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

OMB Number: 2900-0661
Estimated Burden: 1 hour

CERTIFICATION OF STATE MATCHING FUNDS
TO QUALIFY FOR GROUP 1 ON THE PRIORITY LIST
PROJECT DESCRIPTION

PROJECT LOCATION

FAI NUMBER

I certify that the total (35%) State matching funds in the amount of $
July 1,

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.
Description of Funding Source

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 matching funds available for the project.)

TITLE 38 USC 8135 (B) (2) (A)
TITLE 38 CFR 59.40

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

10-0388-6

PAGE 1 OF 1