OMB Number 2900-0661 Estimated burden: 6 hours
MEMORANDUM OF AGREEMENT FOR A GRANT TO CONSTRUCT OR ACQUIRE A STATE VETERANS HOME
This Memorandum of Agreement is hereby made by and between The Department of Veterans Affairs Vermont Avenue, NW, Washington, D.C. 20420, and has submitted to VA an application for a grant to construct or (VA), 810
facility for veterans in
The Federal Application Identifier (FAI) Number for this project is application meets the requirements of Federal Law for this grant. The estimated total cost of equipment, in which VA will participate, is $ will not exceed sixty-five (65) percent of the actual cost of
. The parties agree that this , including , but
. The VA grant will total up to $ as determined at final audit.
In consideration of the foregoing, the parties hereto mutually agree as follows: (1) applicable Federal requirements. (2) agrees that it will construct or acquire a
(a description of the
certifies that the plans and specifications included in the application meet all
, to be completed in accordance with the documentation
project, including number of beds added or replaced)
submitted by the State. (3) submitted by the state. (4) agrees to enter into a contract to construct or acquire a agrees to comply strictly with the assurances contained in the documentation
(a description of the project, including number of beds added or replaced)
within 90 days of the date on which both parties have signed this agreement. agrees to periodically inspect the project and certify to the Chief Consultant , (5) Office of Geriatrics and Extended Care, 810 Vermont Avenue, NW, Washington, D.C. 20420, for payment of such sums which it deems are payable by VA.
VA FORM MAR 2003
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(6) (7) support to maintain and operate the facility. (8) per month until the project area is filled.
agrees to furnish any additional State funds needed to complete the project. agrees that, upon completion of the project, it will provide adequate financial
agrees that following completion of the project, it will open at least eight beds
agrees that it will use the facilities principally to furnish veterans (nursing home care, domiciliary care, adult day health care) and that not more than 25 percent of the bed occupancy at any one time will consist of residents who are not receiving such level of care as veterans. agrees that it will operate and maintain the facility in conformance with State standards and with all applicable State and local laws, codes, regulations and ordinances, and in conformance with the standards prescribed by VA. (11) agrees that it will make such reports in such form and containing such information as the Secretary may from time to time reasonably require, and give the Secretary, upon demand, access to the records upon which such information is based. (10)
The Secretary of the Department of Veterans Affairs hereby approves the project. After certifies its construction or acquition costs as set forth in paragraph (5) above, the Secretary agrees to make partial payments of the grant to cover the costs certified. VA payments will be limited to the unpaid obligated balance of the grant for actual incurred costs for this project. This grant is subject to the recapture provisions stated in 38 CFR 59.100.
IN WITNESS WHEREOF, the parties have hereunto affixed their signature on the dates indicated
Secretary of Veterans Affairs
VA FORM MAR 2005
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