Form VA Form 10-0508 VA Form 10-0508 Supportive Services for Veterans Families Progrm Applica

OMB Number: XXXXXXX
Estimated burden: 35 hours

U.S. Department of Veterans Affairs (VA)
Supportive Services for Veteran Families (SSVF) Program
APPLICATION FOR SUPPORTIVE SERVICES GRANT

We are required to notify you that this information collection is in accordance with the clearance
requirements of Section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for
this collection of information is estimated to average 35 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining data needed, and
completing and reviewing the collection of information. Respondents should be aware that
notwithstanding any other provision of law, no person will be subject to any penalty for failing to
comply with a collection of information if it does not display a currently valid OMB control number.
This collection of information is intended to assist the SSVF Program Office to determine eligibility to
receive supportive services grants under the SSVF Program and to rate and rank these applications.
Response to this survey is voluntary and failure to participate will have no adverse effect on benefits to
which you might otherwise be entitled.
Background: This form is to be completed by eligible applicants for supportive services grants under
VA's SSVF Program. VA will use the collected information to evaluate and select recipients for
supportive services grants. Applicants may be asked to provide additional supporting evidence or to
quantify details during the review process.
Definitions and SSVF Program Information: Definitions and SSVF Program information can be
found in the regulations (38 CFR Part 62) and the Notice of Fund Availability (NOFA) under which
you are submitting this application. Both documents are included as attachments to this application
package and are posted on the SSVF Program web page (http://www1.va.gov/HOMELESS/
SSVF.asp). Please note that to be eligible for a grant under the SSVF Program, the applicant must be
either a private nonprofit organization or a consumer cooperative. See 38 CFR 62.2 and 38 CFR 62.11
for definitions of these and other terms contained throughout the application.
Instructions: Please complete Sections A-F of this form prior to completing the Executive Summary.
The Executive Summary should summarize information that has already been provided in Sections A-F
of the application form.
Submission: Only timely and complete applications will be considered for funding; applications will
not be reviewed if incomplete. To be considered timely, the number of required copies of the
application must be received at the address and by the time and date specified in the NOFA.
Applications received after that time and date will not be accepted even if postmarked by the deadline
date. Following the application deadline, applicants will be notified that their applications have been
received. To be considered complete, all items requested in this grant application must arrive as a single
application package. Materials arriving separately will not be considered and may result in the
application being rejected or not funded.

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Applications should be provided in three-hole punch binders with sections and tabs following the
sequence shown in the application checklist appearing on page 3 of this application form. A
combination of “fill in the blank” and “narrative or essay” questions have been used. Exhibits are also
required to provide supporting documentation of certain information. Exhibits should be labeled and
attached at the back of the application package. Responses should be typed in 12-point Arial font on
8.5-inch by 11-inch paper with 1-inch margins. Please note the page limits for each section specified on
page 3 of this form.
An original completed and collated grant application, plus three collated hard copies and a compact disc
(CD) (containing electronic versions of the entire application as well as separate Microsoft Excel files
for Section D and Exhibit IX - but no file shall be in PDF or “values” format) must be submitted to
the following address: Supportive Services for Veteran Families Program Office, National Center on
Homelessness Among Veterans, 4100 Chester Avenue, Suite 200, Philadelphia, PA 19104. Applicants
who choose to submit on http://www.grants.gov/ must also submit their application package in hard
copy to the SSVF Program Office, as described above.
Documentation and Public Access Requirements: VA will ensure that documentation and other
information regarding each application submitted are sufficient to indicate the basis upon which
assistance was provided or denied. This material, including any letters of support, will be made
available for public inspection for a five-year period beginning not less than 30 days after the grant
award. Material will be made available in accordance with the Freedom of Information Act (5 U.S.C.
552).
Warning: It is a crime to knowingly make false statements to a Federal agency. Penalties upon
conviction can include a fine and imprisonment. For details see 18 U.S.C. 1001. Misrepresentation of
material facts may also be the basis for denial of grant assistance by VA.
Technical Assistance: Information on obtaining technical assistance with this application can be
found on VA's SSVF Program web page at: http://www1.va.gov/HOMELESS/SSVF.asp. In addition,
questions regarding this application may be directed to VA's technical assistance provider, the
Corporation for Supportive Housing at 1-312-332-6690 x17 (this is not a toll-free number) / Email:
SSVFinfo@csh.org.
For Further Information: If you have any questions regarding the SSVF Program, please contact the
SSVF Program Office at 1-877-737-0111 (this is a toll-free number).

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APPLICATION CHECKLIST
An application must include the following items.
Item

Page Limit

Executive Summary

4

Section A: Background, Qualifications, Experience, & Past Performance of Applicant and Any Identified Subcontractors
(35 maximum points)

5

1.

Background and Organizational History

2.

Staff Qualifications

3.

Organizational Qualifications and Past Performance

4.

Experience Working with Veterans

Section B: Program Concept & Supportive Services Plan (25 maximum points)
1.
2.

Outreach and Screening Plan

3.

Program Concept

4.

Program Implementation Timeline

5.

Collaboration and Communication with VA

6.

Ability to Meet VA's Requirements, Goals and Objectives for the SSVF Program

7.

Capacity to Undertake Program

Section C: Quality Assurance & Evaluation Plan (15 maximum points)
1.

Program Evaluation

2.

Monitoring

3.

Remediation

4.

