10-0361-SN Homeless Providers Grant and Per Diem Program Special Ne

Department of Veterans Affairs

OMB Number 2900-0554
Estimated burden: 20 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  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
Special Needs
Application
Section A - Instructions
VA Form
JAN 2003

10-0361-SN

5. Assurances: All applicants must agree to comply with the assurances to VA listed below. If you fail to do
so it may result in the rejection of your application at the threshold review.

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:
1.
2.
3.
4.
5.
6.

Programs so funded will be used to provide special need
assistance to those categories of special need homeless
veteran populations as listed in 38 CFR part 61.40.
The special need assistance will be for services, operation, or
personnel as outlined in 38 CFR 61.43(d) (1) through (4), (e)
(1) through (6), (f) (1) through (5) and or (g) (1) through (5).
The special need assistance will be for services, operation, or
personnel at the level for which the application was made.
Services provided will meet standards prescribed by the
Secretary of Veterans Affairs.
Referral networks will be maintained for, and aid will be
given to, those special need homeless veteran populations.
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.

D. 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.
E. 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.
F. Accuracy of Application Information
All information submitted with this application is accurate, and
does not contain any false, fictitious or fraudulent statement or
entry.
G. Costs Incurred
I certify to the best of my knowledge the cost incurred for the
special need grant assistance would not be incurred but for the
fact that project number________________ is providing beds or
services in supportive housing and/ or a service center for the
homeless populations as designated in 38 CFR 61.40.
H. Compliance
Applicant assures that it will comply with applicable requirements
of 38 C.F.R. Part 61.

C. Continued Financial Support
If this proposal is funded, applicant assures that adequate financial
support will be available for the continued operation of the special
need assistance project funded by VA.

Signature of Authorized Certifying Official Title

Date Submitted

Applicant Organization

Date

VA FORM
JAN 2003

10-0361-SN

Applicant Page Number is: ________

SN Submission - 16