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OMB Number: 2900-0661

Estimated Burden: 6 hours

ADDITIONAL DOCUMENTS AND INFORMATION REQUIRED FOR

STATE HOME CONSTRUCTION AND ACQUISITION GRANTS APPLICATION

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.

SECTION I - INITIAL REQUIREMENTS TO RECEIVE GRANT

The State Representative must submit the following to VA to receive a grant:

SF 424, APPLICATION FOR FEDERAL ASSISTANCE. Mark the box labeled APPLICATION and submit the information

requested for an application.

SF 424C, BUDGET INFORMATION-CONSTRUCTION PROGRAMS. Include:

An estimate for the cost of the equipment not included in the construction contract (not to exceed 10 percent of the

construction costs).

A contingency cost estimate (not to exceed 5 percent of the estimated cost of the project for new construction or 8

percent for remodeling projects).

Evidence of the state authorization of the project (e.g. copy of the signed legislation).

Evidence (act, issued bonds, etc.) that the state has its share of the estimated total costs of construction.

VA Form 10-0388-6, CERTIFICATION OF STATE MATCHING FUND.

SECTION II - SPACE PROGRAM ANALYSIS (Update Only if Necessary)

An updated space program analysis for the proposed project that includes a list of each room or area and the square footage proposed

should be submitted. The plan should note special or unusual services or equipment. The information on VA Form 10-0388-3, SPACE

PROGRAM ANALYSIS-NURSING HOME (or VA Form 10-0388-4, SPACE PROGRAM ANALYSIS-ADULT DAY HEALTH CARE)

should correspond with the charts contained in 38 CFR 59.140 and 59.160. This analysis is needed only if there is a change in the

space program analysis that was previously submitted and approved by VA.

SECTION III - REQUIREMENTS DUE BY MARCH 15 (Each Year)

The State Representative must submit the following certifications to VA by MARCH 15 of each year until the project is completed.

VA Form 10-0388-7, CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY

MATTERS FOR PRIMARY COVERED TRANSACTIONS.

VA Form 10-0388-8, DEPARTMENT OF VETERANS AFFAIRS CERTIFICATION REGARDING DRUG-FREE WORKPLACE

REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS.

VA Form 10-0388-9, CERTIFICATION REGARDING LOBBYING.

VA Form 10-0388-2, CERTIFICATION OF COMPLIANCE WITH PROVISIONS OF THE DAVIS-BACON ACT.

VA FORM

10-0388-5

PAGE 1 OF 4

MAR 2005

Va Form 10-0388-5 - Additional Documents And Information Required For State Home Construction And Acquisition Grants Application