Supportive Services for Veteran Families Program

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Overview

Tab 1 Applic Mthly SSVF Budget
Tab 2 Qtrly Variance Report
Tab 3 Qtrly Spending by Sub
Tab 4 Qtrly Draw Downs
Tab 5 Number Served
Tab 6 Non VA Funding Sources

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Sheet 1: Tab 1 Applic Mthly SSVF Budget

VA's Supportive Services for Veteran Families Program

Application Exhibit IX, Tab 1 - Applicant Budget - Monthly SSVF Grant Funds Budget

Note: Grantee to attach the budget they submitted with their grant application.

Name of Applicant:

INSERT APPLICANT NAME

SSVF Grant Amount:

Application Fiscal Year:

FY 2011

Program Expenses

% of Total SSVF Grant

SSVF Grant Funds Total Annual

SSVF Grant Funds Month 1

SSVF Grant Funds Month 2

SSVF Grant Funds Month 3

SSVF Grant Funds Month 4

SSVF Grant Funds Month 5

SSVF Grant Funds Month 6

SSVF Grant Funds Month 7

SSVF Grant Funds Month 8

SSVF Grant Funds Month 9

SSVF Grant Funds Month 10

SSVF Grant Funds Month 11

SSVF Grant Funds Month 12

I. Provision and Coordination of Supportive Services (Minimum of 90% of Total SSVF Grant Amount)

1. Personnel/Labor

# FTE

% FTE

Base Annual Salary/Wage

Title and Organization

#DIV/0!

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#DIV/0!

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Subtotal Salaries/Wages

#DIV/0!

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Fringe Benefits @

#DIV/0!

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Subtotal Personnel

#DIV/0!

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2. Temporary Financial Assistance

#DIV/0!

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3. Other Non-Personnel Provision and Coordination of Supportive Services Expenses

#DIV/0!

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#DIV/0!

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#DIV/0!

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#DIV/0!

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#DIV/0!

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#DIV/0!

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#DIV/0!

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#DIV/0!

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#DIV/0!

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Subtotal Other Program Expenses

#DIV/0!

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# of Vehicles

4. Lease & Maintenance of Vehicle(s)

#DIV/0!

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Subtotal Provision and Coordination of Supportive Services

#DIV/0!

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II. Administrative Expenses (Maximum of 10% of Total SSVF Grant Amount)

#DIV/0!

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#DIV/0!

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Subtotal Administrative Expenses

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Grand Total

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% of Total SSVF Grant

#DIV/0!

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#DIV/0!

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Sheet 2: Tab 2 Qtrly Variance Report

