VA 40-0895-14 Checklist of Major Requirements for State or Tribal Gove

OMB Number 2900-0559
Expiration Date: Nov. 30, 2023
Respondent Burden: 15 minutes

CHECKLIST OF MAJOR REQUIREMENTS FOR STATE OR TRIBAL GOVERNMENT
CEMETERY CONSTRUCTION GRANTS
Respondent Burden:
Public reporting burden for this collection of information is estimated to average 15 minutes. 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 complies with the NCA Shrine Standards following receipt of a 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. Responding to this collection is voluntary.
Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this 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.
STATE OR TRIBAL GOVERNMENT CEMETERY PROJECT LOCATED AT

DATE RECEIVED (Grants.gov)

TIME RECEIVED (Grants.gov)
DESCRIPTION OF PROJECT

SECTION A - PREAPPLICATION PHASE (Deadline is July 1 each year for VA receipt)
NO.

CHECK
RECEIPT

REQUIREMENT

1.

Form SF 424, 424C, and 424D and project narrative submitted through grants.gov.

2.

State or Tribal Government Application
Identifier (FAI) Number

3.
4.
5.
6.
7.
8.
9.
10.

DATE

NUMBER (If applicable)

FAI NUMBER (To be assigned by VA)

Federal Application Identifier (FAI) Number
Unique Entity ID (Generated by SAM.gov)
VA Receipt Notification Letter to Applicant
AUTHORIZED OFFICIAL

Governor's or Tribal Government's designation of authorized official.
CONTACT PERSON

Governor's or Tribal Government's designation contact person.
State or Tribal Government legal authority to apply for the grant, finance and construct proposed
project (copy of the legislation)
Compliance with VA Form 40-0895-6, Certification of State or Tribal Government Resources to
Initially Fund the Architectural and Engineering Portion of the Project Development (submitted
to VA by July 1)
Title to the State or Tribal Government Cemetery Property

11. Phase I Environment Survey: site plan/'map, site survey, and soil investigation (if applicable)
12.

Phase II Environmental Assessment (if applicable)

13. Letter from state or tribal government historical preservation officer
14. State Clearinghouse Comments (E.O. 12372) or Tribal Government Comments
15.

Master Plan for facility approved

16.

Schematic drawings for the proposed project (if applicable) approved
17. Design development drawings and specifications (35 percent) approved
18. Updated Form SF 424 and SF 424C
19. A schedule of when each of the remaining requirements will be met
20.
21.

Building Space Program Analysis (if applicable)
Final drawings and specifications (100 percent) approved

VA FORM
JUN 2023

40-0895-14

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SECTION A - PREAPPLICATION PHASE (Deadline is April 1 each year for VA receipt) (Continued)
NO.

22.
23.

REQUIREMENT

CHECK
RECEIPT

DATE

Updated Form SF 424, SF 424C, SF 424D
Updated schedule when each of the remaining requirements will be met.

24.

VA Notification to Precede to Bid the Project to Applicant
NOTE: The following certifications from the authorized state or tribal government official must be submitted to VA as part of the
Preapplication Phase.
A. Compliance with VA Form 40-0895-2, Certification of Compliance with Provisions of the
25.
Davis-Bacon Act
B. Compliance with VA Form 40-0895-7, Certification Regarding Debarment, Suspension, and Other
26.
Responsibility Matters - Primary Covered Transactions (State orTribal Government)
C. Compliance with VA Form 40-0895-8, Certification Regarding Drug-Free Workplace
27.
Requirements for Grantees other than individuals
28.
29.

D. Compliance with VA Form 40-0895-9, Certification Regarding Lobbying
E. Compliance with VA Form 40-0895-15, Certification of Cemetery Maintained in Accordance
With National Cemetery Administration Standards.
SECTION B - APPLICATION PHASE (Deadline is July 15 for that FY Grant Award)

30.
31.
32.
33.
34.
35.
36.

Advertisement for bids
Bid tabulations
VA Form 40-0895-10, Certification of Compliance with Federal Requirements-State or Tribal
Government Cemetery Construction Grant.
Final application - SF 424, based on bids and consistent with SF 424C
Revised budget page (SF 424C) based on bids
Compliance with VA Form 40-0895-12, Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions (Contractor)
Three (3) signed copies of the Memorandum of Agreement
SECTION C - POST GRANT AWARD

37.
38.

Submit a written request to the Director, State Cemetery Grants Service (41E), requesting 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.
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.
Add the following statement to the SF 271, Outlay Report and Request for Reimbursement for
Construction Programs and add the statement to the HHS final reimbursement request.

39.

40.
41.
42.
43.
44.

"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."
Compliance with the Single Audit Act requirements
Final Master Plan (one copy for SCGP and one copy for state cemetery), if appropriate.
As Built Drawings (one copy for SCGP and one copy for state cemetery)
Custody and Transfer Receipt Final Release of Claims Final Invoice - one copy for SCGP, if
appropriate.
Close out grant.

VA FORM
JUN 2023

40-0895-14

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