
OMB: 1559-0014
Community Development
Financial Institutions
Fund
-
CDE Certification
Application
(November 2019)
PAPERWORK REDUCTION ACT NOTICE
CDFI -0019
OMB Control Number 1559-0014
This submission requirements package is provided to applicants for Community Development Entity (CDE) certification under the New Markets Tax Credit (NMTC) Program. Applicants are not required to respond to this collection of information unless it displays a currently valid OMB number. The estimated average burden associated with this collection of information is four hours per applicant. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Certification, Compliance Monitoring and Evaluation Program Manager, Department of the Treasury, Community Development Financial Institutions Fund, 1500 Pennsylvania Avenue, Washington, DC 20220.
CDFI FUND MISSION
The mission of the Community Development Financial Institutions Fund (the CDFI Fund) is to expand economic opportunity for underserved people and communities by supporting growth and capacity of a national network of community development lenders, investors, and financial service providers.
WHAT IS A COMMUNITY DEVELOPMENT ENTITY (CDE)?
A Community Development Entity (CDE) is a domestic corporation or partnership that is an intermediary vehicle for the provision of loans, investments, or financial counseling in Low-Income Communities (LICs), under the New Markets Tax Credit (NMTC) Program.
CDE CERTIFICATION DESIGNATION
An entity seeking CDE certification must submit a CDE Certification Application to the CDFI Fund as directed herein. To qualify as a CDE, an Applicant CDE must at the time of application submission:
Be a legally established entity and a domestic corporation or partnership for Federal tax purposes;
Have a primary mission of serving or providing investment capital to LICs or Low-Income Persons; and
Establish accountability to LICs through representation on its governing or advisory board.
Through the CDE Certification Application, an entity may apply for certification solely on its own behalf, or on behalf of itself and one or more Subsidiary Applicants, provided that each applicant entity is legally established at the time of application. Each entity and subsidiary entity seeking CDE certification must have a valid Employer Identification Number (EIN) at the time the CDE Certification Application is submitted.
NOTE: Community Development Financial Institutions (CDFIs) and Specialized Small Business Investment Companies (SSBICs) seeking CDE certification automatically qualify as CDEs and do not need to complete a full Certification Application. Such entities should provide basic organization information to be established in the CDFI Fund’s Award Management Information System (AMIS).
NOTE: Subsidiaries and Affiliates of certified CDEs, CDFIs, and SSBICs do not automatically qualify as CDEs. The parent CDE must submit this CDE Certification Application to have its Subsidiary entities certified as CDEs.
NOTE: Section 7701(a)(4) of the Internal Revenue Code defines "domestic" when applied to a corporation or partnership to mean created or organized in the United States or under the law of the United States or of any State unless, in the case of a partnership, the Secretary provides otherwise by regulations.
Organizations incorporated in US territories are not considered "domestic" corporations or partnerships for the purpose of this definition.
CDE CERTIFICATION BENEFIT
Benefits of being certified as a CDE include being able to apply to the CDFI Fund to receive a New Markets Tax Credit (NMTC) allocation to offer its investors in exchange for equity investments in the CDE and/or its subsidiaries; or to receive loans or investments from other CDEs that have received NMTC allocations.
New Market Tax Credit Program
Under the NMTC Program, taxpayers may claim a credit against Federal income taxes for Qualified Equity Investments made to acquire stock or other capital interests in designated CDEs. Substantially all of the Qualified Equity Investments must be used by the CDE to, among other things, make loans to, or equity investments in, qualified businesses or CDEs operating in Low-Income Communities.
The investor (either the original purchaser or a subsequent holder) receives a tax credit for a seven- year period equal to five percent of the total amount paid for the stock or capital interest, at the time of purchase, for each of the first three years, and six percent annually for the remaining four years.
