10-0388-10 Certification of Compliance With Federal Requirements -

OMB Number: 2900-0661
Estimated Burden: 1 hour

CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS
STATE HOME CONSTRUCTION GRANT
PROJECT DESCRIPTION
PROJECT LOCATION

FAI NUMBER

I certify that to the best of my knowledge and belief all Federal requirements: (1) outlined in 38 Code of Federal
Regulations Part 59 as they pertain to this State Home project; (2) assurances outlined in SF 424D; and (3) all
mandatory comments resulting from the design development review by the U.S. Department of Veterans Affairs (VA)
have been incorporated into construction contact(s) for this State Veterans Home project.

CERTIFICATION - THE LAW PR0VIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION.
NAME OF AUTHORIZED STATE OFFICIAL

SIGNATURE

TITLE OF AUTHORIZED STATE OFFICIAL

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 1 hour 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
JUL 2013

10-0388-10

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