10-0388-10 Certification Of Compliance With Federal Requirements

OMB Number: 2900-0661
Estimated Burden: 6 hours

CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS
STATE HOME CONSTRUCTION GRANT
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 to the best of my knowledge and belief all Federal requirements: (1) outlined in 38 Code of Federal Regulations Part 59 as
they pertain to this State Home project; (2) assurances outlined in SF 424D; and (3) all mandatory comments resulting from the design
development review by the U.S. Department of Veterans Affairs (VA) have been incorporated into construction contact(s) for this State
Veterans Home project to be located at :
,
Location

Project FAI #

TITLE 38 CFR PART 59
NAME OF AUTHORIZED STATE OFFICIAL

DATE (mm/dd/yyyy)

SIGNATURE

VA FORM
MAR 2005

TITLE OF AUTHORIZED STATE OFFICIAL

10-0388-10