Management and Reporting

Section D: Financial Capability & Plan (15 maximum points)
1.

3

5

Organizational Finances

2.

Estimated Monthly Program Cost Summary (one-year period)

3.

Summary of Sources of Program Funds

4.

Risks and Mitigation Strategies

Section E: Area or Community Linkages and Relations (10 maximum points)
1.

5

Need for Program

3

Area or Community Linkages

2.

Past Working Relationships

3.

Local Presence and Knowledge

4.

Integration of Linkages and Program Concept
2

Section F: Certifications
Attachment A: Veterans Integrated Service Networks (VISNs) Map
Attachment B: Applicant Budget Template (Microsoft Excel File)
Exhibits
Exhibit I:

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Eligible Entity Legal Authority

Exhibit II:

Applicant Organizational Chart

Exhibit III:

Evidence of Relationship between Applicant and Subcontractors

Exhibit IV:

Articles of Incorporation, Corporate Resolutions, Certified Partnership, Joint Venture, or LLC Agreement

Exhibit V:

Key Personnel Resumes

Exhibit VI:

Reference Contact Information

Exhibit VII:

Map of Program Area or Community

Exhibit VIII:

Previous Year's Audited Financial Statements

Exhibit IX:

One-Year Program Budget (Complete Attachment B: Microsoft Excel Applicant Budget Template)

Exhibit X:

(Optional) Documentation of Financing

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Executive Summary
Please complete Sections A-F of the application prior to completing the below Executive Summary. Total
narrative for this section should not exceed 4 pages, excluding any exhibits. VA has created the below
template to assist applicants in preparing the Executive Summary; it identifies the specific information that
must be provided to VA.
A)

Administrative Information. Provide the following information for the applicant:

1.

Applicant's Legal Name:

2.

Other Names under Which Applicant Does Business:

3.

Applicant's Proposed Program Name:

4.

Employer Identification Number (EIN) that Corresponds to the Applicant's IRS Ruling Certifying TaxExempt Status under the IRS Code of 1986 (Note: EIN will be used to determine whether applicant is
delinquent or in default on any Federal debt, in accordance with 31 U.S.C. 3701, et seq. and 5 U.S.C.
552a at note):

5.

Business Address:

6.

Mailing Address (if different from above) - include both U.S. mailing address and courier (i.e., no P.O.
Box) address:

7.

Contact Person Name:

8.

Contact Person Title:

9.

Mailing Address for Contact Person (if different from above):

10.

Telephone for Contact Person (where the person can be reached during business hours):

11.

Fax for Contact Person:

12.

E-mail for Contact Person:

13.

Optional: If the applicant would like VA to consider any subcontractors when scoring the applicant,
identify for each subcontractor the following information: name, EIN, business address, mailing address,
contact person (name, title, mailing address, telephone, fax, e-mail). Identify the percentage of work
expected to be subcontracted by applicant to each identified subcontractor.

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B)

Applicant Eligibility.

1.

The applicant is a:
Private Nonprofit Organization (IRS ruling certifying tax-exempt status under the IRS Code of
1986, as amended is attached in Exhibit I)
Consumer Cooperative (State certification of consumer cooperative status is attached in Exhibit I)
Note: To be eligible for a grant under the SSVF Program, the applicant must be either a private nonprofit organization or
consumer cooperative. See 38 CFR 62.2 for definitions of these terms.

2.

Does the applicant have an outstanding obligation to the Federal government that is in arrears?
Yes

3.

No

Does the applicant have an overdue or unsatisfactory response to an audit by a Federal, state or local
agency?
Yes

4.

(If yes, describe in Section A. Question 1.e.)

(If yes, describe in Section A. Question 1.e.)

No

Is the applicant in default by failing to meet the requirements of any previous Federal assistance?
Yes

(If yes, describe in Section A. Question 1.e.)

No

C)

Overview. Explain why VA should award the applicant a supportive services grant under the
SSVF Program.

D)

Amount of Supportive Services Grant Funds Requested. $

E)

Applicant's Related Experience. Describe the applicant's, and any identified subcontractors',
experience undertaking comparable programs.

F)

Applicant's Legal Structure. Provide sufficient detail regarding the legal structure of the applicant
and any potential conflicts of interest.

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G)

Program Description. Describe the proposed program, including its location, purpose, target
participants, number of participant households to be served, services provided, and
implementation schedule.

H)

Use of Supportive Services Grant Funds. Provide an overview and explanation of the overall
proposed program's financial plan, including total annual cost and the expected sources and uses of
funds.

I)

Please discuss other relevant issues that could impact the success of the proposed program.

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SECTION A: Background, Qualifications, Experience, & Past Performance of Applicant and Any
Identified Subcontractors
The information requested below should be included in the application packet with responses attached and
numbered to correspond to the relevant item. Total narrative supporting Section A should not exceed 5 pages,
excluding exhibits. In scoring the application, VA will award up to 35 points based on the applicant's
responses to questions contained in this section.
1.

