OMB Number: 2900-0661 Estimated Burden: 6 hours
CHECKLIST OF MAJOR REQUIREMENTS FOR STATE HOME CONSTRUCTION/ACQUISITION GRANTS
DATE AND TIME RECEIVED
SECTION A - INITIAL APPLICATION PHASE (Deadline is APRIL 15 Each Year for VA Receipt)
1. Form SF 424, 424C, and 424D (includes description of project).
2. Governor's designation of authorized state official and contact person 3. Documentation that there is a reasonable basis to conclude that the facility when complete will be fully occupied. 4. Applicant's recommendation as to the priority, any sub-priority, and any further (38 CFR, 59.50) 5. Needs assessment (Title 38 CFR 59.170, VAF 10-0388-1 requirements) 6. Cost estimate (VA portion at time of initial application). 7. State Clearinghouse Comments (E.O. 12372) single point of contact. 8. State Application Identifier Number (if applicable). 9. Statement regarding the total number of state-operated nursing home and domiciliary. 10. Schematics for the proposed project. 11. Space program analysis. 12. Five-year capital plan for state's entire state home program. 13. Financial plan for state facility's first three years of operation. 14. Authorized state official's certification that the number of state home beds does not exceed the requirement in
15. Justification for number of state home beds exceeding 59.40 based on travel distance (59.40(b)) 16. Federal Application Identifier (FAI) number (to be assigned by VA) 17. DUNS Number. 18. Signed initial application certification (VA Form 10-0388-1).
SECTION B - APPLICATION PHASE (Various Requirements & Recommended Deadlines)
The following is required by law AUGUST 15 each fiscal year for consideration for priority group 1 of the priority list of pending applications: A. Updated Form SF 424, 424 C, 424D (Includes description and scope of project. Estimate for equipment not included in the construction contract (not to exceed 10 percent of the 1. construction costs) 2. Contingency estimate (not to exceed 5 percent of the estimated costs of project for new construction or 8 percent for remodeling projects). B. State authorization for the project (copy of the legislation)
C. State matching funds (to be ranked in priority group 1, VA must have on file, by AUGUST 15, a copy of the act appropriating the state funds and certification from an authorized state budget official that the fundsareavailable, how long the funds will remain available, and that no further action is required by the state to make such funds 2 If you are notified that federal funds are available, it is recommended these items are submitted no later than . DECEMBER 31. A. A schedule of when each of the remaining requirements will be met B. Phase I Environment Survey: site plan/map, site survey, and soil investigation (if applicable). Phase II Environmental Assessment (if outside construction exceeds 75,000 gross C. square feet) or a statement from authorized state official that outside construct does not exceed 75,000 GSF and determination of categorical exclusion (CE). D. Letter from state historical preservation officer and subsequent clearance from VA historical preservation officer.
VA FORM JUL 2005
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If federal funds are available for your project, the following should be submitted by DECEMBER 31, but recommended no later than FEBRUARY 28. Design development drawings and specifications (35 percent). One set of sepias, 8 prints, and 8 copies of specifications. Please send directly to the office of construction management, facility quality service (181a), with a copy of the transmittal letter to the Chief, State Home Construction Program (114). A design development conference at VA Central Office or a teleconference is/may be recommended approximately four (4) weeks after submission of your design development drawings and specifications.
The following certifications from the authorize state official must be submitted to VA as part of the application, preferably by MARCH 15 of each year: A. B. C. D. Compliance Regarding Debarment, Suspension, And Other Responsibility Matters For Primary Covered Transactions (VA Form 10-0388-7). Compliance with Drug-Free Workplace (VA Form 10-0388-8). Compliance with Lobbying Act (VA Form 10-0388-9). Compliance with The Davis-Bacon Act (VA Form 10-0388-2).
If the above requirements are/will be substantially met by SEPTEMBER 15, and federal funds are available, then a conditional approval may be provided and funds obligated for the project. However, a written request for conditional approval must be submitted to VA no later than AUGUST 15. If the state met all requirements, then a final grant may be awarded. If conditional approval is granted, the following items are required within 180 days from the date of conditional approval (Sec. 403 of Public Law 102-585) or the funds, by law, will be de-obligated for your project. A. Final drawings and specifications (100 percent). One labeled set of microfiche aperture cards, microfilm, or compact disc/read only memory (CD/ROM) compact laser disc. Advertise for bids. Bid tabulations. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion From Contractor(S) (VA Form 10-0388-12). Revised budget page (SF 424c) based on bids (2 copies). 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. Reasonable assurance of title to State Home. Signed Application Certification (VA Form 10-0388-5).
B. C. D. E. F. G. H. I. J. 8.
Obligation of federal funds following grant award.
SECTION C - POST GRANT AWARD REQUIREMENT DATE
1. 2. 3. 4. 5. 6. 7.
Equipment list (prior to completion of construction). Claim(s) for payment (SF 271, Outlay Report and Request for Reimbursement for Construction). Final grant program review (must be request by sate official in writing prior to completion of construction). Single Audit Act of 1984; state responsible for audit. Resolution of audit findings (if applicable). Signed Post-Grant Requirements Certification (VA Form 10-0388b). Close out grant.
VA FORM JUL 2005
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