Applying for NMTC Allocations
The CDFI Fund allocates NMTC authority to for-profit and non-profit CDEs through a competitive application process pursuant to a Notice of Allocation Availability (NOAA) published in the Federal Register. NMTC Allocation Application materials and guidance are available from the CDFI Fund’s website. For-profit CDE NMTC Allocation awardees can provide their investors the tax credit in exchange for stock or capital interests. A Non-profit CDE NMTC Allocation awardee must demonstrate to the CDFI Fund, prior to receiving an Allocation Agreement, that: 1) it controls one or more for-profit Subsidiary CDE(s); and 2) it intends to transfer the entire NMTC Allocation to its for- profit Subsidiary CDE(s).
For-profit and non-profit entities that do not apply to the CDFI Fund for NMTC Allocations may obtain CDE certification in order to receive Qualified Low-Income Community Investments from for-profit CDE NMTC Allocation recipients.
MAINTAINING CDE CERTIFICATION
Each CDE NMTC Allocation awardee, as well as CDEs that are recipients of Qualified Low-Income Community Investments (QLICIs) from other CDEs, may be required to annually certify to the Fund that it continues to meet the Primary Mission and Accountability requirements by providing the information below. The Fund may revoke a CDE’s certification if it fails to provide the requested information.
Information indicating that the entity remains accountable to the LIC(s) it is serving; and
A certification statement certifying that no material changes have occurred to affect their current status as a CDE.
APPLICATION PROCESS OVERVIEW
Application Completion Steps:
Carefully review the following documents from the CDFI Fund’s CDE Certification webpage:
The CDE Certification Guidance as published in the Federal Register; and
The CDE Certification Frequently Asked Questions document.
Review the CDE Certification Application and supplemental CDE Certification Application Webinar Presentation materials provided on the CDFI Fund’s CDE Certification page located at www.cdfifund.gov.
Refer to guidance on how to access and use the Awards Management Information System (AMIS), the CDFI Fund’s online portal.
Create or access an existing account for the Applicant entity in AMIS.
Review and, if needed, update the Applicant’s Employer Identification Number (EIN) at the Applicant’s organization detail page in its account in AMIS. Each CDE Certification Applicant must have its own valid EIN and be a legal entity at the time it submits the CDFI Certification Application.
Review and, if needed, update the Applicant’s contact information at its organization detail page in AMIS. An Applicant MUST have at least one Authorized Representative identified in its online CDFI Fund account in order to submit the completed CDE Certification Application. Any of the contacts listed in the Applicant’s online account can fill out the CDFI Certification Application, but only a contact designated as an Authorized Representative will be able to submit it.
Make sure the Applicant’s email system and firewalls are set to accept messages generated by AMIS. For assistance with this, contact the AMIS Help Desk via an AMIS Service Request.
Applicants must provide additional Basic Information and Legal Entity documentation for relevant Subsidiaries in the Applicant’s account in AMIS and/or within the CDE Certification Application.
Follow the instructions provided in each section of the CDE Certification Application to submit a complete application package.
Additional Questions and Resources: Please contact the CDFI Fund staff if you have questions regarding the CDE Certification application. CDFI Fund staff can be contacted by telephone at (202) 653-0423 and by e-mail at ccme@cdfi.treas.gov. Information regarding the CDE Certification application and process can also be obtained by visiting the CDFI Fund’s CDE Certification webpage.
Faxed or E-mailed Certification Applications WILL NOT be accepted without prior approval.
BASIC INFORMATION – APPLICANT CDE
Select the Application Type being submitted (check one):
Type A: An Applicant CDE that is applying for initial CDE certification only on behalf of itself.
Type B: An Applicant CDE that is applying for initial CDE certification on behalf of itself and one or more subsidiary entities.
Type C: An Applicant CDE, which is already certified, that is applying for CDE certification on behalf of one or more subsidiary entities.
Enter Name of Applicant CDE:
Is the Applicant CDE already certified as a CDE? YES NO
If yes, provide the CDE Certification Application Control Number of the Applicant CDE will be auto-populated: _
Enter the number of Subsidiary Applicant(s) submitted under this application, if applicable: _
For Type B and Type C Applications, complete the table below for all subsidiaries submitted under this Application:
Name of Subsidiary (Application Type B & C Only) |
Employer Identification Number (EIN) |
EXPRESS OPTIONS (See page 10) [All boxes must be checked to utilize the Express Option] |
|
|
|
|
|
|
Additional Subsidiary Applicants
(The Applicant will complete the data entry for each Subsidiary in AMIS.)
