10-0388-5 Additional Documents And Information Required For State

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:
1.

SF 424, APPLICATION FOR FEDERAL ASSISTANCE. Mark the box labeled APPLICATION and submit the information
requested for an application.

2.

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

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

b.

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).

3.

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

4.

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

5.

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.
1.

VA Form 10-0388-7, CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY
MATTERS FOR PRIMARY COVERED TRANSACTIONS.

2.

VA Form 10-0388-8, DEPARTMENT OF VETERANS AFFAIRS CERTIFICATION REGARDING DRUG-FREE WORKPLACE
REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS.

3.

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

4.

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

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SECTION IV - REQUIREMENTS IF FEDERAL FUNDS ARE AVAILABLE

If the State is notified that federal funds are available, the State must provide these items:
1.

Requirements Schedule
A schedule of when each of the remaining requirements to receive a proposed grant will be met.

2.

Phase I - Environmental Survey
Site plan/map, site survey, and soil investigation (if applicable). Design development site plan. The applicant shall submit a site
survey, which has been performed by a licensed land surveyor. A description of the site shall be submitted noting the general
characteristics of the site. This should include soil reports and specifications, easements; main roadway approaches,
surrounding land uses, availability of electricity, water and sewer lines, and orientation. The description should also include a
map locating the existing and/or new buildings, major roads, and public services in the geographic area. Additional site plans
should show all site work including property lines, existing and new topography, building locations, utility data, and proposed
grades, roads, parking areas, walks, landscaping, and site amenities.

3.

Phase II - Environmental Assessment
This requirement applies only if the outside construction exceeds 75,000 gross square feet (GSF)). The environmental
documentation will require approval by VA before a final award of a construction or acquisition grant for a state veterans home
(see 26.6 of this chapter for compliance requirements.) When the application submission requires an environmental
assessments, the state shall describe the possible beneficial and/or harmful effect which the project may have on the following
impact categories:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

Transportation
Air Quality
Noise
Solid Waste
Utilities
Geology (Soils/Hydrology/Flood Plains)
Water Quality
Land Use
Vegetation, Wildlife, Aquatic, and Ecology/Wetlands
Economic Activities
Cultural Resources
Aesthetics
Residential Population
Community Services and Facilities
Community Plans and Projects
Other

If an adverse environmental impact is anticipated, the action to be taken to minimize the impact should be explained in the
environmental assessment.
If construction outside the walls of an existing structure will involve more than 75,000 GSF, the application shall include an
environmental assessment to determine if an environmental impact statement is necessary for compliance with section 102(2)
(c) of the national environmental policy act of 1969. If the proposed actions involving construction or acquisition do not
individually or cumulatively have a significant effect on the human environment or if the outside construction does not exceed
75,000 GSF, the applicant shall submit a letter noting a categorical exclusion, subject to approval by VA.
4.

State Historical Preservation Letter
Letter from the state historical preservation officer (SHPO) and subsequent clearance from the VA historical preservation
officer and a copy from the SHPO stating whether the project area includes any properties on, eligible for, or likely to meet the
criteria for the national register of historic places. If the property does, or may include, national register quality properties, the
letter from SHPO should discuss the determination of effect of the proposed project on such property.

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SECTION IV - REQUIREMENTS IF FEDERAL FUNDS ARE AVAILABLE - Continued

5.

Design Development (35 percent) Drawings
The applicant shall provide to the department of veterans affairs one set of sepias and eight sets of prints, rolled individually
per set, to expedite the review process. Please send directly to the office of construction management, facilities quality service
(181a), with a copy of the transmittal letter to be chief, state home construction program (114). The drawings must indicate the
designation of all spaces, size of areas and rooms and indicate in outline the fixed and movable equipment and furniture. The
drawings must be drawn at 1/4" scale. Bedroom and toilet layouts, showing clearances and UFAS requirements, should be
shown 1/4" scale. The total floor and room areas shall be shown in the drawings. The drawings must include:
1. Plan of any proposed demolition work,
2. A plan for each floor (for renovations, the existing conditions and extent of new work should be clearly delineated);
3. Elevations,
4 .Sections and typical details,
5. Roof plan,
6. Fire protection plans, and
7. Technical engineering plans, including structural, mechanical, plumbing, and electrical drawings.
If the project involves acquisition, or renovation, the state should include the current as-built site plan, floor plans and building
sections that show the present status of the building and a description of the building's current use and type of construction.

6.

Design Development Outline Specifications
The state shall provide eight copies of outline specifications which shall include a general description of the project, site,
architectural, structural, electrical, and mechanical systems such as elevators, nurses' call system, air conditioning, heating
plumbing, lighting, power, and interior finishes (floor coverings, acoustical material, and wall and ceiling finishes).

7.

Design Development Cost Estimates
Two copies of the updated SF 424 and SF 424c cost estimates must be included in the application to VA. Estimates must
show the estimated cost of the buildings or structures to be acquired or constructed in the project. Cost estimates must list the
cost of construction, contract contingency, fixed equipment not included in the contract, other equipment, architect's fees, and
construction supervision and inspection. The allowance for equipment, not included in the construction contract. Must not
exceed 10 percent of the construction or acquisition contract cost. The VA allowance for contingencies shall not exceed 5
percent of the total project cost for new construction or 8 percent of the total project cost for renovation projects. If the project
involves non-federal participating areas, such costs should be itemized separately.

8.

Title Assurance
Reasonable assurance that the state home, or another agency or instrumentality of the state has title to the site for the project.

SECTION V - CONDITIONAL APPROVAL

If all requirements for a grant are not met prior to the date established in VA's commitment letter, a State may be eligible for a
conditional approval of a grant under the provisions of 38 CFR 59.70.
SECTION VI - REQUIREMENTS DUE BY THE DATE ESTABLISHED IN VA'S COMMITMENT LETTER

The state representative must submit the following by the date established in VA's commitment letter:
1.

Final drawings and specifications (100 percent - one labeled set of microfiche aperture cards, microfilm, or compact disc/read
only memory (CD/ROM) compact laser disc, with 100% construction documents (plans and specifications));

2.

Advertisement for the proposed project and request for bids;

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SECTION VI - REQUIREMENTS DUE BY THE DATE ESTABLISHED IN VA'S COMMITMENT LETTER - Continued

3.

Two copies of the itemized bid tabulations;

4.

Completed VA form 10-0388-10, CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS STATE HOME
CONSTRUCTION GRANT;

5.

Revised SF 424, SF 424c budget pages, based on the selected bids (including final cost for all items in the project).

6.

Three signed originals of the Memorandum of Agreement that includes provisions in the Sample Memorandum of Agreement
VA Form 10-0388-11 as set forth in 38 CFR.160.

SECTION VII - REQUIREMENTS DUE PRIOR TO GRANT AWARD

Prior to grant award, the State Representative must submit VA Form 10-0388-12, CERTIFICATION REGARDING DEBARMENT,
SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION LOWER TIER COVERED TRANSACTIONS (TO BE SIGNED BY
THE CONTRACTORS.

CERTIFICATION - The law provides severe penalties for willful submission of false information

I certify that the information submitted to VA is true and correct to the best of my knowledge and ability.
NAME OF AUTHORIZED STATE OFFICIAL

SIGNATURE

VA FORM
MAR 2005

TITLE OF AUTHORIZED STATE OFFICIAL

DATE (mm/dd/yyyy)

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