Fillable Printable VA Form 10-10072
Fillable Printable VA Form 10-10072
VA Form 10-10072
Definitions and SSVF Program Information: Definitions and SSVF Program information can be found in
the regulations (38 CFR Part 62) and the Notice of Fund Availability (NOFA) under which you are submitting
this application. Both documents are included as attachments to this application package and are posted on the
SSVF Program web page (http://www.va.gov/homeless/SSVF.asp). Please note that to be eligible for a grant
under the SSVF Program, the applicant must be either a private nonprofit organization or a consumer
cooperative. See 38 CFR 62.2 and 38 CFR 62.11 for definitions of these and other terms contained throughout
the application.
Supportive Services for Veteran Families (SSVF) Program
APPLICATION FOR SUPPORTIVE SERVICES GRANT
OMB Number: 2900-0757
Estimated burden: 35 hours
We are required to notify you that this information collection is in accordance with the clearance requirements
of Section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of
information is estimated to average 35 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining data needed, and completing and reviewing the
collection of information. Respondents should be aware that notwithstanding any other provision of law, no
person will be subject to any penalty for failing to comply with a collection of information if it does not display
a currently valid OMB control number. This collection of information is intended to assist the SSVF Program
Office to determine eligibility to receive supportive services grants under the SSVF Program and to rate and
rank these applications. Response to this survey is voluntary and failure to participate will have no adverse
effect on benefits to which you might otherwise be entitled.
Background: This form is to be completed by eligible applicants for supportive services grants under VA's
SSVF Program. VA will use the collected information to evaluate and select recipients for supportive services
grants. Applicants may be asked to provide additional supporting evidence or to quantify details during the
review process.
Warning: It is a crime to knowingly make false statements to a Federal agency. Penalties upon conviction can
include a fine and imprisonment. For details see 18 U.S.C. 1001. Misrepresentation of material facts may also
be the basis for denial of grant assistance by VA.
Submission: The application must be submitted in accordance with the NOFA. The NOFA specifies the
number of copies and format in which the application must be submitted. Only timely and complete
applications will be considered for funding; applications will not be reviewed if incomplete. To be considered
timely, the number of required copies of the application must be received at the address and by the time and
date specified in the NOFA. Applications received after that time and date will not be accepted even if
postmarked by the deadline date. Following the application deadline, applicants will be notified that their
applications have been received. To be considered complete, all items requested in this grant application must
arrive as a single application package. Materials arriving separately will not be considered and may result in the
application being rejected or not funded.
Documentation and Public Access Requirements: VA will ensure that documentation and other information
regarding each application submitted are sufficient to indicate the basis upon which assistance was provided or
denied. This material will be made available for public inspection for a five- year period beginning not less
than 30 days after the grant award. Material will be made available in accordance with the Freedom of
Information Act (5 U.S.C. 552).
For Further Information: Information on application workshops can be found on VA's SSVF Program
web page at: http://www.va.gov/homeless/SSVF.asp. If you have any questions regarding the SSVF
Program, please contact the SSVF Program Office via e-mail at [email protected] or via phone at
1-877- 737-0111 (this is a toll-free number).
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APPLICATION CHECKLIST
An application must include the following items.
Executive Summary
Section A: Background, Qualifications, Experience, & Past Performance of Applicant and Any Identified
Subcontractors (35 maximum points)
1. Background and Organizational History
2. Organizational Qualifications and Past Performance (Exhibit I)
Section B: Program Concept & Supportive Services Plan (25 maximum points)
1. Need for Program and Outreach/Screening Plan (Exhibit II)
2. Collaboration and Service Delivery Plan
3. Timeline
Section C: Quality Assurance & Evaluation Plan (15 maximum points)
1. Program Evaluation
2. Monitoring and Remediation
Section D: Financial Capability & Plan (15 maximum points)
1. Financial Controls and Estimated Monthly Program Cost Summary (Exhibit III)
2. Summary of Sources of Program Funds
Section E: Area or Community Linkages and Relations (10 maximum points)
1. Area or Community Linkages (Exhibit IV)
2. Coordination with Local Continuum(s) of Care
Section F: Certifications
Exhibits
Exhibit I: Key Personnel Resumes and Hiring Criteria for Proposed Staff
Exhibit II: Eligibility/Screening Tool
Exhibit III: Program Budget (Complete Attached Microsoft Excel Applicant Budget Template)
Exhibit IV: (Optional) Letters of support from Continuums of Care (CoCs) where services are proposed and Relevant MOUs
and MOAs Demonstrating Area or Community Linkages
Exhibit V: Articles of Incorporation, Corporate Resolutions, Certified Partnership, Joint Venture, or LLC Agreement
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Executive Summary
A) Administrative Information. Provide the following information for the applicant:
1. Applicant's Legal Name (as identified in your Articles of Incorporation):
13. Optional: If the applicant would like VA to consider any subcontractors when scoring the applicant,
identify for each subcontractor the following information: name, EIN, business address, mailing address,
contact person (name, title, mailing address, telephone, fax, e-mail). Identify the percentage of work
expected to be subcontracted by applicant to each identified subcontractor.