Background and Organizational History.
a) Describe the applicant's organizational structure, including responsibilities of key personnel and lines
of reporting. Include the legal names of key principals and staff (e.g., program manager and chief
financial officer) and any recent or proposed changes to the organizational structure. Provide an
organizational chart as Exhibit II, to include the major parties involved in planning, financing,
operating, and/or maintaining the proposed program.
b)

c)

d)

If any subcontractors will be retained for the proposed program, list the type and percentage of work
that will be subcontracted, and include such subcontractors in the organizational chart in Exhibit II.
Provide a brief description of the qualifications of the subcontractors who will be retained, and, if
available, include as Exhibit III any Memorandums of Understanding (MOUs), letters of intent or
other documents evidencing the applicant's relationship to the subcontractor(s). Describe the
applicant's plan and ability to coordinate with such subcontractor(s). Identify which, if any,
subcontractors the applicant would like VA to consider along with the applicant in the evaluation of
this application (“identified subcontractors”). Note: The applicant is not required to have selected
subcontractors at the time of this application's submission.
In Exhibit IV, provide the following for the applicant and any identified subcontractors: (1) articles
of incorporation/organization, partnership, joint venture, or limited liability company agreement, as
applicable; (2) by-laws; (3) certificate of good standing; (4) copy of resolutions certified by an
authorized officer authorizing the submission of the application and the applicant's authority to
proceed with the proposed program (if a supportive services grant award is made and VA's approval
is obtained).
Provide a general overview of the applicant, and any identified subcontractors', mission and
organizational history, including number of years in operation, total number of employees, a
description of services provided (past and present), the geographic areas in which those services are
provided, types of programs operated (past and present), and organizational competencies and/or
areas of expertise.

e) List and explain in reasonable detail the following:
i.
Each instance in which the applicant, any identified subcontractor, or any principal, partner,
director, or officer of the applicant or identified subcontractor, was convicted of or pleaded guilty
or nolo contendre to a crime (other than a traffic offense).
ii. Each instance within the past ten (10) years in which an order, judgment, or decree (including as a
result of a settlement) was entered against the applicant, any identified subcontractor, or any
principal, partner, director, or officer of the applicant or identified subcontractor, whether by a
court, an administrative agency, or other governmental body, or an arbitral or other alternative
dispute resolution tribunal, in any civil proceeding or action in which fraud, gross negligence,
willful misconduct, misrepresentation, deceit, dishonesty, breach of any fiduciary duty,
embezzlement, looting, conflict of interest, or any similar misdeed was alleged (regardless of
whether any wrongdoing was admitted or proven).
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iii.

Each action or other proceeding decided within the past ten (10) years, and each action or
proceeding currently pending against the applicant, any identified subcontractor, or any principal,
partner, director, or officer of the applicant or identified subcontractor, whether before a court, an
administrative agency, governmental body, or an arbitral or other alternative dispute resolution
tribunal, which, if decided in a manner adverse to the applicant, identified subcontractor, principal,
partner, director, or officer (as applicable), would reasonably be expected to adversely affect the
ability of the applicant or identified subcontractor to perform its obligations with respect to the
proposed program.
iv. Each instance within the past ten (10) years in which the applicant, any identified subcontractor, or
any principal, partner, director or officer of the applicant or identified subcontractor, has been
debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from
transactions by any Federal department or agency.
v. Each instance within the past ten (10) years in which the applicant, any identified subcontractor, or
any principal, partner, director or officer of the applicant or identified subcontractor, has been
notified that it is in default of any Federal contract or grant, the reason for the default, and whether the
default was cured.
vi. Each instance within the past ten (10) years in which the applicant, any identified subcontractor or
any principal, partner, director or officer of the applicant or identified subcontractor, has been
notified that it is in default of any Federal contract or grant, the reason for the default, and whether
the default was cured.
vii. Each instance within the past ten (10) years in which the applicant, any identified subcontractor, or
any principal, partner, director or officer of the applicant or identified subcontractor, has had one
or more public transactions (Federal, State, or local) terminated for cause or default.
viii. Each instance of litigation or a formal Alternative Dispute Resolution (ADR) process (e.g., binding
arbitration) within the past ten (10) years, and involving a claim in excess of $50,000, to which the
applicant, any identified subcontractor, or any principal, partner, director or officer of the applicant
or identified subcontractor, has been a party relating to partnering and/or financial performance.
For those matters involving a claim equal to or in excess of $500,000, describe in detail the
litigation or ADR process.
2.

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Staff Qualifications.
a) Describe the applicant's staff members', and any identified subcontractors' staff members', experience
providing supportive services to very low-income families, who may include individuals with or
without dependents, including any experience with homelessness prevention, rapid re-housing or
other programs that house and/or provide support to homeless persons.
b) Describe the applicant's staff members', and any identified subcontractors' staff members', experience
administering programs similar, in size and scope, to the proposed program, including any
experience with homelessness prevention, rapid re-housing or other programs that house and/or
provide support to homeless persons.
c) Provide resumes for key personnel (including case managers and other supportive services staff) that
will be involved in operating the proposed program in Exhibit V. If the majority of staff for the
proposed program will need to be hired, provide minimum hiring criteria.

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3.

4.

