VA-10096 Adaptive Sport Grant Application OMB 2900-0820

OMB Number: 2900Exp. Date: Oct., 2025
Respondent Burden: 20 minutes

ADAPTIVE SPORT GRANT APPLICATION
PRIVACY ACT: The information requested on this form is solicited under the authority of Title 38, U.S.C., and Sections 1710, 1712, and 1722. It is
being collected to enable us to determine your eligibility for benefits and will be used for that purpose. The information you supply may be verified
through a computer matching program at any time and information may be disclosed outside the VA as permitted by law. VA may make a routine use
disclosure of the information as outlined in the Privacy Act system of records identified as 58VA21/22/28, Compensation, Pension, Education and
Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary; however, the
information is required in order for us to determine your eligibility for the benefit for which you have applied. Failure to furnish the information will
have no adverse affect on any other benefits to which you may be entitled.
RESPONDENT BURDEN: 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. 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. We anticipate that the time expended by all individuals who must complete this
application will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.

SECTION A - ORGANIZATION AND GRANT INFORMATION
1. ORGANIZATION AND MAILING ADDRESS
(Must provide a 9-digit zipcode)

3. GRANT AMOUNT
REQUESTED

2. PROGRAM NAME AND TITLE

SECTION B - CONTACT INFORMATION
4. PRIMARY CONTACT

5. PRIMARY PHONE NUMBER

6. ALTERNATE PHONE NUMBER

7. EMAIL

SECTION C - PROGRAM AND OTHER INFORMATION
8. UEI NUMBER (Must provide a UEI
number before any payment is disbursed)

9. CONGRESSIONAL DISTRICT

12. PROJECTED START DATE

13. PROJECTED COMPLETION DATE 14. TARGET GEOGRAPHIC AREA(S)

10. SAM CAGE CODE NUMBER

15. CATEGORY
INITIAL

11. EIN NUMBER

16. EXPERIENCE WITH VETERANS WITH DISABILITIES
RENEWAL

17. DISABILITY GROUPS

NON-COMPETITIVE

LESS THAN 2 YEARS

LIMB LOSS

SPINAL CORD
INJURY

TBI

VISUALLY IMPAIRED

PTSD

OTHER

MORE THAN 2 YEARS

18. EXPERIENCE WITH DISABLED VETERANS? 19. COMPLEMENTARY FUNDING?
YES

NO

FEDERAL:

YES

NO

AMOUNT:

NON-FEDERAL:

YES

NO

AMOUNT:

20. DOES YOUR ORGANIZATION HAVE EXPERIENCE IN MANAGING FEDERAL FUNDS?

YES

NO

This application does not constitute a Grant Agreement. Upon approval of the application by VA, an applicant will be required to complete a signed
Grant Agreement specifying terms and conditions of an award. The Program Goals and Deliverables (Exhibit A) and Program Budget (Exhibit B) will
form the basis of the Grant Agreement as agreed upon by VA and the applicant. Upon full execution of the Grant Agreement, the applicant will
perform the services/activities hereto attached in Exhibit A, perform the Program Budget in line with the budget attach hereto in Exhibit B unless
otherwise agreed upon by the applicant and VA.
In the event the applicant and VA do not enter into a Grant Agreement for any reason, and/or in the event the applicant and VA are unable to agree on
the terms of the Grant Agreement within 60 days after approval of the application by VA, this application will automatically terminate.
AUTHORIZED REPRESENTATIVE NAME

VA FORM
NOV 2022

10096

TITLE

EMAIL

21. QUALIFICATIONS OF PERSONNEL
(Include specific experience, education or other qualifications relevant to the grant proposal.)
NAME

TITLE

QUALIFICATIONS

YEARS OF
EXPERIENCE

22. PARTNERING AND COLLABORATING ORGANIZATIONS
(Include partnering or participation in joint activities)
COLLOBORATING ORGANIZATION
NAME AND POC

VA FORM 10096, NOV 2022, page 2

LOCATION
(CITY, STATE)