12. E-mail for Contact Person:
11. Fax for Contact Person:
10. Telephone for Contact Person (where the person can be reached during business hours):
9. Mailing Address for Contact Person (if different from above):
8. Contact Person Title:
7. Contact Person Name:
6. Mailing Address (if different from above) - include both U.S. mailing address and courier (i.e., no P.O.
Box) address:
5. Business Address:
3. Employer Identification Number (EIN) that Corresponds to the Applicant's IRS Ruling Certifying Tax-
Exempt Status under the IRS Code of 1986 (Note: EIN will be used to determine whether applicant is
delinquent or in default on any Federal debt, in accordance with 31 U.S.C. 3701, et seq. and 5 U.S.C.
552a at note):
4. DUNS Number:
2. Other Names under Which Applicant Does Business:
B) Amount of Supportive Services Grant Funds Requested. $
C) Number of Unique Participant Households Estimated to be Served.
D) Average total supportive services grant amount request per participant household. $
(This amount should equal total grant amount divided by number of participant households served.)
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E) Geographic Region Served.
c) Identify which of the following geographic regions applies to the primary area or community in
which the proposed program will operate:
Urban community
Rural community
Other:
Tribal land
F) Compliance with Threshold Requirements (38 CFR 62.21). Check the appropriate box for each of the
following questions.
a. Eligible Entity: Confirm that applicant is either a:
Private Nonprofit Organization (Attached in Exhibit V are one or more of the following: IRS ruling
certifying tax-exempt status under the IRS Code of 1986, as amended; Partnership Agreement;
Articles of Incorporation or By-Laws; and/or Indian Housing Plan Tribal Certification)
Consumer Cooperative (State certification of consumer cooperative status is attached in Exhibit V)
b. Eligible Activities: Applicant proposes to use SSVF funding for eligible activities only (see 38 CFR
62.30- 62.34 for list of eligible activities).
Yes
No
d. Compliance with Final Rule: Applicant agrees to comply with Final Rule.
Yes
No
c. Eligible Participants: Applicant proposes to serve Veteran families who earn less than 50% area median
income and are “occupying permanent housing” as defined in 38 CFR 62.11.
Yes
No
b) Provide the Veterans Integrated Service Network (VISN) number in which the proposed program
will operate
a) Describe the name(s) of the municipalities, counties (or parishes), or tribal lands that the
proposed program will serve. Indicate the name and number of the Continuum(s) of Care (CoCs) to be
served
(see https://www.hudexchange.info/homelessness-assistance/ for CoC locations).
(see http://www2.va.gov/directory/guide/division_flsh.asp?dnum=1
for VISN map).
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f. Default: Applicant either:
Is not in default by failing to meet the requirements for any previous Federal assistance.
