1. Legal Name of Organization: 2. IRS Tax Exempt Number:
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1 ATTACHMENT ONE: NON-PROFIT CHECKLIST HOME PART I: 1. Legal Name of Organization: 2. IRS Tax Exempt Number: 3. Documentation to be uploaded and submitted through THDA s Participant Information Management System (PIMS) A. If the nonprofit is organized and existing under the laws of Tennessee, a current Certificate of Existence from the Tennessee Secretary of State's office. The certificate must be purchased from the Secretary of State's office and must be dated no more than 30 days prior to the application due date. OR If the nonprofit is organized and existing in a state outside of Tennessee, (1) a current Certificate of Existence from the office of the Secretary of State in which the organization is organized and existing and dated no more than 30 days prior to the application due date AND (2) a Certificate of Authorization to do business in Tennessee from the Tennessee Secretary of State and dated no more than 30 days prior to the application date. B. Documentation of an IRS designation under Section 501(c)(3) or 501(c)(4) of the federal tax code. A 501(c)(3) non-profit organization may not submit an application until they have received their designation from the IRS. A 501(c)(4) non-profit applicant must provide documentation satisfactory to THDA, in its sole discretion, that the nonprofit has filed the necessary material with the IRS and received a response from the IRS demonstrating 501(c)(4) status. C. Copy of Organizational Charter and By-laws D. List of Board members including: names; home address; race; occupation; a description of their primary contribution; length of service; income range; and date the term of service expires. (Part V of Application). E. Business plan or strategic management plan that demonstrates the agency s short term and long term goals, objectives, and plans to achieve them. F. The most recent financial audit or audited financial statements of the organization. G. Applicant/Board Member and Corporate Disclosure Forms completed, signed by the organization's Executive Director and each Board Member and notarized. H. Applicant/Board Member and Corporate Disclosure Form completed, signed by the Chairman of the Board or Executive Director on behalf of the organization and notarized. 4. One page explanation of how the Board of Directors is involved in the operation of the agency, including how often the Board meets, how the Board monitors and provides oversight for the agency s programs. FY 2017 HOME Program Page 1 HO 0415 (Revised 1/2017)
2 5. Attach the resolution by the Board of Directors authorizing the submission of this application. 6. Attach the minutes of the most recent Board meeting at which this application and/or proposal were discussed. 7. List of staff members employed by the organization, including how many are full-time or parttime, their specific responsibilities related to housing programs, and how many years of experience each staff member has in housing development. 8. Documentation of operating funds from other sources, including how much annually and from what sources. 9. Explanation of any other programs operated by the organization, including the program(s) and its funding source(s). Do not include a description of the future activities proposed in this application for which funds are sought. 10. One page explanation of your agency's experience in housing, particularly in providing housing to low and very low income households in Tennessee. For organizations seeking CHDO designation under the HOME Program only: 11. Attach explanation of the formal process by which low income residents in the service area advise the organization in all of its decisions regarding the design, site choice, development, and management of all HOME-assisted affordable housing projects. FY 2017 HOME Program Page 2 HO 0415 (Revised 1/2017)
3 PART II: CHDO CHECKLIST AND DESIGNATION This checklist is to be completed and submitted with supporting documentation only by nonprofit organizations seeking designation as a Community Housing Development Organization (CHDO) under the state s HOME program. This form is to be completed by the General Counsel for the organization. The information contained in this checklist refers to the definition of CHDO in Subpart A, Section 92.2 of the 2013 HOME Final Rule. For each requirement indicated, the General Counsel should cite the specific location in the respective document indicated that evidences the requirement. ORANIZATIONAL REQUIREMENTS 1. Legal Structure 1.1 The organization is organized under Tennessee law, as evidenced by: A Articles of Incorporation AND Certificate of Existence from Tennessee Secretary of State The organization has among its purposes the provision of decent housing that is affordable to lowincome and moderate income persons, as evidenced by: Charter, Articles of Incorporation, By-laws, OR Resolutions The organization has no part of its net earnings inuring to the benefit of any member, founder, contributor, or individual, as evidenced by: A Articles of Incorporation, OR. By-laws, OR Resolutions The organization is not under the control or direction of any individual or entity seeking to drive profit or gain, as evidenced by: A 1.5. The organization has one of the following IRS tax exempt statuses, as evidenced by: A 501(c)(3) or 501(c)(4) Designation from the IRS; or Subordinate of a central non-profit under IRC Section 905; or Wholly owned subsidiary of an organization that has a 501(c)(3) or 501(c)(4) status and meets the CHDO definition. FY 2017 HOME Program Page 3 HO 0415 (Revised 1/2017)
