SVHCGP 2019 Checklist.pdf
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- Attached to
- State Veterans Home Construction Grant Program
- Opportunity number
- VA-GRANTS-112508-002
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Checklist (Do not submit this - this is for reference)
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Page of Deadline for the initial application is April 15th each year. Complete items A1-A6 for renovation projects OR Complete A1-A7 forlife safety projects OR Complete A1-A13 for new construction and bed replacement projects.
CHECKLIST OF MAJOR REQUIREMENTS FOR STATE HOME CONSTRUCTION/ACQUISITION GRANTS
SECTION A - INITIAL APPLICATION PHASE
DATE
REQUIREMENT
B.
D.
Form SF 424C.
E.
Budget justification worksheet, tab 1 (supplements SF424C Form).
Form SF 424D.
C.
Form SF 424.
Project Scope (use SVHCGP template).
Governor's designation of authorized state official and contact person 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 (must comply with all of Section II, Item 3 Needs Assessment on Form 10-0388-1 Information should reflect most recent U.S. Census data.)
State Clearinghouse Comments (E.O. 12372) single point of contact and compliance statement.
6.
Safety citation/letter (submit only for projects that threaten the life and safety of residents).
Schematics for the proposed project.
Space program analysis for nursing home domiciliary (VA Form 10-0388-3) or ADHC (VA Form 10-0388-4).
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.
State matching funds are required by August 1st for consideration for priority group 1.
A.
B.
State authorization for the project (copy of the legislation appropriating the funds or statement from state budget official outlining source of funding).
Certificate of State matching funds (VA Form 10-0388-6).
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.
A.
13.
12.
11.
9.
7.
10.
5.
4.
3.
2.
..\..\..\logos\FORMLOGO.jpg Department of Veterans Affairs Logo.
TO BE FILLED OUT BY VA
TO BE FILLED OUT BY VA
VA FORM
JUL 2019
10-0388-14
REQUIREMENT
DATE
6.
Conditional Request Letter: If aforementioned requirements are met, and federal funds are available, then a request for conditional approval may be submitted to VA with written assurance applicant will meet remaining requirements within 180 days after the conditional award letter is signed.
Final drawings and specifications (100 percent).
The following items are needed for final award:
Advertisement for Bids (if using CMAR, copy of selection process).
Final Budget Justification Worksheet, Tabs 1 and 2.
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion From Contractor(s) (VA Form 10-0388-12).
Final Budget Form SF 424C.
Final SF 424 Form.
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 for Grant Closeout)
REQUIREMENT
DATE
1.
Closeout request letter (submitted when construction is 90% completed).
2.
Final Project Photos.
3.
4.
Equipment list (if applicable).
Signed Post-Grant Requirements Certification (VA Form 10-0388-13).
5.
7.
Report of audit findings (report must show compliance with Single Audit Act of 1984 and, if applicable, resolution of audit findings).
8.
Proof of compliance with NEPA mitigation measures (if applicable).
9.
Proof of compliance with NHPA Section 106 (if applicable).
Final Payment Request (VA Form SF271).
6.
Copy of letter to state auditor.
2.
1.
2.
SAM Search Results.
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.
7.
B.
C.
I.
H.
G.
F.
E.
D.
1.
Submit all documentation on MAX.gov except for hard copy MOAs.
TO BE FILLED OUT BY VA
2.
Environmental Review and NEPA Compliance A.
Submit Phase I environmental site assessment (ASTM E1527-13) if conducting ground-disturbing activities or acquiring new site.
B.
Complete categorical exclusion (CatEx) form, if a CatEx applies. If potential extraordinary circumstancesor activities with potential effects are indicated on CatEx form, submit description, plan, regulatory compliance, and protective measures. Conduct environmental assessment if not covered by a CatEx.
Design development drawings and specifications (35 percent).
4.
Letter from state historical preservation officer.
3.