Is in default by failing to meet the requirements for previous Federal assistance. Describe below:
Identify yes or no and explain in reasonable detail each instance within the past 10 years in which the applicant,
any identified subcontractor, or any principal, partner, director, or officer of the applicant or identified
subcontractor was:
Yes/No
Item
If no, please describe (attach
additional pages if necessary):
i. Convicted of or pleaded guilty or nolo contendre to a crime (other than a traffic
offense).
iii. Subject to an action or other proceeding, whether before a court, an
administrative agency, governmental body, or an arbitral or other alternative
dispute resolution tribunal, which, if decided in a manner adverse to the
applicant, identified subcontractor, principal, partner, director, or officer (as
applicable), would reasonably be expected to adversely affect the ability of the
applicant or identified subcontractor to perform its obligations with respect to
the proposed program.
vi. Had one or more public transactions (Federal, State, or local) terminated for
cause or default.
ii. Subject to an order, judgment, or decree (including as a result of a settlement),
whether by a court, an administrative agency, or other governmental body, or
an arbitral or other alternative dispute resolution tribunal, in any civil
proceeding or action in which fraud, gross negligence, willful misconduct,
misrepresentation, deceit, dishonesty, breach of any fiduciary duty,
embezzlement, looting, conflict of interest, or any similar misdeed was alleged
(regardless of whether any wrongdoing was admitted or proven).
v. Notified that it is in default of any Federal contract or grant, the reason for the
default, and whether the default was cured.
iv. Debarred, suspended, proposed for debarment, declared ineligible or
voluntarily excluded from transactions by any Federal department or agency.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
vii. Party to litigation or a formal Alternative Dispute Resolution (ADR) process
(e.g., binding arbitration) involving a claim in excess of $50,000. For those
matters involving a claim equal to or in excess of $500,000, describe in detail
the litigation or ADR process.
e. Outstanding Obligations: Applicant either:
Does not have an outstanding obligation to the Federal government that is in arrears and does not
have an overdue or unsatisfactory response to an audit.
Has an outstanding obligation to the Federal government that is in arrears and/ or an overdue or
unsatisfactory response to an audit. Describe:
No
Yes
No
Yes
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*Note: 38 CFR 62.33 requires grantees to assist participants to obtain, and coordinate the provision of, the above-listed public
benefits if they are being provided by Federal, State, local, or tribal government agencies, or any eligible entity in the area or
community served by the grantee by referring the participant to and coordinating with such entity. With the exception of health care
services and daily living services, grantees may also elect to provide directly to participants the listed public benefits in accordance
with the requirements set forth in 38 CFR 62.34.
Yes
Yes
Applicant will provide
benefit directly
(Yes/No)
Type of Benefit/Service (See 38 CFR 62.33 for
definitions of these services)*
Applicant will assist participants in
obtaining benefit through referrals to
other organizations (Yes/No)
Health care services
Other:
Other:
Other:
Housing counseling, housing search
Child care
Transportation services**
Legal services
Personal financial planning services
Fiduciary and representative payee services
Daily living services
Income support services
No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes
No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
No
Yes No
Yes No
G. Summary Grant Information
a. Identify in the table below which of the following other public benefits the applicant will either provide
directly and/or assist participants in obtaining through referrals to other organizations:
b. Identify below which of the following other supportive services (if any) will be offered to participants (see
38 CFR 62.33 and 38 CFR 62.34 for descriptions of these supportive services):
General Housing Stability Assistance
Moving Costs Assistance
Security or Utility Deposit Assistance
Utility-Fee Payment Assistance
Rental Assistance
Emergency Housing Assistance
Transportation
Child Care Financial Assistance
Other:
Other:
NoYes
NoYes
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Please attach responses to Sections A-F. Total narrative for these sections cannot exceed 8 pages.
Responses must be typed in 12 point, Times New Roman font. All pages must have 1 inch margins.
Attached responses must include question number and heading, for example the response to the first
question would begin with the heading:
SECTION A:
a) Describe your organizational experience and effectiveness in working with individuals and families who are
homeless and at imminent risk of homelessness, noting experience working with Veterans. If you plan on using
subcontractors, detail their experience in the work that they will be subcontracted to perform.
SECTION A: Background, Qualifications, Experience, & Past Performance of Applicant and Any
Identified Subcontractors
In scoring the application, VA will award up to 35 points based on the applicant's responses to questions
contained in this section.
a) Describe your organizational experience and effectiveness in working with individuals and families who are
homeless and at imminent risk of homelessness, noting experience working with Veterans. If you plan on using
subcontractors, detail their experience in the work that they will be subcontracted to perform.
b) What staff do you intend to hire, indicating their background and expected caseload? Provide resumes for
key personnel (including case managers and other direct service staff) that will be involved in operating the
proposed program in Exhibit I. If the majority of the staff for the propose program will need to be hired,
provide minimum hiring criteria in Exhibit I.