Name of Subsidiary (Application Type B & C Only) |
Employer Identification Number (EIN) |
EXPRESS OPTIONS (See page 10) [All boxes must be checked to utilize the Express Option] |
|
|
|
|
|
|
|
|
|
|
|
|
|
For-profit |
|
Non-profit |
|
Publicly traded company |
|
Faith-Based Institution |
|
Thrift, Bank or bank holding company |
|
Credit Union |
|
Small Business Investment Company (SBIC) |
|
Government-controlled entity |
|
Specialized Small Business Investment Company (SSBIC) |
|
Minority Owned or Controlled |
|
Certified Community Development Financial Institution |
|
Tribal Entity |
|
New Markets Venture Capital Company |
|
Real Estate Development Company |
Real Es |
tate Financing (Check only one accompanying sub-category |
|
Retail |
|
Industrial/Manufacturing |
|
Community Facilities |
|
Hospital/Tourism |
|
Office Space |
|
For Sale Housing |
|
Business Financing |
|
Mixed-use (housing commercial, retail) |
Microen |
nterprise Financing |
Financi |
ng other CDEs |
Loan p |
urchase from other CDEs |
Financi |
al Counseling and Other Services. |
|
For-profit |
|
Non-profit |
|
Publicly traded company |
|
Faith-Based Institution |
|
Thrift, Bank or bank holding company |
|
Credit Union |
|
Small Business Investment Company (SBIC) |
|
Government-controlled entity |
|
Specialized Small Business Investment Company (SSBIC) |
|
Minority Owned or Controlled |
|
Certified Community Development Financial Institution |
|
Tribal Entity |
|
New Markets Venture Capital Company |
|
Real Estate Development Company |
|
Not Applicable – Applicant CDE does not have a Controlling Entity |
|
|
Market Served and Estimated % of Total Activities (should total 100 percent)
_ percent - Major urban areas (Counties in
Metropolitan Area with a population equal to or
greater than 1 million include both central city and
surrounding suburbs)
percent
- Minor urban areas (Counties in Metropolitan Area with a population
of less than 1 million
include both central city and surrounding
suburbs)
percent - Rural areas
Applicant Organizational Address(es):
Mailing Address |
Shipping Address (if different, for overnight deliveries) |
|
|
Applicant Contact Information
Authorized Representative: |
Applicant Contact (if different than AR): |
||
Name |
|
Name |
|
Phone |
|
Phone |
|
Fax |
|
Fax |
|
|
|
||
I hereby certify that all of the information provided in connection with the above-named Applicant CDE’s certification as a CDE is true, accurate and complete. The submission of such information has been duly authorized by the above-named Applicant CDE’s governing body. |
|
Authorized Representative Signature: |
Date: |
|
|
REQUIRED:
I certify, on behalf of the Applicant CDE and, if applicable, its Subsidiary Applicants, that it/they will, at all times during the course of its/their designation as a CDE, direct a minimum of sixty percent of its/their activities (including loans, investments and related technical assistance) to Low-Income Persons, to persons or organizations located in Low-Income Communities, or to other organizations that principally serve Low-Income Persons or residents of Low-Income Communities.
I further certify that the Applicant CDE and, if applicable, its Subsidiary Applicant(s), will maintain accountability to the Low-Income Communities that it/they serve, through their representation on the governing board or on an advisory board(s) to the Applicant CDE (and, if applicable Subsidiary Applicants), at all times during the course of its/their designation as a CDE.
