Fillable Printable VA Form 40-0895-13

VA Form 40-0895-13

OMB NUMBER: 2900-0559

Respondent Burden: 2 hours

CERTIFICATION REGARDING DOCUMENTS AND INFORMATION REQUIRED FOR

STATE OR TRIBAL GOVERNMENT CEMETERY CONSTRUCTION GRANTS -

POST GRANT REQUIREMENTS

Respondent Burden: Public reporting burden for this collection of information is estimated to average 2 hours. Statutory authority

for a State Cemetery Grant is 38 U.S.C. 2408. The information requested is necessary to ensure that State or Tribal government is

aware of and complies with all grant responsibilities and to properly and timely close out the grant. VA may not conduct or sponsor

and you are not required to respond to this collection of information unless it displays a valid OMB number. Respond to this

collection is voluntary. Send comments regarding the burden estimate or any other aspects of this collection of information,

including suggestions for reducing the burden to VA Clearance Officer (005R1B), 810 Vermont Avenue NW, Washington, DC

20420. SEND COMMENTS ONLY. Please do not send applications for a grant to this address.

STEPS TO CLOSE OUT A CONSTRUCTION GRANT PROJECT

1. Submit a written request to the Director, State Cemetery Grants Service (41E), 810 Vermont Avenue, N.W., Washington, D.C.

20420, asking the Department of Veterans Affairs to schedule a final grant program review. Include the name and telephone number

of the local point of contact for the project.

2. Submit the project equipment list. If there is no equipment involved in the grant, please make a statement to that effect in the

request for a final grant program review.

3. Add the following statement to the SF 271, Outlay Report and Request for Reimbursement for Construction Programs, and add the

statement to the Health and Human Services final reimbursement request:

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 complied with the Single Audit Act requirements. NOTE: If no more than $500,000 is reimbursed to

the State within any of the fiscal years, this requirement is exempted. Exemption requests should be submitted with the other close

out requirements. The Single Audit Act responsibilities can be found in Title 38 CFR Part 41.5. The State may provide the actual

results of the audit by the State Auditing Agency or evidence that the State has reported to the State Auditing Agency that a Federal

grant was awarded to the State. The letter should clearly identify the Federal Application Identifier (FAI), the date the grant was

awarded, the amount of the Federal assistance, and the approximate end date of the construction.

5. Final Master Plan (one copy for State Cemetery Grant Program and one copy for state cemetery), if appropriate.

6. As Built Drawings (one copy for State Cemetery Grant Program and one copy for state cemetery).

7. Custody and Transfer Receipt Final Release of Claims Final Invoice (one copy for State Cemetery Grant Program), if appropriate.

NOTE: The final payment will be authorized when all closeout requirements are met. If you have questions, please contact

Director, State Cemetery Grants Service (41E).

CERTIFICATION: I certify that the information submitted to Department of Veterans Affairs is true and correct to the best of my

knowledge and ability.

NAME OF AUTHORIZED STATE OR TRIBAL GOVERNMENT OFFICIALTITLE OF AUTHORIZED STATE OR TRIBAL GOVERNMENT OFFICIAL

PROJECT FAI (Federal Application Identifier) NO.DATE GRANT AWARDEDAMOUNT OF FEDERAL ASSISTANCE

SIGNATUREDATE (mm/dd/yyyy)

VA FORM

OCT 2010

40-0895-13