Va Form 10-0388-1 - Documents And Information Required For State Home Construction And Acquisition Grants Initial Application

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OMB Number: 2900-0661
Estimated Burden: 6 hours
DOCUMENTS AND INFORMATION
REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS
INITIAL 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.
GRANT TYPE
An initial application should be submitted to the Chief Consultant, Geriatrics and Extended
ACQUISITION
Care (114) by April 15, if the state wishes consideration of an initial application for placement
on the priority list for the next fiscal year.
CONSTRUCTION
SECTION I - DOCUMENTATION REQUIREMENTS
Documentation that the site of the project is in reasonable proximity to a sufficient concentration and population of veterans that
1.
are 65 years of age and older and that there is a reasonable basis to conclude that the facility when complete will be fully
occupied.
Applicant's recommendation as to the priority, any sub-priority, and any further priority for purposes of placing the project on the
2.
priority list for the next fiscal year (see 38 CFR s 59.50).
SECTION II - STANDARD FORMS
1.
SF 424, APPLICATION (Original and one copy required.)
2.
SF 424C, BUDGET INFORMATION-CONSTRUCTION PROGRAMS. Include:
Cost estimate for equipment not included in the construction contract (not to exceed 10 percent of the construction costs);
a.
and
Contingency cost estimate (not to exceed 5 percent of the estimated cost of project for new construction or 8 percent for
b.
remodeling projects).
3.
SF 424D, ASSURANCES-CONSTRUCTION PROGRAMS.
4.
VA Form 10-0388-2, CERTIFICATION OF COMPLIANCES WITH PROVISIONS OF THE DAVIS-BACON ACT.
SECTION III - ADDITIONAL DOCUMENTATION
1.
Description and scope of the project. Original and one copy required.
2.
Project site description, including county location.
Governor's letter or a letter from the agency authorized by the governor with program oversight designating the state
representative and information that will permit VA to contact the state representative. The state representative must notify the
3.
chief consultant (114), immediately of any changes in who the state representative is and how to reach him or her.
SECTION IV - NEEDS ASSESSMENT - Submit information described in either Part A or Part B
ADDING OR REPLACING NURSING HOME OR DOMICILIARY BEDS:
1.
Demographic characteristics of the veteran population of the proposed catchments area.
2.
If great travel distances (over two hours) are imposed on veterans and their families, availability of beds.
3.
Number of VA nursing home and domiciliary beds and the occupancy rate at those facilities for the previous fiscal year.
VA FORM
10-0388-1
PAGE 1 OF 2
MAY 2005

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