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Organizational Qualifications and Past Performance.
a) Describe the applicant's, and any identified subcontractors', organizational experience providing
supportive services to very low-income families, who may include individuals with or without
dependents, including any experience with homelessness prevention, rapid re-housing or other
programs that house and/or provide support to homeless persons.
b)

Describe the applicant's, and any identified subcontractors', organizational experience coordinating
services for very low-income families among multiple organizations, Federal, State, local and tribal
governmental entities.

c)

Describe the applicant's, and any identified subcontractors', organizational experience in
administering programs similar, in size and scope, to the proposed program. Specifically, provide up
to three (3) examples of past or current programs in which the applicant acted, and up to two (2)
examples in which each identified subcontractor acted, as the coordinator or project/program lead for
a program of similar complexity to the proposed program. Each project/program described must
have been undertaken by the applicant or identified subcontractor (as applicable) within the past ten
(10) years. For each project/program listed, provide sufficient information to allow VA to identify
the project, confirm that the project is comparable in magnitude and complexity to the proposed
program, and contact each of the financing sources and other professionals involved with respect to
the applicant's, or identified subcontractor's, past performance on the project/program.

d)

Provide in Exhibit VI a list of at least three (3) references with or for whom the applicant has
successfully completed or worked on relevant projects/programs within the past ten (10) years. For
any identified subcontractors, provide in Exhibit VI a list of at least three (3) references with or for
whom each subcontractor has successfully completed or worked on relevant projects/programs
within the past ten (10) years. Each reference should be able to assess and provide information to
VA regarding performance and stakeholder satisfaction. Provide the name, title (if any), project/
program role (if any), address, telephone number, facsimile number, and email address for each
reference.

Experience Working with Veterans.
a) Describe the applicant's, and any identified subcontractors', staff members' experience working with
Veterans.
b) Describe the applicant's, and any identified subcontractors', organizational experience providing
supportive services to Veterans.
c) Describe the applicant's, and any identified subcontractors', organizational experience coordinating
services for Veterans among multiple organizations, Federal (including VA), State, local and tribal
governmental agencies.

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SECTION B: Program Concept & Supportive Services Plan
The information requested below should be included in the application packet with responses attached and
numbered to correspond to the relevant item. Total narrative supporting Section B should not exceed 5 pages,
excluding exhibits. In scoring the application, VA will award up to 25 points based on the applicant's
responses to questions contained in this section. Applicants should reference the requirements set forth in the
NOFA in preparing these responses.
1.

Need for Program.
a) Describe the location where the proposed program will operate and attach a map as Exhibit VII
showing the proposed area or community to be served. Include the name(s) of the municipalities,
counties (or parishes), or tribal lands that the proposed program will serve.
b) Provide the Veterans Integrated Service Network (VISN) number in which the proposed program
will operate. Please see Attachment A for a VISN map.
c) Identify which of the following geographic regions applies to the primary area or community in
which the proposed program will operate:
Urban community
Rural community
Tribal land
Other:
d) Estimate the following:
i.
Total number of homeless Veteran families (households) in the area or community to be served.
(Note: Include a description of the basis for the calculation and list all information sources, such as
HUD's Annual Homeless Assessment Report (AHAR), VA CHALLENGE Report, Homeless
Management Information System (HMIS) data, etc.)
ii. Total number of very low-income Veteran families (households) occupying permanent housing in
the area or community to be served. (Note: Include a description of the basis for the calculation
and list all information sources.)
iii. Total number of very low-income Veteran families (households) who are at-risk of homelessness
in the area or community to be served. (Note: This data is available from the VA National Center
on Homelessness Among Veterans web page:
(http://www1.va.gov/HOMELESS/NationalCenter.asp). Supporting data may also be found
through the American Community Survey (http://www.census.gov/acs/www).
e)

2.

Describe the characteristics and needs of the very low-income Veteran families who would be
eligible to receive supportive services through the proposed program in the proposed area or
community (list all information sources).

Outreach and Screening Plan.
a) Describe the proposed outreach and referral plan to identify and assist eligible very low-income
Veteran families who are most in need of supportive services, including coordination with local
affordable housing providers and other local service providers (including VA). Specify the locations
where applicant will conduct outreach. (Note: As described in the NOFA, grantees must spend
certain percentages of their supportive services grant funds on the provision of supportive services to
certain categories of very low-income Veteran families.)
b) Describe the plan for processing and screening very low-income Veteran family referrals. Include
list of screening questions that will be used and describe how very low-income Veteran families'
responses will be used to determine eligibility for supportive services.
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c)
d)
3.

Describe the process for referring ineligible Veteran families to other providers.
Describe the process to assess and accommodate the needs of incoming participants.

Program Concept.
a) Describe the proposed program concept, size, scope, and staffing plan. (Note: As described in the
NOFA, grantees must spend certain percentages of their supportive services grant funds on the
provision of supportive services to certain categories of very low-income Veteran families.)
b) Describe in narrative form how the applicant will provide the following services:
i) outreach services; ii) case management services; iii) assistance in obtaining VA benefits; and iv)
assistance in obtaining and coordinating other public benefits. (Note: Specify any case management
philosophies, approaches or evidence-based practices to be employed.)
c) Describe in narrative form and identify in the table below which of the following other public
benefits the applicant will either provide directly and/or assist participants in obtaining through
referrals to other organizations:

Type of Benefit/Service (See 38 CFR 62.33 for
definitions of these services)*

Applicant will provide
benefit directly
(Yes/No)

Applicant will assist participants in
obtaining benefit through referrals to
other organizations (Yes/No)

Health care services
Daily living services
Personal financial planning services
Transportation services**
Income support services
Fiduciary and representative payee services
Legal services
Child care
Housing counseling, housing search

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No

Other:

Yes

No

Yes

No

Other:

Yes

No

Yes

No

Other:

Yes

No

Yes

No

*Note: 38 CFR 62.33 requires grantees to assist participants to obtain, and coordinate the provision of, the
above-listed public benefits if they are being provided by Federal, State, local, or tribal government agencies,
or any eligible entity in the area or community served by the grantee by referring the participant to and
coordinating with such entity. With the exception of health care services and daily living services, grantees
may also elect to provide directly to participants the listed public benefits in accordance with the
requirements set forth in 38 CFR 62.34. If an applicant is NOT providing one of the above-noted benefits/
services (either directly or through referral), please describe the reason for this decision.
**Note: If the applicant intends to lease any vehicle(s) for the purposes of direct provision of transportation
services, the application must state that the applicant agrees to the following: (i) the vehicle(s) will be safe,
accessible, and equipped to meet the needs of the participants; (ii) the vehicle(s) will be maintained in
accordance with the manufacturer's recommendations; and (iii) all transportation personnel (employees and
subcontractors) will be trained in managing any special needs of participants and handling emergency
situations.