The Applicant CDE and, if applicable, its Subsidiary Applicant(s) acknowledges that it may be required to periodically certify to the Fund that it continues to comply with the above certification requirements, and to notify the Fund if the Applicant CDE and, if applicable, its Subsidiary Applicant(s) fails to comply with these requirements. The Applicant CDE and, if applicable, its Subsidiary Applicant(s) acknowledges further that a failure to comply with these requirements may result in the Applicant CDE and, if applicable, its Subsidiary Applicant(s) losing its designation as a CDE, as well as the revocation of NMTC Allocations provided to the Applicant CDE or Subsidiary Applicants and/or the recapture of NMTCs claimed by investors for making Qualified Equity Investments in the Applicant CDE or Subsidiary Applicants.
OPTIONAL FOR APPLICANT CDE’S APPYING FOR CERTIFICATION ON BEHALF OF ONE OR MORE SUBSIDIARY CDE APPLICANTS:
EXPRESS OPTION - Applicant CDEs (Type B or C) seeking to certify Subsidiary Applicants as CDEs that have the same Primary Mission, Service Area, and Board(s) as the Applicant CDE, may make the following certification by checking the following box below:
I certify, on behalf of Applicant CDE, that the designated Subsidiary Applicant CDE(s) listed in this application, for which all three boxes were checked in the Basic Information Section, are legal entities (having filed the necessary paperwork with the appropriate state agencies), have valid EINs, and
have the same Primary Mission as the Applicant CDE and there have been no unapproved material changes to the Applicant CDE’s Primary Mission; and
have the same Service Area as the Applicant CDE and there have been no unapproved material changes to the Applicant CDE’s Service Area; and
have the same Accountability as the Applicant CDE and there have been no unapproved material changes to the Applicant CDE’s Accountability.
Selecting the option above requires that no further application materials be submitted for those subsidiary CDEs listed on the Applicant’s Basic Information page and for which all three boxes under the EXPRESS OPTION have been checked; EXCEPT LEGAL ENTITY DOCUMENTATION.
Authorized Representative Signature: |
Date: |
|
|
BASIC INFORMATION – SUBSIDIARY CDE
Name of Subsidiary CDE |
|
Subsidiary CDE Employer Identification Number |
|
Contact Name |
|
Contact Telephone |
|
Contact Email |
|
Mailing Address |
|
Market Served and Estimated % of Total Activities (should total 100 percent)
_ percent - Major urban areas in a Metropolitan Area
with a population equal to or greater than
1 million (include both central city and surrounding
suburbs).
percent
- Minor urban areas in a Metropolitan Area with a population of less
than 1 million (include both central city and surrounding
suburbs).
percent - Rural areas
|
For-profit |
|
Non-profit |
|
Publicly traded company |
|
Faith-Based Institution |
|
Thrift, Bank or bank holding company |
|
Credit Union |
|
Small Business Investment Company (SBIC) |
|
Government-controlled entity |
|
Specialized Small Business Investment Company (SSBIC) |
|
Minority Owned or Controlled |
|
Certified Community Development Financial Institution |
|
Tribal Entity |
|
New Markets Venture Capital Company |
|
Real Estate Development Company |
Real Es |
tate Financing (Check only one accompanying sub-category |
|
Retail |
|
Industrial/Manufacturing |
|
Community Facilities |
|
Hospital/Tourism |
|
Office Space |
|
For Sale Housing |
|
Business Financing |
|
Mixed-use (housing commercial, retail) |
Microen |
nterprise Financing |
Financi |
ng other CDEs |
Loan p |
urchase from other CDEs |
Financi |
al Counseling and Other Services |
Criteria: LEGAL ENTITY
Type A & B Only
As of the date its CDE Certification Application is submitted (signed by Authorized Representative), the Applicant, and relevant subsidiaries, must be duly organized and validly exist under the laws of the state jurisdiction in which it is incorporated or established AND be a domestic corporation or partnership for federal tax purposes. Legal documents must be submitted for the Applicant and all subsidiaries, INCLUDING subsidiaries using the EXPRESS OPTION)
APPLICANT CDE:
EVIDENCE OF LEGAL ENTITY STATUS
Is the Applicant CDE a domestic corporation or partnership for federal tax purposes? YES NO If no, the applicant is not eligible to apply for certification as a CDE and therefore should not submit a CDE Certification Application.
