10-0388-13 Documents and Information Required for State Home Constr

OMB Number: 2900-0661
Estimated Burden: 1 hour

DOCUMENTS AND INFORMATION REQUIRED FOR STATE HOME CONSTRUCTION
AND ACQUISITION GRANTS - POST-GRANT REQUIREMENTS
PROJECT DESCRIPTION

PROJECT LOCATION

FAI NUMBER

The state representative must submit to VA the following prior to the final payment of grant funds or when specified below:
1. Completed project photos and a final equipment list (prior to completion of construction). A separate, complete itemized list to include all
fixed and other equipment by category (see 38 CFR Part 59.80) with the cost, quantity, and placement in accordance with the involved final
drawings. (NOTE: if no equipment is Involved in the project, a statement to that effect should be included in the request for final architectural/
engineering review.) This equipment involved list must be approved by VA prior to final payment.
Photographs documenting pre-construction, mid-point construction and final/completed project, including equipment.
Other equipment not included in the construction contract constituting no more than 10 percent of the total construction contract cost of the
project. Other equipment includes: furniture, furnishings, wheeled equipment, kitchen utensils, linens, draperies, blinds, electric clocks,
pictures and trash cans.
2. A request in writing for the final grant program review, including the name and telephone number of the local point of contact for the project.
3. A final claim for payment on Standard Form (SF) 271, OUTLAY REPORT AND REQUEST FOR REIMBURSEMENT FOR
CONSTRUCTION PROGRAMS. Add the statement "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 met its responsibility for an audit under the Single Audit Act of 1984 and 59.124 of this part, if applicable.
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 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
JUN 2020

10-0388-13

Page 1