10-0388-5 Additional Documents and Information Required for State

OMB Number: 2900-0661
Estimated Burden: 6 hours

ADDITIONAL DOCUMENTS AND INFORMATION REQUIRED FOR STATE HOME CONSTRUCTION
AND ACQUISITION GRANTS APPLICATION
PROJECT DESCRIPTION

PROJECT LOCATION

FAI NUMBER

SECTION I - STATE MATCHING FUNDS DOCUMENTATION DUE AUGUST 1ST
The State Representative must submit the following to the Department of Veterans Affairs (VA), State Home Construction Grant Program (SHCGP)
to receive a grant:
1. VA Form 10-0388-6, CERTIFICATION OF STATE MATCHING FUND.
2. Evidence (act, issued bonds, etc.) that the state has its share of the estimated total costs of construction.

SECTION II - APPLICATION REQUIREMENTS
The State Representative must submit the following certifications to VA.
1. Phase I Environmental Site Assessment
For any project that includes ground disturbance or acquisition of a new site, provide a Phase I environmental site assessment (ESA) conducted
in accordance with ASTM Standard E1527-13 Standard Practice for Environmental Site Assessments: Phase I Environmental Site Assessment
Process by an Environmental Professional as defined in Section 7.5.1 of that standard. A Phase I ESA seeks to identify any recognized
environmental conditions (RECs). RECs are the presence or likely presence of any hazardous substances or petroleum products in, on, or at a
property:
(1) due to any release to the environment;
(2) under conditions indicative of a release to the environment; or
(3) under conditions that pose a material threat of a future release to the environment.
2. NEPA Environmental Assessment or Categorical Exclusion
A Categorical Exclusion (CATEX) may apply if:
(a) the proposed project falls within the description of a CATEX listed in 38 CFR Part 26 (see also CATEX form for list); and
(b) there are no extraordinary circumstances that indicate the potential for adverse environmental effects.
The state shall complete the CATEX form for VA review and signature and, as needed, address potential extraordinary circumstances by
providing descriptions, plans, regulatory compliance information, and protective measures for extraordinary circumstances that may be present,
such as asbestos, lead-based paint, PCBs, endangered species, wetlands, historic properties, or any others; see CATEX form for complete list.
If the proposed project does not qualify for a CATEX, the state shall prepare, for VA review, a draft environmental assessment (EA) following the
detailed guidance in 40 CFR Part 1500, 38 CFR Part 26, and VA's Interim NEPA Guidance, along with a draft notice of availability. In general, the
EA states the purpose of and need for the proposed project, identifies alternatives for meeting the purpose and need, and evaluates the potential
environmental impacts of the proposed action and alternatives, including impacts from taking no action. Upon VA approval, the state shall publish
the Draft EA for public, interagency, and tribal comment; address any comments in a Final EA; and draft a finding of no significant impact
(FONSI). The draft Final EA and draft FONSI shall also be provided for VA review and approval. The FONSI will include two signature blocks:
VA's Environmental Engineer and VA's SVH Program Manager.
3. State Historic Preservation Office Consultation
Letter from the grant applicant to the State Historic Preservation Office (SHPO), along with the SHPO response letter, and subsequent approval
memo from the VA Historic Preservation Office.

VA FORM
JUN 2020

10-0388-5

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SECTION II - APPLICATION REQUIREMENTS (Continued)
4. Design Development (35 percent) Drawings
The applicant shall provide one copy of design development drawings and specifications. The drawings must indicate the designation of all
spaces, size of areas and rooms and indicate in outline the fixed and movable equipment and furniture. The total floor and room areas shall be
shown in the drawings. The drawings must include:
1. A plan for each floor (for renovations, the existing conditions and extent of new work should be clearly delineated);
2. Plans of any proposed demolition work;
3. Elevations;
4. Sections and typical details;
5. Roof plan;
6. Fire protection plans; and
7. Technical engineering plans, including structural, mechanical, plumbing, and electrical drawings.
If the project involves acquisition, or renovation, the state should include the current as-built site plan, floor plans and building sections that show
the present status of the building and a description of the building's current use and type of construction.
5. VA Form 10-0388-7, CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS FOR PRIMARY
COVERED TRANSACTIONS.
6. VA Form 10-0388-8, DEPARTMENT OF VETERANS AFFAIRS CERTIFICATION REGARDING DRUG-FREE WORKPLACEREQUIREMENTS
FOR GRANTEES OTHER THAN INDIVIDUALS.
7. VA Form 10-0388-9, CERTIFICATION REGARDING LOBBYING.
8. VA Form 10-0388-2, CERTIFICATION OF COMPLIANCE WITH PROVISIONS OF THE DAVIS-BACON ACT.
CONDITIONAL AWARD REQUIREMENTS
If all previously mentioned requirements for a grant are met, a State may be eligible for a conditional approval of a grant under the provisions of 38
CFR 59.70.
9. Final drawings and specifications
The applicant shall provide to VA one copy of final drawings and specifications.
10. Advertisement for the proposed project and request for bids.
11. Budget Justification Worksheet and SAM Search Results
12. VA Form 10-0388-12, CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION LOWER
TIER COVERED TRANSACTIONS (TO BE SIGNED BY THE CONTRACTORS.)
13. Final SF424 and SF424C Forms
14. VA form 10-0388-10, CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS STATE HOME CONSTRUCTION GRANT.
15. Reasonable assurance that the state home, or another agency or instrumentality of the state has title to the site for the project.
16. Three signed originals of the Memorandum of Agreement that includes provisions in the Sample Memorandum of Agreement.
CERTIFICATION - THE LAW PROVIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION.
I certify that the above information submitted to VA is true and correct to the best of my knowledge and ability.
NAME OF AUTHORIZED STATE OFFICIAL

TITLE OF AUTHORIZED STATE OFFICIAL

SIGNATURE

DATE (mm/dd/yyyy)

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 this Act. The public
reporting burden for this collection of information is estimated to average 6 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. We may not collect or sponsor and you are not required to respond to, a collection unless it has a
valid OMB Control Number. This collection of information is collected under the authority of 38 U.S. Code Sections 8133(a) and 8135(a). VA will use this information, along with other
documents submitted by the States to determine the feasibility of the projects for VA participation, to meet VA requirements for a grant award and to rank the projects in establishing the
annual fiscal year priority list. Although response is voluntary, VA will be unable to authorize a grant without a complete package. Your failure to furnish this information will have no
effect on any of other benefits to which you are entitled.
VA FORM 10-0388-5, JUN 2020

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