SECTION B: Program Concept & Supportive Services Plan
In scoring the application, VA will award up to 25 points based on the applicant's responses to questions
contained in this section. Applicants should reference the requirements set forth in the NOFA in preparing
these responses. Applicants are required to use eligibility/screening tool attached in Exhibit II.
a) Estimate the need for SSVF services. Include the basis for this estimate, highlighting areas of unmet need
(for instance, overall numbers of homeless or at-risk Veteran families might be relatively low, but there may be
few available services to meet these needs). How many household participants do you expect to serve and how
do you expect to engage them? The screening tool provided in Exhibit II identifies eligibility criteria for
program participation. For those Veteran families who are eligible, using Stage 2 of Exhibit II, what threshold
(point score) do you plan to use for targeting Category 1 (prevention) participants?
b) How will you coordinate services with the VA and other providers in the Continuum(s) of Care where you
plan to deliver services, describing how all of the required services will be delivered? Describe which optional
services you also plan to provide (such as temporary financial assistance).
c) Describe your timeline for implementing services.
SECTION C: Quality Assurance & Evaluation Plan
In scoring the application, VA will award up to 15 points based on the applicant's responses to questions
contained in this section.
a) Programs are expected to place over 80 percent of category 2 and 3 participants in permanent housing
and maintain over 90 percent of category 1 participants in their current housing (this may be adjusted up
or down based on complexity). It is expected that once placed, participants will be able to sustain
themselves in housing. How will you monitor your ability to meet this goal as well as achieving the
goal of preventing homelessness?
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b) How will you monitor work, including the work of any subcontractor? If you identify problems with
services delivered by you or your subcontractor, what process is in place to create remediation plans?
SECTION D: Financial Capability & Plan
Exhibit III below must also be provided in the Microsoft Excel template. In scoring the application, VA will
award up to 15 points based on the applicant's responses to questions contained in this section.
a) Describe financial controls in place to ensure that program funds are used appropriately. Using the
attached template, provide a detailed one-year program budget that is itemized on a monthly basis.
Include a detailed description of each of the line items contained in the budget template and the
underlying assumptions associated with each line item amount.
b) Specify all sources of funds to be used to operate the proposed program. Identify each source in a
separate line item and the status of the funding, whether the funding is requested, committed, or
received.
SECTION E: Area or Community Linkages and Relations
In scoring the application, VA will award up to 10 points based on the applicant's responses to questions
contained in this section.
a) Describe how community relationships with area providers, governmental agencies, VA, and consumer
groups will assist in the delivery of SSVF services. Reference specific entity names, attaching
Memorandums of Agreement or other evidence of relevant, formal agreements (Exhibit IV).
b) Describe your current efforts to coordinate services in the Continuum(s) of Care (CoC) where you plan
to deliver services. Describe your involvement in the CoC's Coordinated Assessment efforts.
SECTION F: Applicant Certifications & Assurances
The following items require a single certification on the following page by an authorized representative of the
applicant requesting a supportive services grant. The list below should be included in the application packet
with responses attached and numbered to correspond to the relevant item. VA may require that applicants
provide documentation of these certifications.
1. Compliance. Applicant assures that the applicant and any subcontractors will comply with all
requirements of 38 CFR Part 62. If the applicant intends to request waivers to any requirements
included in the preceding citation, please explain.
2. Accuracy of Application Information. All information submitted with this application is accurate, and
does not contain any false, fictitious or fraudulent statement or entry.
3. Non-Delinquency. The applicant further certifies that the applicant is not currently in default or
delinquent on any debt or loans provided or guaranteed by the Federal Government.
4. Debarment. The applicant further certifies that the applicant has not been in the preceding three years:
a) debarred, suspended or declared ineligible from participating in any Federal program; b) formally
proposed for debarment, with a final determination still pending; c) voluntarily excluded from
participation in a Federal transaction; or d) indicted, convicted, or had a civil judgment rendered against
it for any of the offenses listed in the Regulations Governing Debarment and Suspension
(Governmentwide Nonprocurement Debarment and Suspension Regulations: 49 CFR Part 29).
