Va Form 10-0388-3 - State Home Construction Grant Program Space Program Analysis - Nursing Home & Domiciliary Page 4

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PROPOSED BY

TOTAL VA

COMPUTATIONS

STATE

ALLOWED

ANALYSIS

CRITERIA AREAS

10% DEVIATION

AS REQUIRED AREAS

TOTAL STATE PROPOSED:

TOTAL VA ALLOWED:

FORMULA FOR % OF VA PARTICIPATION:

x.65

VA ALLOWED:

STATE PROPOSED:

OFFICIAL PERCENTAGE OF VA STATE PROPOSED PARTICIPATION =

DATE

CERTIFIED

State Home Grant Program, Office of Facilities Management (181A)

811 Vermont Avenue, NW, Washington, D.C. 20420

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements

of section 3507 of this Act. The public reporting burden for this collection of information is estimated to average 6 hours per response, including the

time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the

collection of information. We may not collect or sponsor and you are not required to respond to, a collection unless it has a valid OMB Control

Number. This collection of information is collected under the authority of 38 U.S. Code Sections 8133(a) and 8135(a). VA will use this

information, along with other documents submitted by the States to determine the feasibility of the projects for VA participation, to meet VA

requirements for a grant award and to rank the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will

be unable to authorize a grant without a complete package. Your failure to furnish this information will have no effect on any of other benefits to

which you are entitled.

10-0388-3

Page 4 of 4

VA FORM

MAR 2005