Form VA Form 10193 VA Form 10193 Veterans Employment Pay for Success (VEPFS) Grant Applic

OMB Control Number: 2900-XXXX

Estimated burden: 80 hours
Expiration Date: XX-XXXX

U.S. Department of Veterans Affairs (VA)
Veterans Employment Pay for Success (VEPFS) Grant

APPLICATION FOR VETERANS EMPLOYMENT PAY FOR SUCCESS 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 80 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 VEPFS Program to determine eligibility to receive grants under the VEPFS Program and to rate and rank these applications. Response to this application 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 a grant under VA’s VEPFS Program. VA will use the collected information to evaluate and select recipients for VEPFS grants. Applicants may be asked to provide additional supporting evidence or to quantify details during the review process.

Definitions and VEPFS Program Information: Definitions and VEPFS Program information can be found in both the regulations 38 U.S.C. 3911 and the Notice of Fund Availability (NOFA) under which you are submitting this application. Both documents are included as attachments to this application. Please note that to be eligible for a grant under the VEPFS Program, the applicant must be a nonprofit organization or institution of higher education.

Submission: The application must be submitted in accordance with the NOFA. The NOFA specifies the format in which the application must be submitted. Only timely and complete applications will be considered for funding; applications will not be reviewed if incomplete. To be considered timely, the application must be received via Grants.gov and by the time and date specified in the NOFA. Applications received after that time and date may not be reviewed. Following the application deadline, applicants will be notified via Grants.gov that their applications have been received. To be considered complete, all items requested in this grant application must be provided in a single application package.

Documentation and Public Access Requirements: VA will conduct a thorough review of each application to 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 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.

For Further Information: If you have any questions regarding the VEPFS program please contact the VA Center for Innovation Executive Director via e-mail at Patrick.Littlefield@va.gov or via phone at (202)-256-7176 (this is not a toll-free number).

APPLICATION CHECKLIST

An application must include the following items.

Executive Summary

Section A: Project Description (30 maximum points)

1. Description of the employment intervention

2. Description of the methodology for delivery of intervention, evidence to support efficacy of the intervention, employment outcomes

3. Geographic scope

4. Explanation of whether the intervention will be deployed in either low-income communities or geographic areas with the highest need

5. Number of Veterans to be served

6. Control group description

7. Any employer engagement, outreach, and training methodology

8. Involvement of mental health care professionals

9. Promotion of a living wage

10. Promotion of increased earnings

11. Strategy to ensure sustainment of outcomes post-award period

Section B: Project Partnership (15 maximum points)

1. Description of the Full or Partial Project Partnership

Section C: Work Plan and Budget (30 maximum points)

1. Description of work plan

2. Budget narrative

3. Matching funds secured above the 1:1 match requirement

Section D: Expertise and Capacity (15 maximum points)

1. Past experience working on PFS or social impact financing projects

2. Experience working with Veterans

3. Workforce supports for individuals with mental health issues

4. Knowledge of sound vocational principles

5. Ability to manage privacy concerns

6. Experience with employment focused and/or mental health service providers

7. Outcomes from previous projects

8. Description of staff capacity and expertise

9. Use of data

Section E: Match (10 maximum points)

1. Provides evidence for receipt of matching funds, letters of commitment, letters of interest, or plan to raise the match requirement (Exhibit I)

Section F: Certifications and Assurances

Exhibits

Exhibit I: Matching Funds Documentation

Executive Summary

1. Administrative Information.

   1. Applicant’s Legal Name (as identified in your Articles of Incorporation):

   2. Other Names under Which Applicant Does Business:

   3. Employer Identification Number (EIN) that Corresponds to the Applicant's IRS Ruling Certifying Tax- Exempt 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):