NOTE: Section 7701(a)(4) of the Internal Revenue Code defines "domestic" when applied to a corporation or partnership to mean created or organized in the United States or under the law of the United States or of any State unless, in the case of a partnership, the Secretary provides otherwise by regulations.
Organizations incorporated in US territories are not considered "domestic" corporations or partnerships for the purpose of this definition.
If the Applicant CDE is an LLC:
Does the LLC have more than one Member? YES NO
If “NO” to the question above, has the LLC elected to be treated as a corporation for federal tax
purposes? YES NO
* Attach, if the Applicant is a single member LLC, a copy of the Applicant’s official IRS Documentation of tax classification election as a corporation (e.g. submitted IRS Form 8832 or IRS acceptance of Form 8832.)
Enter the Applicant CDE’s date of incorporation/organization/establishment (month/day/year):
Enter the Applicant CDE’s total assets as of the date of this application: $
Attach a copy of one of the following (documents must be signed, stamped, and filed with the appropriate state agency):
Articles of Incorporation
Certificate of Formation
Organization Certificate
Other:
* Attach any amendments to attached organizing documents, (documents must be signed, stamped, and filed with the appropriate state agency).
EMPLOYER IDENTIFICATION NUMBER (EIN)
Enter CDE’s Employer Identification Number: _
Attach one of the following for the Applicant CDE (documentation must clearly identify both the entity’s legal name and its EIN):
Official letter from IRS providing EIN;
Confirmation fax from local IRS office with the organization’s name and EIN; or
A printout of completed and submitted online SS-4 (with organization’s EIN in upper right hand corner) from IRS’ website, accompanied by a printout of the online confirmation of receipt of EIN from IRS’ website.
Criteria: LEGAL ENTITY
Type B & C Only
As of the date its CDE Certification Application is submitted (signed and mailed by Authorized Representative), the Applicant, and relevant subsidiaries, must be duly organized and validly exist under the laws of the state jurisdiction in which it is incorporated or established AND be a domestic corporation or partnership for federal tax purposes. Legal documents must be submitted for the Applicant and all subsidiaries, INCLUDING subsidiaries using the EXPRESS OPTION.
SUBSIDIARY CDE Name: _ EVIDENCE OF LEGAL ENTITY STATUS
Is the Subsidiary CDE a domestic corporation or partnership for federal tax purposes? YES NO
If no, the applicant is not eligible to apply for certification as a CDE and therefore should not submit a CDE Certification Application.
NOTE: Section 7701(a)(4) of the Internal Revenue Code defines "domestic" when applied to a corporation or partnership to mean created or organized in the United States or under the law of the United States or of any State unless, in the case of a partnership, the Secretary provides otherwise by regulations.
Organizations incorporated in US territories are not considered "domestic" corporations or partnerships for the purpose of this definition.
If the Subsidiary CDE is an LLC:
Does the LLC have more than one Member? YES NO
If “NO” to the question above, has the LLC elected to be treated as a corporation for federal tax
purposes? YES NO
* Attach, if the Subsidiary CDE is a single member LLC, a copy of the Subsidiary CDE’s official IRS Documentation of tax classification election as a corporation (e.g. submitted IRS Form 8832 or IRS acceptance of Form 8832.)
Enter the Subsidiary CDE’s date of incorporation/organization/establishment (month/day/year):
Enter the Subsidiary CDE’s total assets as of the date of this application: $ _
Attach a copy of one of the following (documents must be signed, stamped, and filed with the appropriate state agency). Indicate which document is submitted below:
Articles of Incorporation
Certificate of Formation
Organization Certificate
Other:
* Attach any amendments to attached organizing documents, (documents must be signed, stamped, and filed with the appropriate state agency).
EMPLOYER IDENTIFICATION NUMBER (EIN)
Enter CDE’s Employer Identification Number:
Attach one of the following for each Subsidiary Applicant (documentation must clearly identify both the entity’s legal name and its EIN):
Official letter from IRS providing EIN;
Confirmation fax from local IRS office with the organization’s name and EIN; or
A printout of completed and submitted online SS-4 (with organization’s EIN in upper right hand corner) from IRS’ website, accompanied by a printout of the online confirmation of receipt of EIN from IRS’ website.
