Va Form 10-0388-14 - Checklist Of Major Requirements For State Home Construction/acquisition Grants
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2OMB Number: 2900-0661
Estimated Burden: 6 hours
CHECKLIST OF MAJOR REQUIREMENTS FOR STATE
HOME CONSTRUCTION/ACQUISITION GRANTS
LOCATION
DESCRIPTION
AQUISITION
DATE AND TIME RECEIVED
GRANT TYPE
CONSTRUCTION
SECTION A - INITIAL APPLICATION PHASE (Deadline is APRIL 15 Each Year for VA Receipt)
REQUIREMENT
DATE
1. Form SF 424, 424C, and 424D (includes description of project).
Governor's designation of authorized state official and contact person
2.
Documentation that there is a reasonable basis to conclude that the facility when complete will be fully occupied.
3.
Applicant's recommendation as to the priority, any sub-priority, and any further (38 CFR, 59.50)
4.
Needs assessment (Title 38 CFR 59.170, VAF 10-0388-1 requirements)
5.
Cost estimate (VA portion at time of initial application).
6.
State Clearinghouse Comments (E.O. 12372) single point of contact.
7.
State Application Identifier Number (if applicable).
8.
Statement regarding the total number of state-operated nursing home and domiciliary.
9.
Schematics for the proposed project.
10.
Space program analysis.
%
11.
Five-year capital plan for state's entire state home program.
12.
Financial plan for state facility's first three years of operation.
13.
Authorized state official's certification that the number of state home beds does not exceed the requirement in
14.
59.40.
Justification for number of state home beds exceeding 59.40 based on travel distance (59.40(b))
15.
Federal Application Identifier (FAI) number (to be assigned by VA)
16.
DUNS Number.
17.
Signed initial application certification (VA Form 10-0388-1).
18.
SECTION B - APPLICATION PHASE (Various Requirements & Recommended Deadlines)
REQUIREMENT
DATE
The following is required by law AUGUST 15 each fiscal year for consideration for priority group 1 of the
1.
priority list of pending applications:
A. Updated Form SF 424, 424 C, 424D (Includes description and scope of project.
Estimate for equipment not included in the construction contract (not to exceed 10 percent of the
1.
construction costs)
Contingency estimate (not to exceed 5 percent of the estimated costs of project for new construction or 8
2.
percent for remodeling projects).
B.
State authorization for the project (copy of the legislation)
State matching funds (to be ranked in priority group 1, VA must have on file, by AUGUST 15, a copy of the
C.
act appropriating the state funds and certification from an authorized state budget official that the
fundsareavailable, how long the funds will remain available, and that no further action is required by the
state to make such funds
2
If you are notified that federal funds are available, it is recommended these items are submitted no later than
.
DECEMBER 31.
A.
A schedule of when each of the remaining requirements will be met
B.
Phase I Environment Survey: site plan/map, site survey, and soil investigation (if applicable).
Phase II Environmental Assessment (if outside construction exceeds 75,000 gross
C.
square feet) or a statement from authorized state official that outside construct does
APPROVED
not exceed 75,000 GSF and determination of categorical exclusion (CE).
Letter from state historical preservation officer and subsequent clearance from VA
D.
APPROVED
historical preservation officer.
VA FORM
Page 1 of 2
10-0388-14
JUL 2005
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