   4. DUNS Number:

   5. SAM Number:

   6. Eligible Entity: (Confirm that the applicant is a public nonprofit organization)

   7. Business Address:

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

   9. Contact Person Name:

   10. Contact Person Title:

   11. Mailing Address for Contact Person (if different from above)

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

   13. Fax for Contact Person:

   14. E-mail for Contact Person:

   15. 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

2. Name of the proposal.

3. Name of the intervention.

4. Type of partnership presented at time of application (Full or Partial Project Partnership)

5. Amount of federal funds sought (up to $3 million)

6. Matching funds proposed

   1. Amount of funding secured as cash on hand at time of application (at least 10% of the non-federal match requirement)

   2. Amount of funding for which applicant has received commitments

   3. Amount of funding for which applicant has received letters of interest

   4. Amount of funding for which applicant has plan to secure

7. Compliance with Threshold Requirements. Check the appropriate box for each of the following questions.

   1. Eligible Activities: Applicant proposes to use VEPFS funding for eligible activities only (Yes/No)

   2. Eligible Participants: Applicant proposes to serve Veterans with a service-connected disability of post-traumatic stress disorder (PTSD) (Yes/No)

8. Compliance with Final Rule: Applicant agrees to comply with Final Rule (Yes/No).

9. Outstanding Obligations: Applicant responds selects the appropriate response

   1. Does not have an outstanding obligation to the Federal government that is in arrears and does not have an overdue or unsatisfactory response to an audit.

   2. Has an outstanding obligation to the Federal government that is in arrears and/ or an overdue or unsatisfactory response to an audit. Describe below:

   3. Is not in default by failing to meet the requirements for any previous Federal assistance.

   4. Is in default by failing to meet the requirements for previous Federal assistance. Describe below:

10. Identify yes or no and explain in reasonable detail each instance within the past 10 years in which the applicant, any identified subcontractor, or any principal, partner, director, or officer of the applicant or identified subcontractor was:

Item	Yes/ No	If no, please describe (attach additional pages if necessary):
Convicted of or pleaded guilty or nolo contendre to a crime (other than a traffic offense).	Yes No
Subject to an order, judgment, or decree (including as a result of a settlement), 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).	Yes No
Subject to an action or other proceeding, 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.	Yes No
Debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from transactions by any Federal department or agency.	Yes No
Notified that it is in default of any Federal contract or grant, the reason for the default, and whether the default was cured.	Yes No
Had one or more public transactions (Federal, State, or local) terminated for cause or default.	Yes No
Party to litigation or a formal Alternative Dispute Resolution (ADR) process (e.g., binding arbitration) involving a claim in excess of $50,000. For those matters involving a claim equal to or in excess of $500,000, describe in detail the litigation or ADR process.	Yes No

Please provide responses to Sections A-F. Total narrative for these sections cannot exceed 50 pages. Responses must be typed in 12 point, Times New Roman font. All pages must have 1 inch margins. Attached responses must include question number and heading, for example, the response to the first question would begin with the heading:

SECTION A:

A) Identifies and describes an employment intervention for Veterans with a Service-connected Disability of PTSD (3 points)

SECTION A: Project Description

In scoring the application, VA will award up to 30 points based on the applicant’s responses to questions contained in this section.

1. Identifies and describes an employment intervention for Veterans with a Service-connected Disability of PTSD (3 points)

2. Identifies and describes the methodology for delivering the intervention through a PFS Agreement that is supported by Strong Evidence, describing the Strong Evidence of the intervention and describing the employment outcomes to be evaluated. Please include information on the measurable outcomes the applicant seeks to improve by replicating or expanding a proven initiative or supporting a new initiative (5 points)

3. Defines and justifies the geographic scope of the intervention to be delivered through the PFS Agreement (2 points)

4. Explains in detail how the intervention to be delivered through the PFS Agreement will serve Veterans with a Service-connected Disability of PTSD in (1) low-income communities or (2) geographical areas that have the highest need for the issue areas (5 points)

5. Identifies and justifies the number and population of Veterans expected to be served by the intervention to be delivered through the PFS Agreement (2.5 points)

6. Defines the method for determining an appropriate Veteran control group for the evaluation of employment outcomes (2.5 points)

7. Describes any employer engagement, development, and training strategies (2.5 points)

8. Describes the integration and role of mental health care professionals in the project (2.5 points)

9. Describes how the PFS project will promote the outcome of a Living Wage (2 points)

10. Describes how the PFS project will promote the outcome of an appreciable increase in annual earnings for Veterans as a result of the intervention as compared to the control group (1 point)

11. Describes how the applicant will sustain the replicated or expanded initiative after the conclusion of the grant period (2 points)

SECTION B: Project Partnership

In scoring the application, VA will award up to 15 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. The response will be scored based on the completeness of the partnership structure proposed. Applicant must provide the name, qualifications, and project responsibilities of partner entities committed to the project:

   1. For applicants presenting a Full Project Partnership at the time of application.

      1. Provides the name, qualifications, and project responsibilities of each of the following partner entities committed to the project (15 points).

