Fillable Printable VA Form 10-0388-14
Fillable Printable VA Form 10-0388-14
VA Form 10-0388-14
10-0388-14
VA FORM
JUL 2013
Page 1 of 2
CHECKLIST OF MAJOR REQUIREMENTS FOR STATE HOME
CONSTRUCTION/ACQUISITION GRANTS
LOCATION DESCRIPTION
SECTION A - INITIAL APPLICATION PHASE (Deadline is APRIL 15 Each Year for VA Receipt)
DATE
REQUIREMENT
Form SF 424, 424C, and 424D (includes description of project).
Governor's designation of authorized state official and contact person
Documentation that there is a reasonable basis to conclude that the facility when complete will be fully
occupied.
Needs assessment (VA Form 10-0388-1, Section II project description and recommended priority.)
State Clearinghouse Comments (E.O. 12372) single point of contact and compliance statement.
State Application Identifier Number (if applicable).
Schematics for the proposed project.
Space program analysis (see VA Community Living Center Design Guide).
Five-year capital plan for state's entire state home program.
Financial plan for state facility's first three years of operation.
Signed initial application certification (VA Form 10-0388-1).
SECTION B - APPLICATION PHASE
REQUIREMENT
DATE
1. The following is required by AUGUST 1 for consideration for priority group 1:
A. Updated Form SF 424, 424 C, 424D (for revised budgets only).
B.
Estimate for equipment not included in the construction contract (not to exceed 10 percent of the
construction costs).
C.
State authorization for the project (copy of the legislation appropriating the funds or statement from state
budget official outlining source of funding).
D.
Certificate of State matching funds (VA Form 10-0388-6).
2. Environmental Survey/Assessment
A.
Phase I Environment Survey: site plan/map, site survey, and soil investigation (if applicable).
B.
Phase II Environmental Assessment (if outside construction exceeds 75,000 gross square feet) or a
statement from authorized state official that outside construct does not exceed 75,000 GSF.
FAI NUMBER DUNS DATE AND TIME SUBMITTED VA COST
Authorized state official's certification of the total number of state-operated nursing home and domiciliary
beds and occupancy rate.
Authorized state official's certification that the number of state home beds does not exceed the requirement in
38 CFR 59.40 or justification for number of state home beds exceeding 38 CFR 59.40 based on travel
distance.
8.
1.
13.
12.
11.
9.
7.
6.
10.
5.
4.
3.
2.
TO BE FILLED OUT BY VA
TO BE FILLED OUT BY VA
Design development drawings and specifications (35 percent)
4.
Letter from state historical preservation officer.
3.
10-0388-14
VA FORM
JUL 2013
Page 2 of 2
REQUIREMENT DATE
6.
Conditional Approval: If aforementioned requirements are substantially met, and federal funds are available, then a request for
conditional approval may be submitted to VA with written assurance State will meet remaining requirements within 180 days. The
following items are needed for final grant award.
Final drawings and specifications (100 percent).
Advertise for bids.
Bid tabulations. (Attach excluded parties list system search results.)
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion From Contractor(s)
(VA Form 10-0388-12).
Revised budget page (SF 424c) based on bids (Including FAI number, Project Description, and Date).
Final application - SF 424, based on bids and consistent with SF 424c.
Certification of Compliance with Federal Regulations (VA Form 10-0388-10).
Three (3) signed copies of Memorandum of Agreement. (Delivered by Overnight Mail)
Reasonable assurance of title to State Home.
Signed Application Certification (VA Form 10-0388-5).
SECTION C - POST GRANT AWARD (Required Prior to Final Payment)
REQUIREMENT DATE
1.
Final grant program review (requested by state official in writing prior to completion of construction).
2. Project Photos (JPG format) and Equipment List.
3.
4.
Single Audit Act of 1984. State audit report and resolution of audit findings (if applicable).
Final Payment Request (VA Form SF271).
5. Signed Post-Grant Requirements Certification (VA Form 10-0388-13)
Compliance Regarding Debarment, Suspension, And Other Responsibility Matters For Primary Covered
Transactions (VA Form 10-0388-7).
Required certifications from the authorizing state official is required for grant award:5.
Compliance with Lobbying Act (VA Form 10-0388-9).
A.
B. Compliance with Drug-Free Workplace (VA Form 10-0388-8).
C.
D.
Compliance with The Davis-Bacon Act (VA Form 10-0388-2).
A.
B.
C.
K.
J.
I.
G.
Budget Summary Narrative (review all 424c)
H.
F.
E.
D.
*Note: Unless otherwise indicated scan and e-mail documents to SHCGP.
TO BE FILLED OUT BY VA