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d)

e)
f)
g)
h)
i)
j)
k)

Describe in narrative form and identify below which of the following other supportive services (if
any) will be offered to participants (see 38 CFR 62.33 and 38 CFR 62.34 for descriptions of these
supportive services):
Child Care Financial Assistance
Rental Assistance
Transportation
Utility-Fee Payment Assistance
Security or Utility Deposit Assistance
Other:
Other:
Moving Costs Assistance
Emergency Supplies Assistance
Describe the applicant's staffing plan if awarded a supportive services grant and the proposed ratio of
case managers to participants.
Describe the setting in which services will be provided (e.g., congregate permanent supportive
housing, scattered-site permanent supportive housing, unsubsidized/private market housing, etc.).
Describe the frequency with which services will be provided to participants.
Describe how the applicant will coordinate the provision of supportive services with the provision of
permanent housing by the applicant or by other organizations.
Describe the process and methods that will be used to maintain the confidentiality of participants and
participants' records.
Describe the process and methods that will be used to maintain the safety of participants.
Describe how individual goals will be set for participants.

4. Program Implementation Timeline.
a) Complete the following table describing the proposed program's implementation timeline - add
additional milestones as applicable:
# of Calendar Days from Date of
Milestone
Grant Agreement Execution
1. Program setup complete
2. Implementation of hiring plan (if applicable)
3. New staff begin work (if applicable)
4. Outreach services begin*
5. Case management, assistance in obtaining VA
benefits and assistance in obtaining and coordinating
other public benefits, and other supportive services
begin**
6. Other:
*Note: Applicants are encouraged to begin outreach services within 30 days of grant agreement execution
**Note: Applicants are encouraged to have their programs fully operational within 60 days of grant
agreement execution
b)
c)

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Describe the program implementation plan that will accomplish the above timeline, including any
hiring plan if required.
Describe possible obstacles to program implementation and potential mitigation strategies.

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5. Collaboration and Communication with VA. Describe the applicant's plan to coordinate outreach and
services with local VA facilities.
6. Ability to Meet VA's Requirements, Goals and Objectives for the SSVF Program.
a) Describe how the proposed program's design, implementation, and evaluation process will meet
VA's requirements, goals and objectives for the SSVF Program as identified in 38 CFR Part 62 and
the NOFA.
b) Estimate the approximate percentage of the proposed program's total participants who either i) are
very low-income Veteran families who are homeless and scheduled to become residents of
permanent housing, or ii) have exited permanent housing within the previous 90 days to seek other
housing that is responsive to their needs and preferences.
c) If applicable, specify which of the following very low-income Veteran family populations will be
targeted by the proposed program (see NOFA for additional information, including definition of
chronically homeless and formerly chronically homeless Veteran families) (Note: Applicant's
response must be consistent with identified need described in Question 2 of this section.):
Target Populations

% of Total Participants Served

Veteran families earning less than 30 percent of
area median income as published annually by the
Department of Housing and Urban Development
(http://www.huduser.org)
Veterans with at least one dependent family
member
Chronically homeless Veteran families
Formerly chronically homeless Veteran families
7. Capacity to Undertake Program.
a) Describe the applicant's, and any identified subcontractors', other ongoing projects and programs.
b) Describe the time commitments of key personnel, including any new hires, who will be involved in
the proposed program. Include a description of workload for each case manager (if applicable) and
the expected allocation of time to the proposed program.

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SECTION C: Quality Assurance & Evaluation Plan
The information requested below should be included in the application packet with responses attached and
numbered to correspond to the relevant item. Total narrative supporting Section C should not exceed 3 pages.
In scoring the application, VA will award up to 15 points based on the applicant's responses to questions
contained in this section
1.

Program Evaluation.
a) Describe in narrative form the proposed program's expected goals and outcomes. (Note: Goals
should reflect the SSVF Program's aim of reducing and preventing homelessness among very lowincome Veteran families.)
b) Explain how the applicant intends to measure the program's achievement of these goals and
outcomes on a quantitative and qualitative basis. (Note: As described in the NOFA, all grantees will
be required to enter participant data into a Homeless Management Information System (HMIS) and
share that data with VA.)
c) Describe how the applicant decided upon these evaluation metrics and expected outcomes.
d) Describe the frequency in which evaluations will occur.

2.

Monitoring.
a) Describe how the applicant will regularly monitor the quality of the supportive services provided to
participants and the program's compliance with all applicable laws, regulations, and guidelines.
b) Explain how the applicant will evaluate the performance of case managers and other supportive
services staff, including any subcontractors that will be retained for the proposed program.
c) Describe the applicant's, and any identified subcontractors', ongoing staff training and/or certification
requirements.
d) Describe the applicant's operational and financial controls that will be put in place to ensure
compliance with SSVF Program requirements and the proper use of supportive services grant funds.

