Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities

State Home Construction Grant Forms
Form No.

Form Title

Usage

10-0388-1

Documents & Information Required for
State Home Construction & Acquisition
Grants-Initial Application

State submit initial application to VA to request
consideration for grant award for Construction
or renovation project

10-0388-2

Certification of Compliance with Provisions
of Davis-Bacon Act

State completes this form certifying they are in
compliance with the wage rates as determined
by DOL for the State project

10-0388-3

State Home Construction Grant Program –
Space Program Analysis – Nursing Home
& Domiciliary

State completes this form for review by VA
Construction & Facilities for Space requirements
for Nursing Homes & Domiciliary

10-0388-4

State Home Construction Grant Program –
Space Program Analysis – Adult Day
Health Care

State completes this form for review by VA
Construction & Facilities for Space requirements
for Adult Day Health Care facilities

10-0388-5

Application - Additional Documents &
Information Required for State Home
Construction & Acquisition Grants

State completes this form to submit additional
information prior to grant award

10-0388-6

Certification of State Matching Funds to
Qualify for Group 1 on the Priority List

State completes this form and submits to VA to
certify 35% matching funds for State Home
project

10-0388-7

Certification Regarding Debarment,
Suspension, and other Responsibility
Matters

State completes this form and submits to VA to
show compliance with the Federal laws
regarding covered transactions

10-0388-8

Certification Regarding Drug-Free
Workplace Requirements for Grantees
Other Than Individuals

State completes this form and submits to VA to
certify they maintain a drug-free workplace

10-0388-9

Certification Regarding Lobbying

State completes this form and submits to VA to
certify no influence from Federal Government
Agency or Congress

10-0388-10

Certification of Compliance with Federal
Requirements-State Home Construction
Grant

State completes this form and submits to VA to
certify that all requirements for State Home
Construction project are met

10-0388-11

Memorandum of Agreement for a Grant to
Construct or Acquire a State Veteran
Home

State completes this form and submits MOA to
VA for Secretary’s approval

10-0388-12

Certification Regarding Debarment,
Suspension, Ineligibility & Voluntary
Exclusion – Lower Tier Covered
Transactions

The Contractor employed by the State
completes this form and the State submits to VA
to ensure Federal laws regarding covered
transactions

10-0388-13

Documents/Certifications Required for
State Home Construction & Acquisition
Grants – Post Grant Requirements

State completes this form and submits to VA
prior to the final payment of grant funds

10-0388-14

Checklist of Major Requirement For State
Home Construction/Acquisition Grants

VA uses this form to help track all major
requirements for State Home Construction
Grants