Criteria: PRIMARY MISSION
Type A & B Only
A CDE must demonstrate that it has a primary mission of serving, or providing investment capital for LICs or low income persons, and that at least 60 percent of its activities (e.g., loans and investments) are targeted to low income persons or LICs.
APPLICANT CDE:
Indicate type of board-approved organizational document that provides evidence of Applicant’s primary mission of promoting community development:
Articles of Incorporation, Organization, or Formation (signed and filed with appropriate state agency)
Bylaws (board-approved)
Board approved resolution
Annual report containing a signed letter from the Board Chairperson
Board-approved, one-page narrative that specifically states how the organization’s collective activities and products evidence the primary mission certification criteria
Other similar board-approved documents
Attach: Copy of the Applicant’s organizational documents, as indicated above, that provide evidence of a primary mission of promoting community development.
Enter primary mission of Applicant (as stated in board approved document(s) indicated above):
Criteria: PRIMARY MISSION
Type B & C Only
A CDE must demonstrate that it has a primary mission of serving, or providing investment capital for LICs or low income persons, and that at least 60 percent of its activities (e.g., loans and investments) are targeted to low income persons or LICs.
SUBSIDIARY CDE Name: _
(Complete and submit requested information for each Subsidiary seeking certification, except those for which the
EXPRESS OPTION is selected. Reproduce additional copies of the form as needed.)
Indicate type of board-approved organizational document that provide evidence of Applicant’s primary mission of promoting community development:
Articles of Incorporation, Organization, or Formation (signed and filed with appropriate state agency)
Bylaws (board-approved)
Board approved resolution
Annual report containing a signed letter from the Board Chairperson
Board-approved, one-page narrative that specifically states how the organization’s collective activities and products evidence the primary mission certification criteria
Other similar board-approved documents
Attach: Copy of the Applicant’s organizational documents, as indicated above, that provide evidence of a primary mission of promoting community development.
Enter primary mission of Applicant (as stated in board approved document(s) indicated above):
Type A & B Only
Criteria: ACCOUNTABILITY & SERVICE AREA
A CDE Applicant must identify the service area that it serves or intends to serve; and demonstrate that it maintains accountability to the LICs in those areas.
APPLICANT CDE:
Select one and identify the service area geography the entity currently serves or intends to serve:
Local service area [e.g., county(ies); PMSA(s)]:
State-wide or
territory-wide service area: _
Multi-state service area:
National service
area:
Select and identify the method of accountability maintained to the residents of LICs (check all that apply):
Enter the number of Advisory Boards used to maintain accountability _
Enter the names of the Advisory Boards used to maintain accountability
o #1
o #2
o #3
APPLICANT CDE:
Complete one Board Table for each governing and/or advisory board listed.
For governing and advisory boards, the options for how board members may be representative of a Service Area are as follows:
-
Categories for Board Members:
Board members may:
A
Reside within a NMTC qualified census tract within the designated service area.
B
Own, control, or manage a business located in a NMTC qualified census tract within the designated service area(s) that principally employs or provides goods and services to area LIC residents.
C
Be an employee or board officer of a non-affiliated community-based or charitable organization providing more than 50% of its program activities and services to LICs within the designated area.
D
Be a religious leader whose congregation is located in a NMTC qualified census tract.
E
Be an employee of a governmental agency or department that primarily serves LICs, or whose job responsibilities primarily involve serving LICs.
F
Be, or work for, an elected official whose constituency is comprised principally of, or are residents of, qualified NMTC census tracts.
BOARD TABLE
-
BOARD TYPE: Governing: (Name) Advisory: (Name) BOARD COMPOSITION DATE (as of):
Name
(List all board member’s names)
LIC
Representative
(yes or no)?