	VA's Supportive Services for Veteran Families Program
	Attachment 1, Tab 2: Grantee Quarterly Financial Report - Quarterly Variance Report
	Name of Grantee:	INSERT APPLICANT NAME
	SSVF Program Number:
	SSVF Grant Amount:	$0.00
	Grant Fiscal Year:	FY 2011
										1ST QUARTER					2ND QUARTER						3RD QUARTER					4TH QUARTER
	Program Expenses				% of Total SSVF Grant	ACTUAL SSVF Grant Funds Spent (Total Annual to Date)	BUDGETED SSVF Grant Funds (Total Annual to Date)	% VARIANCE SSVF Grant Funds (Total Annual to Date)		ACTUAL 1ST QTR SSVF Grant Funds Spent	BUDGETED 1ST QTR SSVF Grant Funds	% VARIANCE 1ST QTR SSVF Grant Funds	Explanation of Any Variance		ACTUAL 2ND QTR SSVF Grant Funds Spent	BUDGETED 2ND QTR SSVF Grant Funds	% VARIANCE 2ND QTR SSVF Grant Funds	Explanation of Any Variance			ACTUAL 3RD QTR SSVF Grant Funds Spent	3RD QTR SSVF Grant Funds	% VARIANCE 3RD QTR SSVF Grant Funds	Explanation of Any Variance		ACTUAL 4TH QTR SSVF Grant Funds Spent	BUDGETED 4TH QTR SSVF Grant Funds	% VARIANCE 4TH QTR SSVF Grant Funds	Explanation of Any Variance
	I. Provision and Coordination of Supportive Services (Minimum of 90% of Total SSVF Grant Amount)
	1. Personnel/Labor	# FTE	% FTE	Base Annual Salary/Wage
	Title and Organization
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
	Subtotal Salaries/Wages				#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
	Fringe Benefits @				#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
	Subtotal Personnel				#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
	2. Temporary Financial Assistance
	Rent, penalties, fees				#DIV/0!	$-	NA	NA		$-	NA	NA	NA		$-	NA	NA	NA			$-	NA	NA	NA		$-	NA	NA	NA
	Utility fees				#DIV/0!	$-	NA	NA		$-	NA	NA	NA		$-	NA	NA	NA			$-	NA	NA	NA		$-	NA	NA	NA
	Security deposits				#DIV/0!	$-	NA	NA		$-	NA	NA	NA		$-	NA	NA	NA			$-	NA	NA	NA		$-	NA	NA	NA
	Utility deposits				#DIV/0!	$-	NA	NA		$-	NA	NA	NA		$-	NA	NA	NA			$-	NA	NA	NA		$-	NA	NA	NA
	Moving costs				#DIV/0!	$-	NA	NA		$-	NA	NA	NA		$-	NA	NA	NA			$-	NA	NA	NA		$-	NA	NA	NA
	Purchase of emergency supplies				#DIV/0!	$-	NA	NA		$-	NA	NA	NA		$-	NA	NA	NA			$-	NA	NA	NA		$-	NA	NA	NA
	Transportation				#DIV/0!	$-	NA	NA		$-	NA	NA	NA		$-	NA	NA	NA			$-	NA	NA	NA		$-	NA	NA	NA
	Child Care				#DIV/0!	$-	NA	NA		$-	NA	NA	NA		$-	NA	NA	NA			$-	NA	NA	NA		$-	NA	NA	NA
	Other as approved by VA				#DIV/0!	$-	NA	NA		$-	NA	NA	NA		$-	NA	NA	NA			$-	NA	NA	NA		$-	NA	NA	NA
	Subtotal Temporary Financial Assistance				#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
	3. Other Non-Personnel Provision and Coordination of Supportive Services Expenses
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
	Subtotal Other Program Expenses				#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
				# of Vehicles
	4. Lease & Maintenance of Vehicle(s)			0	#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
	Subtotal Provision and Coordination of Supportive Services				#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
	II. Administrative Expenses (Maximum of 10% of Total SSVF Grant Amount)
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
					#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
	Subtotal Administrative Expenses				#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!
	Grand Total				#DIV/0!	$-	$-	#DIV/0!		$-	$-	#DIV/0!			$-	$-	#DIV/0!				$-	$-	#DIV/0!			$-	$-	#DIV/0!

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Sheet 3: Tab 3 Qtrly Spending by Sub

	VA's Supportive Services for Veteran Families Program
	Attachment 1, Tab 3: Grantee Quarterly Financial Report - Quarterly Spending by Subcontractor
	Name of Grantee:	INSERT APPLICANT NAME
	SSVF Program Number	0
	SSVF Grant Amount:	$0.00
	Grant Fiscal Year:	FY 2011
							PROGRAM EXPENSES PAID TO DATE TO:
	Program Expenses				% of Total SSVF Grant	SPENT SSVF Grant Funds Total Annual to Date	GRANTEE	INSERT SUB-CONTRACTOR NAME & ADDRESS	INSERT SUB-CONTRACTOR NAME & ADDRESS	INSERT SUB-CONTRACTOR NAME & ADDRESS	INSERT SUB-CONTRACTOR NAME & ADDRESS	INSERT SUB-CONTRACTOR NAME & ADDRESS
	Description of Activities Performed
	I. Provision and Coordination of Supportive Services (Minimum of 90% of Total SSVF Grant Amount)
	1. Personnel/Labor
	Subtotal Personnel				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	2. Temporary Financial Assistance				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	3. Other Non-Personnel Provision and Coordination of Supportive Services Expenses
	Subtotal Other Program Expenses				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
				# of Vehicles
	4. Lease & Maintenance of Vehicle(s)				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	Subtotal Provision and Coordination of Supportive Services				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	II. Administrative Expenses (Maximum of 10% of Total SSVF Grant Amount)
	Subtotal Administrative Expenses				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	Grand Total				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	% of Total SSVF Grant					#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!

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Sheet 4: Tab 4 Qtrly Draw Downs

VA's Supportive Services for Veteran Families Program
Attachment 1, Tab 4: Grantee Quarterly Financial Report - Quarterly Draw Downs
Name of Grantee:	INSERT APPLICANT NAME
SSVF Program Number:	0
SSVF Grant Amount:	$0.00
Grant Fiscal Year:	FY 2011
	% of Total SSVF Grant	TOTAL	1st QTR	2nd QTR	3rd QTR	4th QTR
Grantee SSVF Draw Downs	#DIV/0!	$-	$-	$-	$-	$-
Grantee Spending to Date	#DIV/0!	$-	$-	$-	$-	$-
% Variance		#DIV/0!	0%	0%	0%	0%
Explain any variances:

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Sheet 5: Tab 5 Number Served

VA's Supportive Services for Veteran Families Program
Attachment 1, Tab 5: Grantee Quarterly Financial Report - Number of Participants Served
Name of Grantee:	INSERT APPLICANT NAME
SSVF Program Number:	0
SSVF Grant Amount:	$0.00
Grant Fiscal Year:	FY 2011
Current Caseload*		End of 1st Quarter	End of 2nd Quarter	End of 3rd Quarter	End of 4th Quarter
Number of Participant Households Currently Receiving Assistance		0	0	0	0
# of Single Participant Households Currently Receiving Assistance
# of Participant Households w/ Dependents Currently Receiving Assistance
*Note: Include only those households who received case management, assistance in obtaining VA benefits, assistance in obtaining and coordinating other public benefits, and/or other services (see Final Rule Sections 62.31-62.34). Exclude those households receiving only outreach services.
New Participants Served*	TOTAL	1st Quarter	2nd Quarter	3rd Quarter	4th Quarter
Number of New Unique Participant Households Who Received Assistance	0	0	0	0	0
# of New Unique Single Participant Households Who Received Assistance	0
# of New Unique Participant Households w/ Dependents Who Received Assistance	0
*Note: Include only those households who received case management, assistance in obtaining VA benefits, assistance in obtaining and coordinating other public benefits, and/or other services (see Final Rule Sections 62.31-62.34). Exclude those households receiving only outreach services.
New Participants Served Category of Occupying Permanent Housing*	TOTAL	1st Quarter	2nd Quarter	3rd Quarter	4th Quarter
Number of New Unique Participant Households Who Received Assistance	0	0	0	0	0
i) are residing in permanent housing	0
ii) are very low-income Veteran families who are homeless and scheduled to become residents of permanent housing	0
iii) have exited permanent housing within the previous 90 days to seek other housing that is responsive to their needs and preferences are rapidly transitioned to stable housing	0
*Note: Include only those households who received case management, assistance in obtaining VA benefits, assistance in obtaining and coordinating other public benefits, and/or other services (see Final Rule Sections 62.31-62.34). Exclude those households receiving only outreach services.
New Participants Served Target Populations*	TOTAL	1st Quarter	2nd Quarter	3rd Quarter	4th Quarter
Veteran families earning less than 30 percent of area median income as published annually by HUD (http://www.huduser.org)	0
Chronically homeless Veteran families	0
Formerly chronically homeless Veteran families	0
Households with one or more female Veterans	0
Returning Veterans from Afghanistan and/or Iraq	0
Participants Receiving VA Health Care and/or Other VA Benefits	0
*Note: Include only those households who received case management, assistance in obtaining VA benefits, assistance in obtaining and coordinating other public benefits, and/or other services (see Final Rule Sections 62.31-62.34). Exclude those households receiving only outreach services.
By submitting this report, we are certifying that our program’s data for 100% of participants has been exported from HMIS and uploaded to the SSVF Data Repository not less than on a monthly basis. If this is not the case, we have described why in the attached Quarterly Performance Report.

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Sheet 6: Tab 6 Non VA Funding Sources

	VA's Supportive Services for Veteran Families Program
	Attachment 1, Tab 6: Grantee Quarterly Financial Report - Non-VA Funding Sources
	Name of Grantee:	INSERT APPLICANT NAME
	SSVF Program Number	0
	SSVF Grant Amount:	$0.00
	Grant Fiscal Year:	FY 2011
							PROGRAM EXPENSES PAID TO DATE TO:
	Program Expenses				% of Total SSVF Grant	SPENT SSVF Grant Funds Total Annual to Date	GRANTEE	Non-VA Funding Source #1: INSERT NAME	Non-VA Funding Source #2: INSERT NAME	Non-VA Funding Source #3: INSERT NAME	Non-VA Funding Source #4: INSERT NAME	Non-VA Funding Source #5: INSERT NAME
	I. Provision and Coordination of Supportive Services (Minimum of 90% of Total SSVF Grant Amount)
	1. Personnel/Labor
	Subtotal Personnel				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	2. Temporary Financial Assistance				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	3. Other Non-Personnel Provision and Coordination of Supportive Services Expenses
	Subtotal Other Program Expenses				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	4. Lease & Maintenance of Vehicle(s)				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	Subtotal Provision and Coordination of Supportive Services				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	II. Administrative Expenses (Maximum of 10% of Total SSVF Grant Amount)
	Subtotal Administrative Expenses				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	Grand Total				#DIV/0!	$-	$-	$-	$-	$-	$-	$-
	% of Total SSVF Grant					#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!	#DIV/0!