Form VA 10096 VA 10096 Adaptive Sports Grant Application

OMB Number: 2900-0820
Exp. Date: Feb., 2015
Respondent Burden: 20 minutes

ADAPTIVE SPORT GRANT APPLICATION
PRIVACY ACT: The information requested on this form is solicited under the authority of Title 38, U.S.C., and Sections 1710, 1712, and 1722. It is
being collected to enable us to determine your eligibility for benefits and will be used for that purpose. The information you supply may be verified
through a computer matching program at any time and information may be disclosed outside the VA as permitted by law. VA may make a routine use
disclosure of the information as outlined in the Privacy Act system of records identified as 58VA21/22/28, Compensation, Pension, Education and
Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary; however, the
information is required in order for us to determine your eligibility for the benefit for which you have applied. Failure to furnish the information will
have no adverse affect on any other benefits to which you may be entitled.
RESPONDENT BURDEN: 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 the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond
to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this
application will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.

SECTION A - ORGANIZATION AND GRANT INFORMATION
1. ORGANIZATION AND MAILING ADDRESS

3. GRANT AMOUNT
REQUESTED

2. PROGRAM NAME AND TITLE

SECTION B - CONTACT INFORMATION

4. PRIMARY CONTACT

5. PRIMARY PHONE NUMBER

6. ALTERNATE PHONE NUMBER

7. EMAIL

SECTION C - PROGRAM AND OTHER INFORMATION
8. DUNS NUMBER (Must provide a DUNS
number before any payment is disbursed)

9. CONGRESSIONAL DISTRICT

12. PROJECTED START DATE

13. PROJECTED COMPLETION DATE 14. TARGET GEOGRAPHIC AREA(S)

10. SAM NUMBER

11. EIN NUMBER

15. CATEGORY
INITIAL

RENEWAL

16. DISABILITY GROUPS

NON-COMPETITIVE
AMPUTEE

SPINAL CORD
INJURY

TBI/STROKE

BLIND/VI

PTS

17. EXPERIENCE WITH DISABLED VETERANS? 18. COMPLEMENTARY FUNDING?
YES

NO

FEDERAL:

YES

NO

AMOUNT:

NON-FEDERAL:

YES

NO

AMOUNT:

Program Details
1. Program Past Performance:
Applicant must demonstrate eligibility to receive a grant award in accordance with 38 USC 77(2). Limit response to one written page.
2. Program Specifics:
Applicant must clearly describe specific aspects of the proposed program to include: type of adaptive sport(s) provided (community/national events,
introductory/competitive events, local/or requires travel), frequency and duration of occurrence, location(s) of programming, estimated number of
unique Veterans/ Service Members served (required to be reported by last name, first name and zip code on quarterly reports), type of disabilities
served by the proposed adaptive sport, and benefits of the programming to participants. Limit responses to 2 pages.
VA FORM
MAR 2015

10096

3. TIMELINE OF ACTIVITIES
OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

4. OUTREACH PROGRAM SPECIFICS

This application does not constitute a Grant Agreement. Upon approval of the application by VA, an applicant will be required to complete a signed
Grant Agreement specifying terms and conditions of an award. The Program Goals and Deliverables (Exhibit A) and Program Budget (Exhibit B)
will form the basis of the Grant Agreement as agreed upon by VA and the applicant. Upon full execution of the Grant Agreement, the applicant will
perform the services/activities hereto attached in Exhibit A, perform the Program Budget in line with the budget attach hereto in Exhibit B unless
otherwise agreed upon by the applicant and VA.
In the event the applicant and VA do not enter into a Grant Agreement for any reason, and/or in the event the applicant and VA are unable to agree on
the terms of the Grant Agreement within 60 days after approval of the application by VA, this application will automatically terminate.
SIGNATURE

ORGANIZATION NAME

NAME

TITLE

DATE

5. QUALIFICATIONS OF PERSONNEL
(Include specific experience, education or other qualifications relevant to the grant proposal.)
NAME

TITLE

QUALIFICATIONS

6. PARTNERING AND COLLABORATING ORGANIZATIONS
(Include signed agreements for partnering or joint activities.)
VA/DOD/VAMC/VSO/ POC
COLLOBORATING ORGANIZATION NAME