Category (Choose from category
listed above)
Geographic
Area(s) Serve
Conflict of Interest Certification: Check here to certify that neither board member, nor any of his/her family members, is (are) principal(s) or staff member(s) of the Applicant CDE (or Subsidiary Applicant), its affiliated entities, or its investors.
1.
No
NA
NA
There is no conflict of interest.
2.
No
NA
NA
There is no conflict of interest.
3.
No
NA
NA
There is no conflict of interest.
4.
No
NA
NA
There is no conflict of interest.
5.
No
NA
NA
There is no conflict of interest.
6.
No
NA
NA
There is no conflict of interest.
7.
No
NA
NA
There is no conflict of interest.
8.
No
NA
NA
There is no conflict of interest.
9.
No
NA
NA
There is no conflict of interest.
10.
No
NA
NA
There is no conflict of interest.
Total # of board members
%of LIC Reps
For each board member designated as a LIC Representative, complete an LIC Representative Form, have the LIC Representative sign the form and submit with the application.
If the applicant entity intends to maintain accountability to the residents of its LIC through their representation on Advisory Board(s), provide a narrative statement, detailing the following for each Advisory Board named above:
The process by which members are selected for the Advisory Board;How often the Advisory Board meets (to be accountable, a board must meet at least annually);
How the Advisory Board solicits, or intends to solicit, feedback from LIC residents, and how often this information is, or will be, collected (e.g., feedback collected semi-annually at community meetings, feedback collected annually through surveys, etc.); andHow the information is used, or will be used, to influence the Governing Board’s actions in developing the organization’s policies (e.g., an Advisory Board representative sits on the Governing Board; a member of the Advisory Board presents reports to the Governing Board, etc.).
Type B & C Only
Criteria: ACCOUNTABILITY & SERVICE AREA
A CDE Applicant must identify the service area that it serves or intends to serve; and demonstrate that it maintains accountability to the LICs in those areas.
SUBSIDIARY CDE Name:
(Complete and submit requested information for each Subsidiary seeking certification, except those for which the
EXPRESS OPTION is selected. Reproduce additional copies of the form as needed.)
-
Select one and identify the service area geography the entity currently serves or intends to serves: Local service area [e.g., county(ies); PMSA(s)]:
State-wide or territory-wide service area: _
Multi-state service area:
National service
area:
Select and identify the method of accountability maintained to the residents of LICs (check all that apply):
Enter the number of Advisory Boards used to maintain accountability _
Enter the names of the Advisory Boards used to maintain accountability
o #1
o #2
o #3
SUBSIDIARY CDE Name:
Complete one Board Table for each governing and/or advisory board listed.
For governing and advisory boards, the options for how board members may be representative of a Service Area are as follows:
-
Categories for Board Members:
Board members may:
A
Reside within a NMTC qualified census tract within the designated service area.
B
Own, control, or manage a business located in a NMTC qualified census tract within the designated service area(s) that principally employs or provides goods and services to area LIC residents.
C
Be an employee or board officer of a non-affiliated community-based or charitable organization providing more than 50% of its program activities and services to LICs within the designated area.
D
Be a religious leader whose congregation is located in a NMTC qualified census tract.
E
Be an employee of a governmental agency or department that primarily serves LICs, or whose job responsibilities primarily involve serving LICs.
F
Be, or work for, an elected official whose constituency is comprised principally of, or are residents of, qualified NMTC census tracts.
BOARD TABLE
-
BOARD TYPE: Governing:(Name) Advisory: (Name) BOARD COMPOSITION DATE (as of):
Name
(List all board member’s names)
LIC
Representative
(yes or no)?
Category (Choose from category
listed above)
Geographic
Area(s) Serve
Conflict of Interest Certification: Check here to certify that neither board member, nor any of his/her family members, is (are) principal(s) or staff member(s) of the Applicant CDE (or Subsidiary Applicant), its affiliated entities, or its investors.
1.
No
NA
NA
There is no conflict of interest.
2.
No
NA
NA
There is no conflict of interest.
3.
No
NA
NA
There is no conflict of interest.
4.
No
NA
NA
There is no conflict of interest.
5.
