10-318a Application for Legal Services Grant

OMB Control Number: 2900-XXXX
Estimated burden: 24 hours
Expiration Date: XX/XX/XXXX

Legal Services for Homeless Veterans and Veterans At-Risk for Homelessness
(LSV) Grant Program

APPLICATION FOR LEGAL SERVICES GRANT

The Paperwork Reduction Act of 1995: This information is collected in accordance with Section 3507 of the Paperwork Reduction Act of 1995. The public
reporting burden for this collection of information is estimated to average 24 hours per response, including the time to review instructions, search existing data
sources, gather and maintain data needed, and complete and review the collection of information. Respondents should be aware that 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. This collection of information is intended to assist the
Homeless Program Office (HPO) to determine eligibility to receive legal services grants under the LSV Program and to rate and rank these applications. Response
to this grant application is voluntary, and failure to participate will have no adverse effect on benefits to which you might otherwise be entitled.
Privacy Act Statement: VA is asking you to provide the information requested in this form under the authority of 38 U.S.C. section 2044 in order for HPO to
determine eligibility to receive a legal services grant under the LSV Program. VA may disclose the information that you put on the form as permitted by law. VA
may make a "routine use" disclosure of the information for: civil or criminal law enforcement; congressional communications; the collection of money owed to the
United States; litigation in which the United States is a party or has interest; the administration of VA grant programs, including verification of your eligibility to
participate; and personnel administration. You do not have to provide the requested information to VA; but if you do not, VA may be unable to process your request
for consideration in this program. If you provide your Employer Identification Number (EIN), VA will use it to obtain information relevant to determining whether
to award a grant and to administer your grant, if awarded. This information also may be used for other purposes as authorized or required by law

Background:
This form is to be completed by eligible applicants for legal services grants under VA's LSV Program. VA will use the collected information to
evaluate and select recipients for legal services grants. Applicants may be asked to provide additional supporting evidence or to quantify details
during the review process.
Definitions and LSV Program Information:
Definitions and LSV Program information can be found in both the regulations (38 CFR Part 79) and the Notice of Fund Opportunity (NOFO)
under which you are submitting this application. Both documents are included as attachments to this application package and are posted on the
LSV Program web page (http://www.va.gov/homeless/lsv.asp). Please note that to be eligible for a grant under the LSV Program, the applicant
must meet the criteria in 38 CFR 79.10.
Submission:
The application must be submitted in accordance with the NOFO. Applications must be submitted by following instructions at www.va.gov/
homeless/lsv.asp. Applications may not be submitted in any other way. Applications must be received by the LSV Program Office no later than
4:00 p.m. Eastern Time on the application deadline date. Applications must be submitted as a complete package. Materials arriving separately
will not be included in the application package for consideration and may result in the application being rejected or not funded.
Documentation and Public Access Requirements:
VA will 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:
Information on application technical assistance can be found on VA's LSV Program web page at: http://www.va.gov/homeless/lsv.asp
If you have any questions regarding the LSV Program, please contact the LSV Program Office via e-mail at lsv@va.gov

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APPLICATION CHECKLIST
An application must include the following items.
Complete sections I-VII.
Section I: Administrative Information
Section II: Background, Qualifications, Experience, & Past Performance of Applicant and Any Identified Subcontractors (35 maximum
points)
1. Background and Organizational History
2. Staff Qualifications
3. Organizational Qualifications and Past Performance
4. History past 10 years (table)
Section III: Program Concept & Legal Services Plan (25 maximum points)
1. Need for Program
2. Outreach and Screening Plan
3. Program Concept
4. Program implementation timeline
5. Collaboration and communication with VA
Section IV: Quality Assurance & Evaluation Plan (15 maximum points)
1. Program Evaluation
2. Monitoring and Remediation
3. Management and Reporting
Section V: Financial Capability & Plan (15 maximum points)
1. Organizational Finances
2. Financial Feasibility of Program
Section VI: Area or Community Linkages and Relations (10 maximum points)
1. Local Presence and Knowledge
2. Area or Community Linkages (Exhibit II)
Section VII: Certifications
Exhibits
Exhibit I:

Program Budget (Complete Attached Microsoft Excel Applicant Budget Template)

Exhibit II: (Optional) Relevant MOUs and MOAs Demonstrating Area or Community Linkages

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SECTION I. ADMINISTRATIVE INFORMATION
A. PROVIDE THE FOLLOWING INFORMATION FOR THE APPLICANT
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

4. SAMS NUMBER:

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):

5. BUSINESS ADDRESS:

6. MAILING ADDRESS (if different from above) (include both U.S.mailing address and courier (i.e., no P.O. Box) address):

7. CONTACT PERSON NAME:

8. CONTACT PERSON TITLE:

9. MAILING ADDRESS FOR CONTACT PERSON (if different from above):

10. TELEPHONE FOR CONTACT PERSON (where the person can be reached
during business hours):

11. FAX FOR CONTACT PERSON

12. EMAIL FOR CONTACT PERSON:

B. LEGAL SERVICES FUNDS REQUESTED
1. AMOUNT OF LEGAL SERVICES GRANT FUNDS REQUESTED:

C. PROJECTED ELIGIBLE INDIVIDUALS TO BE SERVED
1. NUMBER OF UNIQUE VETERANS ESTIMATED TO BE SERVED:

D. AVERAGE PROJECTED COST PER VETERANS
1. AVERAGE TOTAL LEGAL SERVICES GRANT AMOUNT REQUEST PER VETERANS:

(This amount should equal total grant amount divided by number of unique Veterans served.)
E. GEOGRAPHIC REGION SERVED
1. DESCRIBE THE NAME(S) OF THE MUNICIPALITIES, COUNTIES (OR PARISHES), OR TRIBAL LANDS THAT THE PROPOSED PROGRAM WILL SERVE.

2. PROVIDE THE VETERANS INTEGRATED SERVICE NETWORK (VISN) NUMBER IN WHICH THE PROPOSED PROGRAM WILL OPERATE:
(https://www.va.gov/HEALTH/visns.asp)

3. IDENTIFY WHICH OF THE FOLLOWING GEOGRAPHIC REGIONS APPLIES TO THE PRIMARY AREA OR COMMUNITY IN WHICH THE PROPOSED PROGRAM
WILL OPERATE:
A. URBAN COMMUNITY

C. TRIBAL LAND

B. RURAL COMMUNITY

D. OTHER:

F. COMPLIANCE WITH THRESHOLD REQUIREMENTS (38 CFR 79.30)
1. APPLICATION FILED ON TIME: CONFIRM THAT APPLICATION IS FILED WITHIN THE TIME PERIOD ESTABLISHED IN THE NOFO:
YES

NO

2. APPLICATION IS COMPLETE:
YES

NO

3. ELIGIBLE ACTIVITIES: APPLICANT PROPOSES TO USE LSV FUNDING FOR ELIGIBLE ACTIVITIES ONLY (see 38 CFR 79.20 for list of eligible activities):
YES

NO

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4. ELIGIBLE PARTICIPANTS: APPLICANT PROPOSES TO SERVE VETERANS WHO ARE HOMELESS OR AT RISK OF HOMELESSNESS AS DEFINED AT 38 CFR
79.15:
YES

NO

5. COMPLIANCE WITH INTERIM FINAL RULE: APPLICANT AGREES TO COMPLY WITH INTERIM FINAL RULE:
YES

NO

6. OUTSTANDING OBLIGATIONS: APPLICANT EITHER
A. 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.
B. HAS AN OUTSTANDING OBLIGATION TO THE FEDERAL GOVERNMENT THAT IS IN ARREARS AND/OR AN OVERDUE OR UNSATISFACTORY
RESPONSE TO AN AUDIT. DESCRIBE BELOW:

7. DEFAULT: APPLICANT EITHER
A. IS NOT IN DEFAULT BY FAILING TO MEET THE REQUIREMENTS FOR ANY PREVIOUS FEDERAL ASSISTANCE
B. IS IN DEFAULT BY FAILING TO MEET THE REQUIREMENTS FOR PREVIOUS FEDERAL ASSISTANCE. DESCRIBE BELOW:

SECTION II: BACKGROUND, QUALIFICATIONS, EXPERIENCE, & PAST PERFORMANCE OF APPLICANT
AND ANY IDENTIFIED SUBCONTRACTORS
The information requested below should be typed into the boxes following each question in the application form. Limit your responses to the
space provided. In scoring the application, VA will award up to 35 points based on the applicant’s responses to questions contained in this section.
A. BACKGROUND AND ORGANIZATIONAL HISTORY
1. DESCRIBE YOUR ORGANIZATION’S BACKGROUND AND HISTORY PROVIDING LEGAL SERVICES TO VETERANS AND/OR POPULATIONS WHO ARE
HOMELESS, AT RISK OF HOMELESSNESS, OR VERY LOW INCOME. INCLUDE BACKGROUND AND HISTORY FOR ANY SUBCONTRACTORS. DESCRIBE
YOUR ORGANIZATIONAL REPORTING STRUCTURE AND RESPONSIBILITIES OF KEY ROLES. DESCRIBE YOUR HISTORY COMPLYING WITH AGREEMENTS
AND MEETING FINANCIAL OBLIGATIONS:

2. DESCRIBE YOUR EXISTING AND PROSPECTIVE STAFF’S EXPERIENCE WORKING WITH HOMELESS OR VERY LOW INCOME POPULATIONS, AND
EXPERIENCE WORKING WITH VETERANS:

3. DESCRIBE YOUR ORGANIZATIONAL QUALIFICATIONS AND PAST PERFORMANCE: (I) APPLICANT, AND ANY IDENTIFIED SUBCONTRACTORS, HAVE
ORGANIZATIONAL EXPERIENCE PROVIDING LEGAL SERVICES TO INDIVIDUALS WHO ARE HOMELESS, AT RISK FOR HOMELESSNESS, OR WHO HAVE
VERY LOW INCOME AS DEFINED IN THIS PART; (II) APPLICANT AND ANY IDENTIFIED SUBCONTRACTORS, HAVE ORGANIZATIONAL EXPERIENCE
ADMINISTERING A PROGRAM SIMILAR IN TYPE AND SCALE TO THE GRANT PROGRAM:

4. EXPERIENCE WORKING WITH VETERANS:
STAFF HAVE EXPERIENCE WORKING WITH VETERANS
STAFF HAVE ORGANIZATIONAL EXPERIENCE PROVIDING LEGAL SERVICES TO VETERANS
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5. 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:
IF NO, PLEASE DESCRIBE

ITEM

(attach additional pages if necessary in Exhibit IX):

A. 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

B. Debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded
from transactions by any Federal department or agency.

YES

C. Notified that it is in default of any Federal contract or grant, the reason for the default, and
whether the default was cured.

YES

D. Had one or more public transactions (Federal, State, or local) terminated for cause or default.
E. 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.

NO

NO
NO
YES
NO
YES
NO

SECTION III: PROGRAM CONCEPT & LEGAL SERVICES PLAN
The information requested below should be typed into the boxes following each question in the application form. Limit your responses to the
space provided. In scoring the application, VA will award up to 25 points based on the applicant’s responses to questions contained in this section.
Applicants should reference the requirements set forth in the NOFO in preparing these responses.
1. DESCRIBE YOUR OUTREACH AND SCREENING PLAN: (I) FEASIBLE OUTREACH AND REFERRAL PLAN TO IDENTIFY AND ASSIST VETERANS MOST IN
NEED OF LEGAL SERVICES, (II) PLAN TO PROCESS AND RECEIVE REFERRALS; (III) PLAN TO ASSESS AND ACCOMMODATE THE NEEDS OF INCOMING
ELIGIBLE VETERANS:

2. DESCRIBE YOUR PROGRAM CONCEPT, SIZE, SCOPE AND STAFFING PLAN AND HOW YOUR PROGRAM IS DESIGNED TO MEET THE LEGAL NEEDS OF
ELIGIBLE VETERANS:

3. DESCRIBE YOUR PROGRAM IMPLEMENTATION TIMELINE, HOW LEGAL SERVICES WILL BE DELIVERED AS QUICKLY AS POSSIBLE WITHIN A SPECIFIED
TIMELINE, HIRING PLAN IN PLACE OR EXISTING STAFF TO MEET TIMELINE:

4. HOW WILL YOU COORDINATE OUTREACH SERVICES WITH LOCAL VA FACILITIES:

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SECTION IV: QUALITY ASSURANCE AND EVALUATION PLAN
The information requested below should be typed into the boxes following each question in the application form. Limit your responses to the
space provided. In scoring the application, VA will award up to 15 points based on the applicant’s responses to questions contained in this section.
1. THE GOAL OF LSV IS TO ADDRESS THE NEEDS OF HOMELESS AND AT RISK VETERANS BY ADDRESSING LEGAL NEEDS THAT CONTRIBUTE TO
HOUSING INSTABILITY. PROGRAMS FUNDED NEED TO HAVE MEASURABLE GOALS THAT REFLECT THE APPLICANT’S ABILITY TO ADDRESS THE LEGAL
NEEDS OF ELIGIBLE VETERANS. DESCRIBE YOUR EVALUATION PLAN, INCLUDING YOUR GOALS, AND WHAT DATA YOU WILL COLLECT TO MONITOR IF
YOU HAVE MET THOSE GOALS:

2. DESCRIBE YOUR MONITORING STRUCTURE, INCLUDING MONITORING OF SUBCONTRACTORS, FOR COMPLIANCE WILL LAWS, REGULATIONS AND
GUIDELINES. DESCRIBE YOUR FINANCIAL MONITORING TO ENSURE PROPER USE OF GRANT FUNDS. DESCRIBE YOUR STAFF TRAINING PLAN. WHAT
PROCESSES WILL YOU PUT IN PLACE TO REMEDIATE ANY NON-COMPLIANT ASPECTS OF THE PROGRAM:

3. DESCRIBE YOUR MANAGEMENT AND REPORTING AND HOW YOUR PROGRAM MANAGEMENT TEAM HAS THE CAPABILITY AND A SYSTEM IN PLACE TO
PROVIDE TO VA TIMELY AND ACCURATE REPORTS AT THE FREQUENCY SET BY VA:

SECTION V: FINANCIAL CAPABILITY AND PLAN
The following items concern the applicant’s financial plan. The information requested below should be typed into the boxes following each
question in the application form. Limit your responses to the space provided. Exhibit I below must also be provided in the Microsoft Excel
template. In scoring the application, VA will award up to 15 points based on the applicant’s responses to questions contained in this section.
1. DESCRIBE FINANCIAL CONTROLS IN PLACE TO ENSURE THAT PROGRAM FUNDS ARE USED APPROPRIATELY AND PROGRAM IS COST EFFECTIVE.
USING THE ATTACHED TEMPLATE, PROVIDE A REALISTIC PLAN FOR OBTAINING ALL FUNDING REQUIRED TO OPERATE THE PROGRAM AND DETAILED
ONE-YEAR PROGRAM BUDGET THAT IS ITEMIZED ON A QUARTERLY BASIS:

2. SPECIFY ALL SOURCES OF FUNDS TO BE USED TO OPERATE THE PROPOSED PROGRAM FOR APPLICANT AND ANY IDENTIFIED CONTRACTORS.
IDENTIFY EACH SOURCE IN A SEPARATE LINE ITEM AND THE STATUS OF THE FUNDING, WHETHER THE FUNDING IS REQUESTED, COMMITTED, OR
RECEIVED:

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SECTION VI: AREA OR COMMUNITY LINKAGES AND RELATIONS
The information requested below should be typed into the boxes following each question in the application form. Limit your responses to the
space provided. In scoring the application, VA will award up to 10 points based on the applicant’s responses to questions contained in this section.
1. DESCRIBE HOW COMMUNITY RELATIONSHIPS WITH AREA PROVIDERS, GOVERNMENTAL AGENCIES, VA, MEDICAL LEGAL PARTNERSHIPS AND
CONSUMER GROUPS WILL ASSIST IN THE DELIVERY OF LSV LEGAL SERVICES. REFERENCE SPECIFIC ENTITY NAMES, ATTACHING MEMORANDUMS OF
AGREEMENT OR OTHER EVIDENCE OF RELEVANT, FORMAL AGREEMENTS (Exhibit II):

2. DESCRIBE YOUR CURRENT EFFORTS TO COORDINATE LEGAL SERVICES IN THE COMMUNITY OR COMMUNITIES WHERE YOU PLAN TO DELIVER
SERVICES:

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SECTION VII: APPLICANT CERTIFICATIONS AND ASSURANCES
The following items require a single certification on the following page by an authorized representative of the applicant requesting a legal 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 CFR Part 79. 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 debtor 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 Nonprocurement Debarment and Suspension Regulations: 49
CFR Part 29).
5. Reports and Record Retention If this legal services 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.
6. Fiscal Control If this legal 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 legal services 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 in Exhibit XI explaining any exceptions to this certification.
8. Lobbying The undersigned certifies, to the best of their knowledge and belief, that:
a) 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.
b) 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 15 Standard Forms
LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
c) The undersigned 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.
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:

SIGNATURE:

DATE (MM/DD/YYYY)

NAME AND TITLE:

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EXHIBIT I: APPLICANT BUDGET TEMPLATE (Microsoft Excel File)
Applicants are required to provide a detailed one-year program budget in Exhibit I that itemizes on a quarterly basis the legal services and
administrative costs associated with the proposed program. Applicants must also provide a detailed a description of each of the line items
contained in this budget and the underlying assumptions associated with each line item amount in Section D of the application form. The one-year
program budget must be completed in the Microsoft Excel template provided. Instructions on the use of this template are as follows:
General
a. Applicant is responsible for filling in yellow cells only.
b. All non-yellow cells are locked and populate automatically.
Provision and Coordination of Legal Services (Total must be a minimum of 90% of the total LSV Grant Amount)
a. Personnel/Labor (Note: The spreadsheet will spread these costs evenly across all 12 months. If the applicant does not anticipate an even spread
of costs, this should be explained in the narrative.):
• Title and Organization - input the titles of all LSV-funded personnel (e.g., Program Director, Attorney, etc.) and the organization at which
they are or will be employed (i.e., list applicant organization or team member organization name as applicable). Add additional lines to the
spreadsheet as necessary
• # of Full-Time Employees (FTE) - input the number of FTE who will hold the specified title at the specified organization
• % FTE - input the percentage of time the staff member will devote to the LSV-funded program (e.g., full-time staff would be shown at 100%)
• Base Annual Salary / Wage - input the annual salary of the specified personnel, assuming full-time employment
• Fringe Benefits - cost of fringe benefits as a percentage of annual salary (if any)
b. Other Non-Personnel Provision and Coordination of Legal Services Expenses: List any other expenses related to the provision and
coordination of legal services expenses in this section and the monthly costs associated with those expenses.
c. Lease & Maintenance of Vehicle(s): Per 38 CFR 62.33, if public transportation options are not sufficient within an area or community, costs
related to the lease of vehicle(s) may be included in the application. Specify the number of vehicles to be leased and the cost per month
associated with these vehicles.
Administrative Expenses (Total cannot exceed 10% of total LSV Grant Amount)
List all administrative expenses and the monthly costs associated with each expense. Per 38 CFR 62.70, administrative expenses are defined as all
direct and indirect costs associated with the management of the program. These costs will include the administrative costs, both direct and
indirect, of subcontractors. A line item of “administrative costs” is not sufficiently descriptive. Administrative costs must be broken down into
multiple line items by category.

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