Fillable Printable VA Form 10-0388-13

VA Form 10-0388-13

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

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.

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."

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.

1. 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.

The state representative must submit to VA the following prior to the final payment of grant funds or when specified below:

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.

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

PAGE 1 OF 1

10-0388-13

JUL 2013