Checklist of Major Requirements for State Home Construction/Acquisition Grants

CHECKLIST OF MAJOR REQUIREMENTS FOR STATE HOME
CONSTRUCTION/ACQUISITION GRANTS
LOCATION

DESCRIPTION

FAI NUMBER

DUNS

DATE AND TIME SUBMITTED

VA COST

TO BE FILLED OUT BY VA

SECTION A - INITIAL APPLICATION PHASE (Deadline is APRIL 15 Each Year for VA Receipt)
DATE

REQUIREMENT

1. Form SF 424, 424C, and 424D (includes description of project).
2. Governor's designation of authorized state official and contact person
3. Needs assessment (Title 38 CFR 59.170, VAF 10-0388-1 requirements)
4. State Clearinghouse Comments (E.O. 12372) single point of contact.
5. Schematics for the proposed project.
6. State Application Identifier Number (if applicable).
7. Signed initial application certification (VA Form 10-0388-1).
8. Certification for safety project
9.

Documentation that there is a reasonable basis to conclude that the facility when complete will be fully
occupied.

10. Space program analysis.
11. Five-year capital plan for state's entire state home program.
12. Financial plan for state facility's first three years of operation.
13. Statement regarding the total number of state-operated nursing home and domiciliary.
14.

Authorized state official's certification that the number of state home beds does not exceed the requirement in
59.40.

15. Justification for number of state home beds exceeding 59.40 based on travel distance (59.40(b))
TO BE FILLED OUT BY VA

SECTION B - APPLICATION PHASE
REQUIREMENT

1.

DATE

The following is required by AUGUST 1 for consideration for priority group 1:
A. Updated Form SF 424, 424 C, 424D.
B. Estimate for equipment not included in the construction contract (not to exceed 10 percent of the
construction costs).
C. State authorization for the project (copy of the legislation appropriating the funds or statement from state
budget official outlining source of funding).
D. Certificate of State matching funds (VA Form 10-0388-6).

2. Environmental Survey/Assessment
A. Phase I Environment Survey: site plan/map, site survey, and soil investigation (if applicable).
B. Phase II Environmental Assessment (if outside construction exceeds 75,000 gross square feet) or a
statement from authorized state official that outside construct does not exceed 75,000 GSF.
VA FORM
JUL 2013

10-0388-14

Page 1 of 2

REQUIREMENT

DATE

3. Letter from state historical preservation officer.
4. Design development drawings and specifications (35 percent)
5. Required certifications from the authorizing state official is required for grant award:
A.

Compliance Regarding Debarment, Suspension, And Other Responsibility Matters For Primary Covered
Transactions (VA Form 10-0388-7).

B.

Compliance with Drug-Free Workplace (VA Form 10-0388-8).

C.

Compliance with Lobbying Act (VA Form 10-0388-9).

D.

Compliance with The Davis-Bacon Act (VA Form 10-0388-2).

Conditional Approval: If aforementioned requirements are substantially met, and federal funds are available, then a request for
6. conditional approval may be submitted to VA with written assurance State will meet remaining requirements within 180 days. The
following items are needed for final grant award.
A.

Final drawings and specifications (100 percent). Send CD's to 00CFM and SHCGP

B.

Advertise for bids.

C.

Bid tabulations. (Attach excluded parties list system search results.)

D.

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion From Contractor(s)
(VA Form 10-0388-12).

E.

Revised budget page (SF 424c) based on bids (Including FAI number, Project Description, and Date).

F.

Final application - SF 424, based on bids and consistent with SF 424c.

G.

Certification of Compliance with Federal Regulations (VA Form 10-0388-10).

H.

Budget Summary Narrative (review all 424c)

I.

Three (3) signed copies of Memorandum of Agreement. (Delivered by Overnight Mail)

J.

Reasonable assurance of title to State Home.

K.

Signed Application Certification (VA Form 10-0388-5).
TO BE FILLED OUT BY VA

SECTION C - POST GRANT AWARD (Required Prior to Final Payment)
REQUIREMENT

DATE

1. Equipment list (prior to completion of construction).
2. Project Photos (JPG format) sent to State Homes Construction Grants Program and 00CFM
3. Single Audit Act of 1984; state responsible for audit. Resolution of audit findings (if applicable).
4. Final Payment Request
5. Signed Post-Grant Requirements Certification (10-0388-13)
*Note: Unless otherwise indicated scan and e-mail documents to SHCGP.

VA FORM
JUL 2013

10-0388-14

Page 2 of 2