TEMPLATE Checklist Item A12 Number of Beds-Rate.docx

**The state must submit the authorized state representative's certified statement that the list of the total number of state-operated nursing home and domiciliary beds for veterans is the total number of such beds existing, under construction, or pending approval by VA at the time of the initial application. Note that this is a template, and you are free to adapt as needed or submit supplemental documentation to meet this requirement. Delete any instructions that are italicized once updated. Submit as PDF.**

February 10, 2019 (Insert date)

Anna Gaug Program Manager U.S. Department of Veterans Affairs State Home Construction Grant Program (10NA5) 810 Vermont Avenue NW Washington, D.C. 20005

Re: Insert project title or description, location (city or county, state)

Dear Ms. Gaug, This document is to fulfill checklist item A.12. and certifies that the list of the total number of state-operated nursing home and domiciliary beds for veterans is the total number of such beds existing, under construction, or pending approval by VA at the time of this initial application.

Sincerely, Insert signature

Insert signature block