3.

Remediation. Describe the process by which the applicant will remediate non-compliant aspects of the
program if and when they are identified.

4.

Management and Reporting.
a)
b)

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Describe the role of the management team in overseeing the ongoing reporting activities of the
proposed program.
Describe the applicant's plan to ensure the timeliness, quality, and accuracy of information submitted
to VA in reports and of data entered into the web-based HMIS for use by VA in monitoring program
outcomes.

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SECTION D: Financial Capability & Plan
The following items concern the applicant's financial plan. The narrative descriptions for the sources and uses
of funds should include the sources of information for the forecasts and the methodology used for developing
the forecasts. Any documentation that provides the basis for the projected costs/revenues should be included
within Exhibit IX (see Attachment B, Applicant Budget Template).
The information below should be included in the application packet with responses attached and numbered to
correspond to the relevant item. Exhibit IX below must also be provided in the Microsoft Excel template
provided in Attachment B. Total narrative supporting Section D should not exceed 5 pages, excluding exhibits.
In scoring the application, VA will award up to 15 points based on the applicant's responses to questions
contained in this section.
1.

Organizational Finances.
a)
b)
c)

2.

Provide a general overview of the applicant's, and any identified subcontractors', financial health.
Provide a summary of the total sources and uses of funds for the organization(s).
Attach the previous year's audited financial statements for the applicant and any identified
subcontractors as Exhibit VIII.
Describe any other circumstances that VA should take into account in reviewing the financial
position of the applicant and any identified subcontractors.

Estimated Monthly Program Cost Summary (one-year period).
a) Provide a detailed one-year program budget that is itemized on a monthly basis and provide a
summary of total program costs, including those costs paid for by non-SSVF sources. To meet this
requirement, applicants must complete these tasks in the Microsoft Excel template contained in
Attachment B of this application package. The Microsoft Excel file, along with the rest of the
application, must be both printed and submitted electronically as Exhibit IX.
b)

If indirect charges, such as administrative costs, are included in the proposed budget, provide the
following:
i.
Name and address of the cognizant government audit agency (the agency that is providing the
most Federal funds).
ii. Name, address and phone number of the government auditor
iii. Documentation from the cognizant agency indicating: a) Indirect cost rate and the base against
which the rate should be applied; b) Effective period (dates) for the rate; and, c) Date that the last
rate was computed and negotiated.
iv. If no government audit agency computed and authorized the rate claimed, applicant must provide a
brief explanation of computation, who computed it, and the date of computation.

c)

Total supportive services grant amount request: $

d)

Average supportive services grant amount request per participant household: $
Describe any factors that VA should take into account in reviewing this amount.

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e)

Provide detailed description of the allocation of supportive services grant funds as a percentage of
the overall proposed program budget for the following cost categories:
Cost Category

Estimated % of Total Supportive Services Grant Funds

Outreach services
Case management services
Assistance in obtaining VA benefits
Assistance in obtaining and coordinating other public
benefits
Temporary financial assistance
Other supportive services proposed by the applicant in this
application
Administrative costs

f)

Describe in narrative form the uses of funds for the proposed program. Narrative should include a
justification of the supportive services grant amount specified both in Part D of the Executive
Summary and in this section. Narrative should also explain how applicant will track the amount of
funds spent on the different categories of participants “occupying permanent housing” in order to
comply with the requirements set forth in the NOFA.
g) Describe the applicant's plan for implementing the proposed program on-budget.
Note: All cost estimates should be expressed on a cash (year-of-expenditure/receipt) basis and should include a
narrative describing assumptions used to arrive at such estimates.
3.

Summary of Sources of Program Funds.
a) Describe all sources of funds to be used to operate the proposed program and specify the nature of
the sources. Sources should include separate line items, as applicable, for Federal grants, State
grants, local government grants, and any other contributions, including any borrowing (specify type
of borrowing). For each line item, describe the status of the source (e.g., requested, committed, and
received).
b)

If available, attach documentation (e.g., executed letters of credit and funding agreements) as Exhibit
X to provide the basis for projected sources of funds.
c) Describe the applicant's plan to continuously seek new sources of assistance to ensure the long-term
provision of supportive services to participants.
Note: Total sources and uses should be equal to one another and equal the estimated total proposed program
costs. All estimates should be expressed on a cash (year-of-expenditure/receipt) basis.
4.

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Risks and Mitigation Strategies. In general, describe the financial risks associated with the
implementation of the proposed program. Provide a detailed strategy for mitigating each of these risks.

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SECTION E: Area or Community Linkages and Relations
The information below should be included in the application packet with responses attached and numbered to
correspond to the relevant item. Total narrative supporting Section E should not exceed 3 pages. In scoring the
application, VA will award up to 10 points based on the applicant's responses to questions contained in this
section.
1.
Area or Community Linkages.
a) Provide evidence of established linkages (e.g., MOUs or letters of intent/support) with the Federal
government (including VA), State, local or tribal governmental agencies, or private entities for the
purposes of providing additional services to participants (e.g., HUD's Homelessness Prevention and
Rapid Re-Housing Program (HPRP), Low-Income Home Energy Assistance Program (LIHEAP),
Housing and Urban Development - Veterans Affairs Supportive Housing (HUD-VASH),
Community Services Block Grant services, etc.). Applicant may also include a plan to establish
such linkages for the purposes of providing additional services to participants.
b)
c)

Provide evidence of the applicant's, and any identified subcontractors', current and/or planned
coordination and outreach with State and/or County (parish) Veterans' affairs departments/agencies.
Provide evidence of the applicant's, and any identified subcontractors', current coordination and
outreach with local VA facilities. If possible, include a letter of support from the Director of the
local VA Community-Based Outpatient Clinic or Medical Center.