Project Coordinator

Evaluator

Investor(s) if the PFS Agreement will involve PFS financing

Service Provider(s). Please include as part of qualifications any experience working with Veterans.

2. For applicants presenting a Partial Project Partnership at the time of application (10 points).

   1. Provides the name, qualifications, and project responsibilities of any of the following partner entities committed to the project (7 points).

Project Coordinator

Evaluator

Investor(s) if the PFS Agreement will involve PFS financing

Service Provider(s). Please include as part of the qualifications any experience working with Veterans.

2. Describes a plan that has a high likelihood of success to transparently form a Full Project Partnership (2 points).

3. Provides evidence of experience in developing partnerships for social innovation generally and/or PFS specifically (1 point).

SECTION C: Work Plan and Budget

In scoring the application, VA will award up to 30 points based on the applicant’s responses to criteria contained in this section.

1. Proposes a high-level work plan that provides specific, realistic, and actionable timelines tied to completion of the following tasks within the project period and includes staff roles assigned to complete the following tasks, noting whether such staff members are already hired (10 points):

   1. Secure any remaining non-Federal funds for the match requirement

   2. Form a Full Project Partnership if it has not been formed yet

   3. Execute a PFS Agreement for a High-Quality PFS Project that evaluates outcomes within the period of performance and potential release of Outcomes Payments

   4. Define reporting structure, data collection methods, outcomes and performance metrics, and evaluation approach

2. Provides a budget narrative: the following information must be provided for the funds distribution (10 points):

   1. Amount of total funding for indirect costs

   2. Amount of total funding for Outcomes Payments

   3. The amount of the Federal share

   4. The amount of the non-Federal share (i.e., matching funds)

   5. Justifies the amount budgeted for Outcomes Payments in terms of an appropriate rate of return for Investors and number of Veterans to be served

3. Identifies the amount of any matching funds it proposes above the 1:1 requirement and provides evidence it has secured, has received letters of interest to provide, or has a credible plan to raise these additional matching funds (10 points maximum). For every $250,000 above the matching requirement the applicant proposes for the budget, the applicant will receive 1 point, for a maximum of 10 points.

SECTION D: Expertise and Capacity

VA will award up to 15 points based on the applicant’s responses that provide evidence of past experience related to the questions contained in this section.

1. Past experience among its in-house staff (and/or Board of Directors if applicant is a 501c(3) nonprofit organization) working on Pay for Success or other social finance strategies (4 points)

2. Issues specific to Veterans (1 point)

3. Workforce supports for individuals facing mental health challenges, including PTSD (1 point)

4. Demonstrated knowledge of sound vocational rehabilitation principles (1 point);

5. Knowledge of and adherence to Service-Connected Disability related privacy concerns (1 point)

6. Experience with employment focused and/or mental health service providers (1 point)

7. Data on the measurable outcomes the applicant has improved (1 point).

8. Identifies and explains sufficient capacity (i.e., knowledge, skill, and time) among existing in-house staff or those to be hired, to carry out its responsibilities if selected as a Recipient (3 points)

9. Describes how the applicant uses data to analyze and improve its initiatives (2 points).

SECTION E: Match

In scoring the application, VA will award up to 10 points based on the applicant’s responses to questions contained in this section. Documentation to support securing the match requirement and/or letters of commitment or interest must be provided (exhibit II).

1. Identifies and provides evidence for the percentage of its match requirement that meets each of the four categories.

   1. Funds that the applicant has secured (i.e., made available if itself providing the funds or already received from others) as cash on hand to meet the match requirement

   2. Funds for which the applicant has received commitments

   3. Funds for which the applicant has received letters of interest from funders

   4. Funds the applicant has a credible plan to secure

2. Points will be allocated as follows:

   1. Each applicant will identify the percentage of its match requirement that meets each of the four categories above.

      1. For example, Applicant ABC identifies that it has secured half its match requirement and received letters of interest from funders in providing the remaining half.