4 1.6. The organization is not a government entity (including participating jurisdiction, other jurisdiction, Indian tribe, public housing agency, Indian housing authority, housing finance agency, redevelopment authority, zoning board or commission, as evidenced by: A Articles of Incorporation, OR. By-Laws. 2. Independence 2.1. Public officials and employees of a governmental entity may comprise no more than one-third (1/3) of the board, as evidenced: 2.2. Officers and employees of a governmental entity cannot be officers (e.g. CEO, CFO or COO) or employees of a CHDO, as evidenced by: 2.3. If the organization was created by a governmental entity, then the governmental entity that created the organization may not appoint more than one-third (1/3) of the board members and board members appointed by the governmental entity may not appoint the remaining two-thirds (2/3), as evidenced by: 2.4. If the organization was created by a for-profit entity: The for profit entity that sponsored or created the organization may not have as its primary purpose the development or management of housing, such as a builder, developer, or real estate management firm; The for-profit entity that created the organization may not appoint more than one-third (1/3) of the board members, and for-profit appointed board members may not appoint the remaining two-thirds (2/3) of the board; Officers and employees of the for-profit entity that created the organization cannot be officers or employees of the CHDO; and The organization must be free to contract for goods and services with others. FY 2017 HOME Program Page 4 HO 0415 (Revised 1/2017)
5 Requirements of 2.4 are met, as evidenced by: 3. Accountability to the Low Income Community 3.1. The organization has a designated service area (i.e. the community in which it produces housing). A community can be a neighborhood or neighborhoods, city, county, metropolitan area or multi-county area (but not the entire State), as evidenced by: By-laws, 3.2 At least one-third of the board members are: (1) low-income; (2) residents of a low-income neighborhood; or (3) elected representatives of a low income neighborhood organization as evidenced by Part VI to the HOME Application. Total Number of Board Members on Date of Application Submission: Number of Board Members on Application Date who are Low Income Representatives: 3.3. The organization has a formally adopted process for low-income beneficiaries to advise it on decisions regarding design, siting, development, and management of housing, as evidenced by: The organization's By-laws, A written statement of operating procedures approved by the governing body The organization has at least one year of serving the community, or if newly formed by local churches, service organizations, or neighborhood organizations, its parent organization meets this requirement, as evidenced by: By-laws, FY 2017 HOME Program Page 5 HO 0415 (Revised 1/2017)
6 4. Capacity 4.1. The organization has paid employees with demonstrated experience relevant to the nonprofit s role in undertaking the HOME activity to be funded. Note: This does not include volunteers, board members, donated or shared staff, or consultants, as evidenced by: List of staff members employed by the organization and copies of their current W-2s or W-4 issued by the nonprofit entity During the first year of an organization s participation as a CHDO only, capacity can be demonstrated through a contract with a consultant who has housing development experience to train appropriate key staff of the organization, as evidenced by: Copy of the contract and resume of the consultant. 4.2 Has standards of financial accountability that conforms to 2 CFR Part 200 Uniform Administrative Requirements, Audit Requirements, and Cost Principles, as evidenced by: CHDO ROLE A certification from a Certified Public Accountant OR A HUD approved audit summary. 5. CHDO Set-Aside Project 5.1. The CHDO is undertaking a homebuyer projects with CHDO set-aside funds in accordance with as a Developer. CHDO CERTIFICATION 6. CHDO Certification The organization is or will be the owner in fee simple and the developer of new or rehabilitated units for sale to low-income buyers, and The organization will control the development process including, at a minimum, arranging financing for the project and being in sole charge of construction. The organization meets all CHDO regulatory thresholds. And one or more of the following: The organization has a project that meets the eligibility requirements of for a reservation of CHDO set-aside funds. The organization qualifies for Operating Expenses. I attest that to the best of my knowledge the above information is true and correct and that this information is supported by appropriate documentation in the organization's files. Signature: Typed Name: General Counsel for: Date: FY 2017 HOME Program Page 6 HO 0415 (Revised 1/2017)
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