Form 10-0361-CG Homeless Providers Grant and Per Diem Program Captial Gr

Department of Veterans Affairs

OMB Number 2900-0554
Estimated burden: 35 hours

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. The
public reporting burden for this collection of information is estimated to average 35 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. Respondents should be aware that
notwithstanding any other provision of law, no person will be subject to complete a collection of information if it
does not display a currently valid OMB control number. This collection of information is intended to assist VA
officials determine eligibility to receive grant and/or per diem payments and to rate and rank these applications.

Homeless Providers Grant
and Per Diem Program
Capital Grant
Application
Section A - Instructions
VA Form
JAN 2003

10-0361-CG
Supersedes all previous editions of VA Form 10-0361

13. Assurances (cont):
All applicants must agree to the following assurances to VA as described below. No other format will be accepted as
evidence of reasonable assurances. Warning: Section 1001 of Title 18 of the United States Code (Criminal Code and
Criminal Procedure) shall apply to these assurances. Section 1001 of title 18 United States Code provides, that whoever
knowingly and willfully makes or uses a document or writing containing any false, fictitious, or fraudulent entry, in any
matter within the jurisdiction of any department or agency of the United States shall be fined not more than $ 10,000 or
imprisoned not more than five years, or both.

A. Services Benefiting Veterans
If this proposal is funded applicant assures that upon completion
of the project:
1.

2.
3.

4.
5.

6.

Programs so funded will be used principally to furnish to
veterans the level of care for which the application was made
at locations accessible to homeless veterans;
Vans so funded will be used principally for the purpose of
providing supportive services to homeless veterans;
Not more than 25 percent of participants at any one time will
consist of participants who are not receiving such services as
veterans;
Services provided will meet standards prescribed by the
Secretary of Veterans Affairs;
Referral networks will be maintained for, and aid will be
given to, homeless veterans in establishing eligibility for
assistance and obtaining services under available entitlement
and assistance programs;
Confidentiality of records pertaining to homeless veterans
will be maintained in accordance with applicable laws,
Federal, State, and Local, (e.g., HIPAA, Privacy Act).

B. Reports; Record Retention
If this proposal is funded, applicants assure that any and all
reports required by the Secretary of Veterans affairs shall be made
in such form and contain such information as the Secretary may
require and/or are required by law. Applicant further assures that
upon demand, the Secretary of Veterans Affairs has access to the
records upon which such information is based.
C. Title to Vest with Grantee
If this proposal is funded, applicant assures that title to vans
and/or sites constructed, acquired, expanded, remodeled and/or
altered with grant funds, will be vested solely in the applicant.

D. Continued Financial Support
If this proposal is funded, applicant assures that adequate financial
support will be available for the continued maintenance, repair
and operation of the project or van funded by VA.
E. Fiscal Control
If this proposal is funded, 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 grant.
F. Non-Delinquency
This institution certifies that it is not delinquent on any Federal Debt
and does not have any overdue or unsatisfactory response to an audit.
Applicant, further assures that is not in default by failing to meet the
requirements of any previous assistance from VA.
G. Accuracy of Application Information
All information submitted with this application is accurate, and
does not contain any false, fictitious or fraudulent statement or
entry.
H. Applicant Cash Resources.
If this proposal is funded, applicant will commit $
of its own funds for
to be made available to the VA
Homeless Providers Grant and Per Diem program. The funds will
be available on
.
I. Compliance
Applicant assures that it will comply with applicable requirements
of 38 C.F.R. Part 61.

Signature of Authorized Certifying Official Title

Date Submitted

Applicant Organization

Date

VA FORM
JAN 2003

10-0361-CG

Applicant Page Number is: ________

CG First Submission - 39