VA FORM 10096, MAR 2015, page 2

LOCATION
(CITY, STATE)

COLLABORATIVE ACTIVITIES

EXHIBIT A
Program Goal and Deliverables
Organization Name:
Program Deliverable
DELIVERABLE SUBCOMPONENTS

PROJECTED
START

PROJECTED
COMPETION
EVENT

1

TRAINING
ENABLER
EVENT

2

TRAINING
ENABLER
EVENT

3

TRAINING
ENABLER
EVENT

4

TRAINING
ENABLER
EVENT

5

TRAINING
ENABLER
EVENT

6

TRAINING
ENABLER
EVENT

7

TRAINING
ENABLER
EVENT

8

TRAINING
ENABLER
EVENT

9

TRAINING
ENABLER
EVENT

10

TRAINING
ENABLER
EVENT

11

TRAINING
ENABLER
EVENT

12

TRAINING
ENABLER

VA FORM 10096, MAR 2015, page 3

EXHIBIT B
VA ADAPTIVE SPORTS GRANT PROGRAM BUDGET
Program Budget and Expected Expenditures (Grant Funds Only)
CATEGORY

AMOUNT

DESCRIPTION OF EXPENDITURES

PROJECTED SPENDING IN EACH QUARTER ($)
OCT-DEC
OCT-DEC
APR-JUN
JUL-SEPT
(Q1)
(Q2)
(Q3)
(Q4)

Operations
Equipment
Travel
Supplies
Administrative
Personnel
(Operational)
Personnel
(Administrative)
Other
Total

BUDGET CATEGORY DEFINITIONS
ONLY include amounts spent against this award. DO NOT report expenditures that are funded by other sources.
For further information regarding allowable costs, please reference OMB guidance (2 CFR 200 and 38 CFR 77).
Operations - Expenditures associated with implementing this grant program such as coaching fees, lift tickets and facility fees.
Equipment - Sport equipment purchased to meet program objectives. To be categorized as equipment must have a useful life of more than one year
and a unit price equal to or greater than $5,000. Equipment expenditures must be identified in your Grant Application and listed on Exhibit C.
Travel - Expenses for transportation, lodging, subsistence, and related items incurred to meet program objectives. Costs must be consistent with those
allowed in like circumstances in your organization's other activities.
Supplies - Consumable items in direct support of carrying out the award or equipment purchases with a per-unit value less than $5,000.
Administrative (non-Personnel) - Sum of Administrative and In-Direct Costs that do not include Personnel (Administrative). When combined with
Personnel (Administrative) costs, may not exceed 5% of the total award. Costs must be clearly identified and associated with the implementation and
tracking of the award.
Personnel (Operational) - Includes both Personnel and Fringe Benefit expenses that should be based on documented payrolls approved by a
responsible official(s) of the organization. Reports need to reflect the distribution of activity for those whose compensation is charged, in whole or in
part, directly to this award. Operational activities are identified as "time spent by such employee directly providing coaching or training for
participants" per 38 CFR 77.14(c)(2). The reports must reflect an after-the-fact determination of the actual activity worked on the program. Reports
must account for the total activity for which employees are compensated.
Personnel (Administrative) - Includes both Personnel and Fringe Benefits expenses that should be based on documented payrolls approved by a
responsible official(s) of the organization. Reports need to reflect the distribution of activity for those whose compensation is charged, in whole or in
part, directly to this award. Administrative activities are identified as all personnel activities that are not "time spent by such employee directly
providing coaching or training for participants" per 38 CFR 77.14(c)(2). The reports must reflect an after-the-fact determination of the actual activity
worked on the program. Reports must account for the total activity for which employees are compensated.

VA FORM 10096, MAR 2015, page 4

EXHIBIT C
EQUIPMENT PURCHASES
Organization Name:
Equipment Purchases
*Report the purchase of single units/pieces of equipment equal to or in excess of $5,000. This is only for equipment purchases using this award.
TYPE OF EQUIPMENT

MAKE AND MODEL

APPROXIMATE
VALUE

QUANTITY

EXHIBIT D
ADAPTIVE SPORTS OFFERED

Please indicate the type of adaptive sport activity: introductory, participatory, or competitive.
SPORT

VA FORM 10096, MAR 2015, page 5

INTRODUCTORY

PARTICIPATION

COMPETITION