VA 40-0895-13 Documents and Information Required for State or Tribal G

OMB NUMBER: 2900-0559
Expiration Date: Nov. 30, 2023
Respondent Burden: 2 hours

CERTIFICATION REGARDING DOCUMENTS AND INFORMATION REQUIRED FOR
STATE OR TRIBAL GOVERNMENT CEMETERY CONSTRUCTION GRANTS POST GRANT REQUIREMENTS
Respondent Burden: Public reporting burden for this collection of information is estimated to average 2 hours. Statutory authority
for a State Cemetery Grant is 38 U.S.C. 2408. The information requested is necessary to ensure that State or Tribal government is
aware of and complies with all grant responsibilities and to properly and timely close out the grant. VA may not conduct or sponsor
and you are not required to respond to this collection of information unless it displays a valid OMB number. Respond to this
collection is voluntary. Send comments regarding the burden estimate or any other aspects of this collection of information,
including suggestions for reducing the burden to VA Clearance Officer (005R1B), 810 Vermont Avenue NW, Washington, DC
20420. SEND COMMENTS ONLY. Please do not send applications for a grant to this address.
STEPS TO CLOSE OUT A CONSTRUCTION GRANT PROJECT

1. Submit a written request to the Director, State Cemetery Grants Service (41E), 810 Vermont Avenue, N.W., Washington, D.C.
20420, asking the Department of Veterans Affairs to schedule a final grant program review. Include the name and telephone number
of the local point of contact for the project.
2. Submit the project equipment list. If there is no equipment involved in the grant, please make a statement to that effect in the
request for a final grant program review.
3. Add the following statement to the SF 271, Outlay Report and Request for Reimbursement for Construction Programs, and add the
statement to the Health and Human Services final reimbursement request:
It is hereby agreed that the monetary commitment of the Federal Government will have been met
and the project will be considered terminated upon payment of this voucher.
4. Evidence that the State has complied with the Single Audit Act requirements. NOTE: If no more than $500,000 is reimbursed to
the State within any of the fiscal years, this requirement is exempted. Exemption requests should be submitted with the other close
out requirements. The Single Audit Act responsibilities can be found in Title 38 CFR Part 41.5. The State may provide the actual
results of the audit by the State Auditing Agency or evidence that the State has reported to the State Auditing Agency that a Federal
grant was awarded to the State. The letter should clearly identify the Federal Application Identifier (FAI), the date the grant was
awarded, the amount of the Federal assistance, and the approximate end date of the construction.
5. Final Master Plan (one copy for State Cemetery Grant Program and one copy for state cemetery), if appropriate.
6. As Built Drawings (one copy for State Cemetery Grant Program and one copy for state cemetery).
7. Custody and Transfer Receipt Final Release of Claims Final Invoice (one copy for State Cemetery Grant Program), if appropriate.
NOTE: The final payment will be authorized when all closeout requirements are met. If you have questions, please contact
Director, State Cemetery Grants Service (41E).
CERTIFICATION: I certify that the information submitted to Department of Veterans Affairs is true and correct to the best of my
knowledge and ability.
NAME OF AUTHORIZED STATE OR TRIBAL GOVERNMENT OFFICIAL

PROJECT FAI (Federal Application Identifier) NO.

SIGNATURE

VA FORM
OCT 2010

40-0895-13

DATE GRANT AWARDED

TITLE OF AUTHORIZED STATE OR TRIBAL GOVERNMENT OFFICIAL

AMOUNT OF FEDERAL ASSISTANCE

DATE (mm/dd/yyyy)