10-0388-2 Certification Of Compliance With Provisions Of The Davis

OMB Number: 2900-0661
Estimated Burden: 1 hour

CERTIFICATION OF COMPLIANCE
WITH PROVISIONS OF THE DAVIS-BACON ACT
(40 U.S.C. Sections 276a to 276a-7)
PROJECT DESCRIPTION

PROJECT LOCATION

FAI NUMBER

I certify that I have obtained the latest prevailing wage rates from the U.S. Department of Labor for the State Home
project located in

and that these rates have been

incorporated into the construction contract for the proposed State Veterans Home project in compliance with the
Davis-Bacon Act.

TITLE 38 U.S.C. 8135(A) 8

CERTIFICATION - THE LAW PR0VIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION.
I certify that the above information submitted to VA is true and correct to the best of my knowledge and ability.
NAME OF AUTHORIZED STATE OFFICIAL

SIGNATURE

TITLE OF AUTHORIZED STATE OFFICIAL

DATE (mm/dd/yyyy)

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 1 hour 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.

VA FORM
DEC 2010

10-0388-2

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