10-0388-13 Documents And Certification Required For State Home Cons

OMB Number: 2900-0661
Estimated Burden: 6 hours

DOCUMENTS AND CERTIFICATION REQUIRED FOR STATE HOME
CONSTRUCTION AND ACQUISITION GRANTS - POST-GRANT REQUIREMENTS
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.
The state representative must submit to VA the following prior to the final payment of grant funds or when specified below:
1.

Standard Form SF 271, OUTLAY REPORT AND REQUEST FOR REIMBURSEMENT FOR CONSTRUCTION
PROGRAMS.

2.

A final equipment list (prior to completion of construction). A separate, complete itemized list to include fixed and
other equipment (not including equipment in the construction contract) by category with the cost, quantity, and
placement in accordance with the final drawings, but not including consumable goods or office supplies. (NOTE: if
no equipment is involved in the project, a statement to that effect should be included in the request for the final
architectural/engineering inspection.) This equipment list must be approved by VA prior to final claim
payment.

3.

A request in writing for the final grant program review, including the name and telephone number of the local point
of contact for the project.

4.

A final claim for payment on Standard Form SF 271, OUTLAY REPORT AND REQUEST FOR REIMBURSEMENT
FOR CONSTRUCTION PROGRAMS. Add the statement "it is hereby agreed that the monetary commitment of the
federal government will have been met and the project will be considered terminated upon payment of this
voucher."

5.

Evidence that the state has met its responsibility for an audit under the Single Audit Act of 1984 and 59.124 of this
part, if applicable.

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)

10-0388-13