VA FORM 10-0388-14, JUL 2019
8.0.1291.1.339988.308172 10-0388-14
CHECKLIST OF MAJOR REQUIREMENTS FOR STATE HOME CONSTRUCTION/ACQUISITION GRANTS
| CurrentPage: |
| PageCount: |
| V. A. COST.: $529,750.00 |
| DESCRIPTION.: |
| 1B. Form S F 4 24.: 0 |
| 1B. Form S F 4 24.: 0 |
| 1B. Form S F 4 24.: 0 |
| 1B. Form S F 4 24.: 0 |
| 1B. Form S F 4 24.: 0 |
| 1. A. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 2. Governor's designation of authorized state official and contact person.: |
| 2. Governor's designation of authorized state official and contact person.: 0 |
| 2. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 3. Needs assessment (must comply with all of Section 2, Item 3 Needs Assessment on Form 10-0388-1 |
Information should reflect most recent U.S. Census data.): 0
| 3. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 4. State Clearinghouse Comments (E.O. 12372) single point of contact and compliance statement.: 0 |
| 4. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 5. Schematics for the proposed project.: 0 |
| 5. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 6. Signed initial application certification (V. A. Form 10-0388-1).: 0 |
| 6. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 7. Safety citation/letter (Submit only for projects that threaten the life and safety of residents).: 0 |
| 7. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 9. Five-year capital plan for state's entire state home program.: 0 |
| 9. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 10. Financial plan for state facility's first three years of operation.: 0 |
| 10. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 11. Documentation that there is a reasonable basis to conclude that the facility when complete will be fully occupied.: 0 |
| 11. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 13. Authorized state official's certification that the number of state home beds does not exceed the requirement in 38 C F R 59.40 or justification for number of state home beds exceeding 38 C F R 59.40 based on travel distance.: 0 |
| 13. Authorized state official's certification that the number of state home beds does not exceed the requirement in 38 C F R 59.40 or justification for number of state home beds exceeding 38 C F R 59.40 based on travel distance.: 0 |
| 13. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| TO BE FILLED OUT BY V. A. SECTION B - APPLICATION PHASE. REQUIREMENT. 1. State matching funds are required by August 1st for consideration for priority group 1. A. State authorization for the project (copy of the legislation appropriating the funds or statement from state budget official outlining source of funding).: 0 |
| 1. A. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 1B. Certificate of State matching funds (V. A. Form 10-0388-6).: 0 |
| 1B. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 3. Letter from state historical preservation officer.: 0 |
| 3. Letter from state historical preservation officer.: 0 |
| 3. Letter from state historical preservation officer.: 0 |
| 3. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 5. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 5. Copy of letter to state auditor.: 0 |
| 5. Copy of letter to state auditor.: 0 |
| 5. Copy of letter to state auditor.: 0 |
| 5. Copy of letter to state auditor.: 0 |
| 5. Copy of letter to state auditor.: 0 |
| 7. A. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 7B. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 7C. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 7D2. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 6D1. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion From Contractor(s) (V. A. Form 10-0388-12).: 0 |
| 6D1. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion From Contractor(s) (V. A. Form 10-0388-12).: 0 |
| 7E1. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 7E2. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 7F. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 7G. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 7H. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 7I. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 1. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 2. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 3. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 4. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 7. The following items are needed for final award. A. Final drawings and specifications (100 percent).: 0 |
| 7B. Advertisement for Bids (if using C M A. R, copy of selection process).: 0 |
| 7C. Final Budget Justification Worksheet, Tabs 1 and 2.: 0 |
| 7E1. Final budget form S F 4 24C .: 0 |
| 7 E 2. Final S F 4 24 form.: 0 |
| 7F.. Certification of Compliance with Federal Regulations (V. A. Form 10-0388-10).: 0 |
| 7G. Reasonable assurance of title to State Home. : 0 |
| 7H. Signed Application Certification (V. A. Form 10-0388-5): 0 |
| 7I. Three (3) signed copies of Memorandum of Agreement. (Delivered by Overnight Mail).: 0 |
| TO BE FILLED OUT BY V. A. SECTION C - POST GRANT AWARD (Required Prior to Final Payment). REQUIREMENT. 1. Closeout request letter (Submitted when construction is 90 percent completed).: 0 |
| 2. Final Project Photos.: 0 |
| 3. Equipment List (if applicable).: 0 |
| 4. Signed Post-Grant Requirements Certification (V. A. Form 10-0388-13).: 0 |
| 5. A. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 5B. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 5C. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 6. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 5D. Compliance with The Davis-Bacon Act (V. A. Form 10-0388-2).: 0 |
| 5D. Compliance with The Davis-Bacon Act (V. A. Form 10-0388-2).: 0 |
| 5. Required certifications from the authorizing state official is required for grant award. A. Compliance Regarding Debarment, Suspension, And Other Responsibility Matters For Primary Covered Transactions (V. A. Form 10-0388-7).: 0 |
| 5B. Compliance with Drug-Free Workplace (V. A. Form 10-0388-8).: 0 |
| 5C. Compliance with Lobbying Act (V. A. Form 10-0388-9).: 0 |
| 2. A. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 2. Environmental Review and N E P. A. Compliance. A. Submit Phase 1 Environmental site assessment (A. S T M E 15 27-13) if conducting ground-disturbing activities or acquiring new site.: 0 |
| 2B. Complete categorical exclusion (Cat Ex) form, if a Cat Ex applies. If potential extraordinary circumstances |
or activities with potential effects are indicated on Cat Ex form, submit description, plan, regulatory compliance, and protective measures. Conduct environmental assessment if not covered by a Cat Ex.: 0 2B. DATE. Enter 2 digit month, 2 digit day and 4 digit year.:
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