10-0388-6 Certification of State Matching Funds To Qualify for Gro

OMB Number: 2900-0661
Estimated Burden: 15 minutes

CERTIFICATION OF STATE MATCHING FUNDS
TO QUALIFY FOR GROUP 1 ON THE PRIORITY LIST
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 15 minutes 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.

I certify that State funds totaling $
for FAI #

,i.e., 35% of the total project cost which is $

were available on August 1,

, and that further State action is not needed to make

such funds available (such as further action to issue bonds)."

TITLE 38 USC 8135 (B) (2) (A)
TITLE 38 CFR 59.40
NAME OF AUTHORIZED STATE BUDGET OFFICIAL

SIGNATURE

TITLE OF AUTHORIZED STATE BUDGET OFFICIAL

DATE (mm/dd/yyyy)

ENCLOSURE: Copy of Act, as approved by the Governor, authorizing the project and making available the State's 35 percent matching funds for the project. (If the State
has not appropriated the State matching funds, then , sufficient documentation must be provided to show that the State has available the State has matching funds for the
project.)
VA FORM
JUL 2013

10-0388-6

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