2.

Past Working Relationships. Describe the applicant's (or applicant's staff's), and any identified
subcontractors' (or any subcontractor's staff), successful past working relationships with public and/or
private institutions providing services to Veterans or very low-income families. Provide the name of each
institution and the nature of the relationships, including measurable benefits and positive outcomes from
those relationships.

3.

Local Presence and Knowledge. Provide evidence of knowledge of and presence in the area or
community in which the proposed program will be operated.

4.

Integration of Linkages and Program Concept. Describe how linkages to the local area or community are
expected to enhance the effectiveness of the proposed program and the provision of supportive services to
participants.

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SECTION F: Applicant Certifications & Assurances
The following items require a single certification on page 19 by an authorized representative of the applicant
requesting a supportive services grant. The list below should be included in the application packet with
responses attached and numbered to correspond to the relevant item. VA may require that applicants provide
documentation of these certifications.
1.
Compliance. Applicant assures that the applicant and any subcontractors will comply with all
requirements of 38 CFR Part 62. If the applicant intends to request waivers to any requirements included
in the preceding citation, please explain.
2.
Accuracy of Application Information. All information submitted with this application is accurate, and
does not contain any false, fictitious or fraudulent statement or entry.
3.
Non-Delinquency. The applicant further certifies that the applicant is not currently in default or
delinquent on any debt or loans provided or guaranteed by the Federal Government.
4.
Debarment. The applicant further certifies that the applicant has not been in the preceding three years: a)
debarred, suspended or declared ineligible from participating in any Federal program; b) formally
proposed for debarment, with a final determination still pending; c) voluntarily excluded from
participation in a Federal transaction; or d) indicted, convicted, or had a civil judgment rendered against it
for any of the offenses listed in the Regulations Governing Debarment and Suspension (Governmentwide
Nonprocurement Debarment and Suspension Regulations: 49 CFR Part 29).
5. Reports and Record Retention. If this supportive services grant is awarded, applicant assures that any and
all reports required by VA will be made available in such form and contain such information as VA may
require. Applicant further assures that upon demand, VA has access to the records upon which such
information is based.
6.
Fiscal Control. If this supportive services grant is awarded, applicant assures that it will establish and
maintain such procedures for fiscal control and fund accounting as may be necessary to ensure proper
disbursement and accounting with respect to the supportive services grant.
7.
Civil Rights. This program will comply with all provisions of Title VI of the Civil Rights Act of 1964
(42 U.S.C. 2000d et seq.).
Yes
No If no, explain on an attached sheet
8.

Lobbying. Section 1352 of Title 31, United States Code and 49 CFR §20.100, provides that none of the
funds appropriated by any Act of Congress may be expended by a recipient of a contract, grant, loan, or
cooperative agreement to pay any person for influencing or attempting to influence an officer or
employee of any Federal agency, a Member of Congress, or an employee of a Member of Congress in
connection with the award or making of a Federal contract, grant, loan, or cooperative agreement or the
modification thereof. VA interprets this provision to include the use of appropriated funds to influence or
attempt to influence the selection for a secured loan, loan guarantee, or line of credit under the SSVF
Program.
SSVF Program applicants must file a declaration: (a) with the submission of an application for SSVF
Program assistance; (b) upon receipt of a SSVF Program credit instrument (unless the information
contained in the declaration accompanying the SSVF Program application has not materially changed);
and (c) at the end of each calendar quarter in which there occurs any event that materially affects the
accuracy of the information contained in any declaration previously filed in connection with the SSVF
Program assistance.
A declaration filed in connection with the SSVF Program assistance shall contain:
a)

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The name of any registrant under the Lobbying Disclosure Act of 1995 who has made lobbying
contacts on behalf of the SSVF Program applicant.

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b) A certification by the person making the declaration that none of the funds appropriated by any Act
of Congress has been or will be expended to pay any person for influencing or attempting to
influence an officer or employee of VA or any Federal agency, a Member of Congress, an officer or
employee of Congress, or employee of a Member of Congress with regard to the SSVF Program
assistance.
In addition, any person or entity that requests or receives a subcontract from a SSVF Program applicant is
required to file a declaration which shall contain the name of any registrant under the Lobbying Disclosure
Act who has made lobbying contacts and a certification that the person or entity has not made or will not
make prohibited payments.
The applicant certifies, to the best of his or her knowledge and belief, that: (a) no federally appropriated
funds have been paid or will be paid by or on behalf of the applicant to influence or attempt to influence
an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress,
or an employee of a Member of Congress in connection with an award of SSVF Program assistance; and
(b) if non-federally appropriated funds have been or will be paid for the above purposes, the applicant will
disclose such payments through the completion and submission of Standard Form LLL (“Disclosure Form
to Report Lobbying”). The applicant shall file Standard Form LLL in accordance with its instructions.
Submission of this statement with the SSVF Program application is a prerequisite for obtaining SSVF
Program assistance.
Any person who makes an expenditure of appropriated funds prohibited by 31 U.S.C. 1352(a) or fails to
file the required statement or amended statement shall be subject to a civil penalty of not less than $10,000
and not more than $100,000 for each such failure in accordance with 31 U.S.C. 1352(c).
Signature: By submitting this application, the applicant certifies that the facts stated and the certifications and
representations made in this application are true, to the best of the applicant's knowledge and belief after due
inquiry, and that the applicant has not omitted any material facts. The undersigned is an authorized
representative of the applicant.
Applicant:
Signed:
Name and Title:
Date:

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Attachment A: Veterans Integrated Service Networks (VISNs) Map
Section B, question 2b requests that the applicant identify the VISN in which their proposed program will
operate. Below is a map of VA's VISNs.

