10-0388-5 Additional Documents And Information Required For State

OMB Number: 2900-0661
Estimated Burden: 6 hours

ADDITIONAL DOCUMENTS AND INFORMATION REQUIRED FOR
STATE HOME CONSTRUCTION AND ACQUISITION GRANTS APPLICATION
PROJECT DESCRIPTION

FAI NUMBER

PROJECT LOCATION

SECTION I - INITIAL REQUIREMENTS DUE AUGUST 1st

The State Representative must submit the following to the Department of Veterans Affairs (VA) Chief, State Home Construction

Grant Program (SHCGP) to receive a grant:
1.

VA Form 10-0388-6, CERTIFICATION OF STATE MATCHING FUND.

2.

Evidence (act, issued bonds, etc.) that the state has its share of the estimated total costs of construction.
SECTION II - ADDITIONAL REQUIREMENTS

The State Representative must submit the following certifications to VA.
1.

Phase I - Environmental Survey
Site plan/map, site survey, and soil investigation (if applicable). Design development site plan. The applicant shall
submit a site survey, which has been performed by a licensed land surveyor. A description of the site shall be
submitted noting the general characteristics of the site. This should include soil reports and specifications,
easements; main roadway approaches, surrounding land uses, availability of electricity, water and sewer lines, and
orientation. The description should also include a map locating the existing and/or new buildings, major roads, and
public services in the geographic area. Additional site plans should show all site work including property lines,
existing and new topography, building locations, utility data, and proposed grades, roads, parking areas, walks,
landscaping, and site amenities.

2.

Phase II - Environmental Assessment
This requirement applies only if the outside construction exceeds 75,000 gross square feet (GSF). When the
application submission requires an environmental assessments, the state shall describe the possible beneficial
and/or harmful effect which the project may have on the following impact categories:
1. Transportation
2. Air Quality
3. Noise
4. Solid Waste
5. Utilities
6. Geology (Soils/Hydrology/Flood Plains)
7. Water Quality
8. Land Use
9. Vegetation, Wildlife, Aquatic, and Ecology/Wetlands
10. Economic Activities
11. Cultural Resources
12. Aesthetics
13. Residential Population
14. Community Services and Facilities
15. Community Plans and Projects
16. Other

VA FORM
JUL 2013

10-0388-5

PAGE 1 OF 3

SECTION II CONTINUED

3.

Phase II - Environmental Assessment Continued
If an adverse environmental impact is anticipated, the action to be taken to minimize the impact should be explained
in the environmental assessment.
If the proposed actions involving construction or acquisition do not individually or cumulatively have a significant
effect on the human environment or if the outside construction does not exceed 75,000 GSF, the applicant shall
submit a letter noting a categorical exclusion, subject to approval by VA.

4.

State Historical Preservation Letter
Letter from the state historical preservation officer (SHPO) and subsequent clearance from the VA historical
preservation officer and a copy from the SHPO stating whether the project area includes any properties on, eligible
for, or likely to meet the criteria for the national register of historic places. If the property does, or may include,
national register quality properties, the letter from SHPO should discuss the determination of effect of the proposed
project on such property.

5.

Design Development (35 percent) Drawings
The applicant shall provide to the VA one CD of the submittal. Please send directly to the VA Office of Facilities &
Construction Management (OOCFM1A), with a copy of the transmittal letter to the Chief, State Home Construction
Program. The drawings must indicate the designation of all spaces, size of areas and rooms and indicate in outline
the fixed and movable equipment and furniture. The total floor and room areas shall be shown in the drawings. The
drawings must include:
1. A plan for each floor (for renovations, the existing conditions and extent of new work should be clearly
delineated);
2. Plans of any proposed demolition work;
3. Elevations;
4 .Sections and typical details;
5. Roof plan;
6. Fire protection plans; and
7. Technical engineering plans, including structural, mechanical, plumbing, and electrical drawings.
If the project involves acquisition, or renovation, the state should include the current as-built site plan, floor plans
and building sections that show the present status of the building and a description of the building's current use and
type of construction.

6.

VA Form 10-0388-7, CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY
MATTERS FOR PRIMARY COVERED TRANSACTIONS.

7.

VA Form 10-0388-8, DEPARTMENT OF VETERANS AFFAIRS CERTIFICATION REGARDING DRUG-FREE WORKPLACE
REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS.

8.

VA Form 10-0388-9, CERTIFICATION REGARDING LOBBYING.

9.

VA Form 10-0388-2, CERTIFICATION OF COMPLIANCE WITH PROVISIONS OF THE DAVIS-BACON ACT.
SECTION V - CONDITIONAL APPROVAL

If all previously mentioned requirements for a grant are met, a State may be eligible for a conditional approval of a grant under the
provisions of 38 CFR 59.70.

VA FORM
JUL 2013

10-0388-5

PAGE 2 OF 3

SECTION II CONTINUED

10.

Final drawings and specifications
The applicant shall provide to VA one copy of specifications, and one CD of the submittal. Please send directly to
the VA Office of Facilities & Construction Management (00CFM1A) with a copy of the transmittal letter to Chief,
State Home Construction Program.

11.

Advertisement for the proposed project and request for bids.

12.

Two copies of the itemized bid tabulations.

13.

VA Form 10-0388-12, CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY
EXCLUSION LOWER TIER COVERED TRANSACTIONS (TO BE SIGNED BY THE CONTRACTORS.)

14.

Revised SF 424, SF 424c budget pages, based on the selected bids (including final cost for all items in the project).

15.

VA form 10-0388-10, CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS STATE HOME
CONSTRUCTION GRANT.

16.

Budget Summary Narrative.

17.

Reasonable assurance that the state home, or another agency or instrumentality of the state has title to the site for the
project.

18.

Three signed originals of the Memorandum of Agreement that includes provisions in the Sample Memorandum of Agreement.

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 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.
VA FORM
JUL 2013

10-0388-5

PAGE 3 OF 3