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

OMB Number: 2900-0661
Estimated Burden: 1 hour

DOCUMENTS AND INFORMATION REQUIRED FOR STATE HOME
CONSTRUCTION AND ACQUISITION GRANTS - POST-GRANT REQUIREMENTS
PROJECT DESCRIPTION
PROJECT LOCATION

FAI NUMBER

The state representative must submit to VA the following prior to the final payment of grant funds or when specified below:
1.

A final equipment list. 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.

2.

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.

3.

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."

4.

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 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

10-0388-13

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