VISN 1: VA New England Healthcare System
VISN 2: VA Healthcare Network Upstate New York
VISN 3: VA NY/NJ Veterans Healthcare Network
VISN 4: VA Healthcare - VISN 4
VISN 5: VA Capitol Health Care Network
VISN 6: VA Mid-Atlantic Health Care Network
VISN 7: VA Southeast Network
VISN 8: VA Sunshine Healthcare Network
VISN 9: VA Mid South Healthcare Network
VISN 10: VA Healthcare System of Ohio
VISN 11: Veterans In Partnership

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VISN 12: VA Great Lakes Health Care System
VISN 15: VA Heartland Network
VISN 16: South Central VA Health Care Network
VISN 17: VA Heart of Texas Health Care Network
VISN 18: VA Southwest Health Care Network
VISN 19: Rocky Mountain Network
VISN 20: Northwest Network
VISN 21: Sierra Pacific Network
VISN 22: Desert Pacific Healthcare Network
VISN 23: VA Midwest Health Care Network

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Attachment B: Applicant Budget Template (Microsoft Excel File)
In response to application Section D, question 2.a), applicants are required to provide a detailed one-year
program budget that itemizes on a monthly basis the supportive services and administrative costs associated
with the proposed program. Per Application Section D, question 2.f), a detailed narrative must accompany the
program budget.
The one-year program budget must be completed in the Microsoft Excel template provided. Instructions on the
use of this template are as follows:
Overview
The Microsoft Excel Applicant Budget Template contains two separate “worksheets” or “tabs.” Applicants are
required to complete both tabs. Tab 1 consists of a monthly breakdown of projected uses of SSVF grant funds.
Tab 2 consists of a summary of total program costs, including those costs paid for by non-SSVF sources. Both
tabs of the Microsoft Excel file must be printed and submitted electronically as Exhibit IX.
Tab 1: Monthly SSVF Grant Funds Budget
General
a.
b.

Applicant is responsible for filling in yellow cells only.
All non-yellow cells are locked and populate automatically.

Provision and Coordination of Supportive Services (Total must be a minimum of 90% of the total SSVF Grant
Amount)
a.

Personnel/Labor (Note: The spreadsheet will spread these costs evenly across all 12 months. If the
applicant does not anticipate an even spread of costs, this should be explained in the narrative.):

b.

Temporary Financial Assistance: Input the estimated cost of temporary financial assistance, which
includes time-limited payments to third parties for rent, utilities, moving expenses, security and utility
deposits, transportation, child care and emergency supplies. (Note: Please reference the NOFA for
limitations on the percentage of the total SSVF grant that can be used for this purpose.)
• Title and Organization - input the titles of all SSVF-funded personnel (e.g., Program Director, Case
Manager, Employment Specialist, etc.) and the organization at which they are or will be employed
(i.e., list applicant organization or team member organization name as applicable). Add additional
lines to the spreadsheet as necessary.
• # of Full-Time Employees (FTE) - input the number of FTE who will hold the specified title at the
specified organization
• % FTE - input the percentage of time the staff member will devote to the SSVF-funded program (e.g.,
full-time staff would be shown at 100%)
• Base Annual Salary / Wage - input the annual salary of the specified personnel, assuming full-time
employment
• Fringe Benefits - cost of fringe benefits as a percentage of annual salary (if any)

c.

Other Non-Personnel Provision and Coordination of Supportive Services Expenses: List any other
expenses related to the provision and coordination of supportive services expenses in this section and the
monthly costs associated with those expenses.

d.

Lease & Maintenance of Vehicle(s): Per 38 CFR 62.33, if public transportation options are not sufficient
within an area or community, costs related to the lease of vehicle(s) may be included in the application.
Specify the number of vehicles to be leased and the cost per month associated with these vehicles.

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Administrative Expenses (Total cannot exceed 10% of total SSVF Grant Amount)
List all administrative expenses and the monthly costs associated with each expense. Per 38 CFR 62.70,
administrative expenses are defined as all direct and indirect costs associated with the management of the
program. These costs will include the administrative costs, both direct and indirect, of subcontractors.
Tab 2: Monthly SSVF Grant Funds Budget
General
a.
b.
c.
d.
e.
f.

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Applicant is responsible for filling in yellow cells only.
All non-yellow cells are locked and populate automatically.
List each non-SSVF source of program funding across the Program Expenses line of the worksheet.
List the share each funding source, including the SSVF Program, will pay of total program costs.
The SSVF Grant Funds column must match the “SSVF Grant Funds Total Annual” column in Tab 1.
See Tab 1 instructions for explanations of each section and line item.

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