   2. Those percentages will be multiplied as follows: by 100% for funds that are secured; by 90% for funds that have been committed; by 60% for funds that funders have expressed interest in providing; and by 30% for funds that the applicant has a credible plan to secure.

      1. For Applicant ABC, the reviewer would multiply 50% x 100% for the secured funds (50% x 100% = 50%) and multiply 50% x 30% for the funds supported for which the applicant has a credible plan to secure (50% x 30% = 15%).

   3. The resultant percentages will be added to yield the applicant’s “match score multiplier.” It will be no more than 100%.

      1. For Applicant ABC, the “match score multiplier” would be 65% (50% + 15%).

   4. The “match score multiplier” will be applied to 10 points. This is the applicant’s point allocation for this selection criteria.

      1. For Applicant ABC, the score would be 6.5 points (65% x 10 points)

SECTION F: Applicant Certifications & Assurances

The following items require a single certification on the following page 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 USC 3119. 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 (Government wide Non-procurement Debarment and Suspension Regulations: 49 CFR Part 29).

5. Reports and Record Retention. If this VEPFS 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. The reporting requirement will be established in the terms and conditions of the grant agreement. VA will seek PRA approval for this collection of information at that time.

   

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 VEPFS grant.

7. Civil Rights. Applicant certifies that this program will comply with all provisions of Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.). If applicant does not certify this, applicant has provided information explaining any exceptions to this certification.

8. Lobbying. The applicant certifies, to the best of their knowledge and belief, that:

   1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

   2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Forms­LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.

   3. The applicant shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31 U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

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

Exhibit I: Matching Funds Documentation

Match Verification Documentation: At the time of application, applicants must demonstrate through a letter or other form of documentation that they have cash-on-hand that meets 10% of their match requirement. Applicants may demonstrate cash-on-hand by a statement from the Chief Financial Officer or other officer that the organization has established a reserve of otherwise uncommitted funds for the purposes of fulfilling this match requirement. A bank statement or report of assets is not sufficient without the accompanying statement that the funds are uncommitted. Applicants may also demonstrate commitments by a dated and signed letter from each donor/foundation, indicating the amount of funds committed for the specific use of supporting this grant. Such a letter must contain a firm commitment to provide the applicant the stated funding upon award of a grant by VA.

In addition to demonstrating that the applicant has cash on hand equivalent to 10% of its match requirement, the applicant should document any additional matching funds that it has pursued. The applicant should demonstrate additional matching funds:

• That the applicant has secured as cash on hand;

• Where the applicant has received letters of interest from funders in providing those additional matching funds;

• Where the applicant has a credible plan to raise those additional matching funds.

To demonstrate cash on hand, applicants may demonstrate cash-on-hand by a statement from the Chief Financial Officer or other officer that the organization has established a reserve of otherwise uncommitted funds for the purposes of fulfilling this match requirement. A bank statement or report of assets is not sufficient without the accompanying statement that the funds are uncommitted. Applicants may also demonstrate commitments by a dated and signed letter from each donor/foundation, indicating the amount of funds committed for the specific use of supporting this grant. Such a letter must contain a firm commitment to provide the applicant the stated funding upon award of a grant by VA. To demonstrate letters of interest from funders in providing the additional matching funds, applicants must submit those letters of interest signed by a senior official of the funder(s). To demonstrate a credible plan to raise the additional matching funds, the applicant must submit that written plan not to exceed two typed pages double-spaced. Documentation must be uploaded as part of the grant application package to Grants.gov. Applicants should include the following information:

• The legal applicant name and applicant’s point of contact information;

• The application ID number;

• A list of documents attached to the email;

• Individually saved files that are clearly labeled; and

• Files that include the legal applicant name and application ID number within the body of the document.

Applications must be submitted as a complete package, including the additional documents. Materials arriving separately will not be considered and may result in the application being rejected. Match verification, as well as all other documentation must be received by the application deadline. Submission of evidence of match by the application deadline is a compliance criterion.

END OF FORM

VA Form 10193 Page 1

JUL 2016