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5. Reports and Record Retention. If this supportive services grant is awarded, applicant assures that any
and all reports required by VA will be made available in such form and contain such information as VA
may require. Applicant further assures that upon demand, VA has access to the records upon which
such information is based.
6. Fiscal Control. If this supportive services grant is awarded, applicant assures that it will establish and
maintain such procedures for fiscal control and fund accounting as may be necessary to ensure proper
disbursement and accounting with respect to the supportive services grant.
7. Civil Rights. Applicant certifies that this program will comply with all provisions of Title VI of the
Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.). If applicant does not certify this, applicant has
provided information explaining any exceptions to this certification.
8. Lobbying. The undersigned certified, to the best of their knowledge and belief, that:
(a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to
any person for influencing or attempting to influence an officer or employee of any agency, a Member
of Congress, an officer or employee of congress, or an employee of a Member of Congress in
connection with the awarding of any Federal contract, the making of any Federal grant, the making of
any Federal loan, the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
(b) If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with this
Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit
Standard FormsLLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
(c) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants,
loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction imposed by section 1352, title 31 U.S. Code. Any person who fails to file
the required certification shall be subject to a civil penalty of not less than $10,000 and not more than
$100,000 for each such failure.
Applicant:
Date:
Name and Title:
Signed:
Signature: By submitting this application, the applicant certifies that the facts stated and the certifications and
representations made in this application are true, to the best of the applicant's knowledge and belief after due
inquiry, and that the applicant has not omitted any material facts. The undersigned is an authorized
representative of the applicant.
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Applicants are required to provide a detailed one-year program budget in Exhibit II that itemizes on a monthly
basis the supportive services and administrative costs associated with the proposed program. Applicants must
also provide a detailed a description of each of the line items contained in this budget and the underlying
assumptions associated with each line item amount in Section D of the application form. The one-year program
budget must be completed in the Microsoft Excel template provided. Instructions on the use of this template are
as follows:
Exhibit III Applicant Budget Template (Microsoft Excel File)
General
a. Applicant is responsible for filling in yellow cells only.
b. All non-yellow cells are locked and populate automatically.
Provision and Coordination of Supportive Services (Total must be a minimum of 90% of the total SSVF Grant
Amount)
a. Personnel/Labor (Note: The spreadsheet will spread these costs evenly across all 12 months. If the
applicant does not anticipate an even spread of costs, this should be explained in the narrative.):
Title and Organization - input the titles of all SSVF-funded personnel (e.g., Program Director, Case
Manager, Employment Specialist, etc.) and the organization at which they are or will be employed
(i.e., list applicant organization or subcontractor organization name as applicable.)
•
# of Full-Time Employees (FTE) - input the number of FTE who will hold the specified title at the
specified organization
•
% FTE - input the percentage of time the staff member will devote to the SSVF-funded program
(e.g., full-time staff would be shown at 100%)
•
Base Annual Salary / Wage - input the annual salary of the specified personnel, assuming full- time
employment.
•
Fringe Benefits - cost of fringe benefits as a percentage of annual salary (if any)
•
b. Temporary Financial Assistance: Input the estimated cost of temporary financial assistance, which
includes time-limited payments to third parties for rent, utilities, moving expenses, security and utility
deposits, transportation, child care and emergency supplies. (Note: Please reference the NOFA for
limitations on the percentage of the total SSVF grant that can be used for this purpose.)
c. Other Non-Personnel Provision and Coordination of Supportive Services Expenses: List any other
expenses related to the provision and coordination of supportive services expenses in this section and
the monthly costs associated with those expenses. (Note: Some mandated training expenses have
already been added to the budget.)
d. Lease & Maintenance of Vehicle(s): Per 38 CFR 62.33, if public transportation options are not
sufficient within an area or community, costs related to the lease of vehicle(s) may be included in the
application. Specify the number of vehicles to be leased and the cost per month associated with these
vehicles.
Administrative Expenses (Total cannot exceed 10% of total SSVF Grant Amount)
List all administrative expenses and the monthly costs associated with each expense. Per 38 CFR 62.70,
administrative expenses are defined as all direct and indirect costs associated with the management of the
program. These costs will include the administrative costs, both direct and indirect, of subcontractors. A line
item of “administrative costs” is not sufficiently descriptive. Administrative costs must be broken down into
multiple line items by category.
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