COLLABORATIVE ACTIVITIES

EXHIBIT A
Program Goal and Deliverables
(Include locations, activities, frequency of occurrence and number of veterans.
Note: for training of providers include an estimated number of Veterans that will benefit)
Program Deliverable
DELIVERABLES

1

2

3

4

5

6

7

8

9

10

11

12

VA FORM 10096, NOV 2022, page 3

NUMBER OF
VETERANS

DELIVERABLE
START

DELIVERABLE
COMPLETION

BUDGET
ESTIMATE

EXHIBIT B
VA ADAPTIVE SPORTS GRANT PROGRAM BUDGET
Program Budget and Expected Expenditures (Grant Funds Only)
CATEGORY

AMOUNT

DESCRIPTION OF EXPENDITURES

PROJECTED SPENDING IN EACH QUARTER ($)
JAN-MAR
APR-JUN
JUL-SEPT
(Q2)
(Q3)
(Q4)

OCT-DEC
(Q1)

Operations
Equipment
Travel
Supplies
Administrative
*Personnel
(Operational)
*Personnel
(Administrative)
Total

BUDGET CATEGORY DEFINITIONS
ONLY include amounts spent against this award. DO NOT report expenditures that are funded by other sources.
For further information regarding allowable costs, please reference OMB guidance (2 CFR 200 and 38 CFR 77).
Operations - Expenditures associated with implementing this grant program such as coaching fees, lift tickets and facility fees.
Equipment - Sport equipment purchased to meet program objectives. To be categorized as equipment must have a useful life of more than one year
and a unit price equal to or greater than $5,000. Equipment expenditures must be identified in your Grant Application and listed on Exhibit C.
Travel - Expenses for transportation, lodging, subsistence, and related items incurred to meet program objectives. Costs must be consistent with those
allowed in like circumstances in your organization's other activities. Travel costs must comply with GSA lodging and subsistence rates for designated
locations which can be found at http://www.gsa.gov/portal/category/100120.
Supplies - Consumable items in direct support of carrying out the award or equipment purchases with a per-unit value less than $5,000.
Administrative (non-Personnel) - Sum of Administrative and In-Direct Costs that do not include Personnel (Administrative). Costs must be clearly
identified and associated with the implementation and tracking of the award. When combined with Personnel (Administrative) costs, may not exceed
the amount/percentage stated in the funding announcement
*Personnel (Operational) - Includes both Personnel and Fringe Benefit expenses that should be based on documented payrolls approved by a
responsible official(s) of the organization. Reports need to reflect the distribution of activity for those whose compensation is charged, in whole or in
part, directly to this award. Operational activities are identified as "time spent by such employee directly providing coaching or training for
participants" per 38 CFR 77.14(c)(2). The reports must reflect an after-the-fact determination of the actual activity worked on the program. Reports
must account for the total activity for which employees are compensated.
*Personnel (Administrative) - Includes both Personnel and Fringe Benefits expenses that should be based on documented payrolls approved by a
responsible official(s) of the organization. Reports need to reflect the distribution of activity for those whose compensation is charged, in whole or in
part, directly to this award. Administrative activities are identified as all personnel activities that are not "time spent by such employee directly
providing coaching or training for participants" per 38 CFR 77.14(c)(2). The reports must reflect an after-the-fact determination of the actual activity
worked on the program. Reports must account for the total activity for which employees are compensated.

VA FORM 10096, NOV 2022, page 4

EXHIBIT C
EQUIPMENT PURCHASES
Equipment Purchases
*Report the purchase of single units/pieces of equipment equal to or in excess of $5,000. This is only for equipment purchases using this award.
TYPE OF EQUIPMENT

VA FORM 10096, NOV 2022, page 5

MAKE AND MODEL

APPROXIMATE
VALUE

QUANTITY

EXHIBIT D
ADAPTIVE SPORTS OFFERED
Indicate your organization or the partner organization executing the event; indicate the sport, and other activity details.
ORGANIZATION

VA FORM 10096, NOV 2022, page 6

TYPE OF SPORT

CITY

STATE

DATES OFFERED

POINT OF CONTACT/
WEBSITE