No
NA
NA
There is no conflict of interest.
6.
No
NA
NA
There is no conflict of interest.
7.
No
NA
NA
There is no conflict of interest.
8.
No
NA
NA
There is no conflict of interest.
9.
No
NA
NA
There is no conflict of interest.
10.
No
NA
NA
There is no conflict of interest.
Total # of board members
0%
%of LIC Reps
a) For each board member designated as a LIC Representative, complete an LIC Representative Form, have the LIC Representative sign the form and submit with the application.
If the applicant entity intends to maintain accountability to the residents of its LIC through their representation on Advisory Board(s), provide a narrative statement, detailing of the following for each Advisory Board named above:
-
The process by which members are selected for the Advisory Board; How often the Advisory Board meets (to be accountable, a board must meet at least annually);
-
How the Advisory Board solicits, or intends to solicit, feedback from LIC residents, and how often this information is, or will be, collected (e.g., feedback collected semi-annually at community meetings, feedback collected annually through surveys, etc.); and How the information is used, or will be used, to influence the Governing Board’s actions in developing the organization’s policies (e.g., an Advisory Board representative sits on the Governing Board; a member of the Advisory Board presents reports to the Governing Board, etc.).
LOW INCOME REPRESENTATIVE FORM
(Complete and submit requested information for each proposed LIC representative. Reproduce additional copies of the form as needed.)
Board Member’s Name: _
Service Area BOARD MEMBER (not Applicant) represents (e.g. County(ies), (P)MSA, State(s), National):
How is the Board Member representative of LICs? (Check and complete information in only one
category below)
-
Board Member’s Complete Home Address:
Census Tract (11 digit FIPS code):
Attach the “Address Geocoder Report” from The Fund’s CIMS mapping program.
B. Is a small business owner who controls, operates or manages a
business located in a LIC that:
provides goods and services to LIC residents; or b) principally employs LIC residents.
-
Business Name:
Business’ Complete Street Address:
Census Tract (11 digit FIPS code):
Attach the “Address Geocoder Report” from The Fund’s CIMS mapping program.
Provide a clear and concise description of the goods and/or services the business provides to the LIC, and/or how it was determined that the business principally employs LIC residents.
-
Description of goods and/or services:
Explain how and what percentage of LIC residents the business employs:
-
Board Member Title:
Charitable organization name:
Organization Website Address:
Geographic area organization serves (County(ies), State, or
Metropolitan Statistical Areas):
Describe the organization’s primary activities and services that directly benefit Low-Income Persons and/or
Communities:
Primary Low-Income Mission Certification:
The organization named above has a primary mission to serve low-income persons and/or communities, and more than 50% of the organization’s program activities and services are directed to benefiting low-income
persons and/or communities.
D. Is a religious leader whose congregation is based in an LIC.
-
Board Member Title:
Religious Entity Name:
Religious Entity’s Complete Street Address:
Census Tract (11 digit FIPS code):
Attach the “Address Geocoder Report” from The Fund’s CIMS mapping program.
-
Board Member Title:
Agency/Department Name:
Agency/Department Website:
Geographic area agency/\department Serves
(County(ies), state, or Metropolitan Statistical Areas):
Describe the Agency/Department’s primary activities and services, or the Board Member’s primary job responsibilities, that benefit Low-
Income Persons and/or Communities:
Primary Low-Income Mission Certification:
The agency/department has a primary mission, or the Board Member has primary responsibilities, to serve low-income persons and/or communities, and more than 50% of the agency/department’s program activities and services, or more than 50% of the Board Member’s
responsibilities, are directed to benefiting low-income persons and/or communities.
F. Is, or works for, an elected official whose constituency is
comprised primarily of LICs or residents of LICs.
Provide information below.
-
Board Member organization title:
Elected Official Name:
Elected Official’s Geographic Jurisdiction:
Explain how it was determined that the elected official’s constituency is comprised primarily of LICs or LIC
residents:
Attach the “Address Geocoder Report” from The Fund’s CIMS mapping program.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
© 2024 OMB.report | Privacy Policy