10-0388-6 Certification Of State Matching Funds To Qualify For Gro

OMB Number: 2900-0661
Estimated Burden: 6 hours

CERTIFICATION OF STATE MATCHING FUNDS
TO QUALIFY FOR GROUP 1 ON THE PRIORITY LIST
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.
I certify that the total (35%) State matching funds in the amount of $
August 15,

is now available, or will be available by

, for the proposed State Home project, Federal Application Identifier (FAI) #

funds will remain available until

. These State

. No further State action, other than

administrative, is required to make these fund available.

TITLE 38 USC 8135 (B) (2) (A)
TITLE 38 CFR 59.40
NAME OF AUTHORIZED STATE BUDGET OFFICIAL

TITLE OF AUTHORIZED STATE BUDGET OFFICIAL

DATE (mm/dd/yyyy)

SIGNATURE

ENCLOSURE: Copy of Act, as approved by the Governor, authorizing the project and making available the State's 35 percent
matching funds for the project. (If the State has not appropriated the State matching funds, then, sufficient documentation must be
provided to show that the State has available the State has matching funds for the project.)
VA FORM
MAR 2005

10-0388-6