VA_Form_10096_Adaptive_Sports_Grant_Application.pdf

OMB Number: 2900-0820 Exp. Date: Feb., 2019 Respondent Burden: 20 minutes

ADAPTIVE SPORT GRANT APPLICATION

PRIVACY ACT: The information requested on this form is solicited under the authority of Title 38, U.S.C., and Sections 1710, 1712, and 1722. It is being collected to enable us to determine your eligibility for benefits and will be used for that purpose. The information you supply may be verified through a computer matching program at any time and information may be disclosed outside the VA as permitted by law. VA may make a routine use disclosure of the information as outlined in the Privacy Act system of records identified as 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary; however, the information is required in order for us to determine your eligibility for the benefit for which you have applied. Failure to furnish the information will have no adverse affect on any other benefits to which you may be entitled.

RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this application will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.

SECTION A - ORGANIZATION AND GRANT INFORMATION

1. ORGANIZATION AND MAILING ADDRESS 2. PROGRAM NAME AND TITLE 3. GRANT AMOUNT

REQUESTED

SECTION B - CONTACT INFORMATION

4. PRIMARY CONTACT 5. PRIMARY PHONE NUMBER 6. ALTERNATE PHONE NUMBER

7. EMAIL

SECTION C - PROGRAM AND OTHER INFORMATION

8. DUNS NUMBER (Must provide a DUNS number before any payment is disbursed)

9. CONGRESSIONAL DISTRICT 10. SAM CAGE CODE NUMBER 11. EIN NUMBER

12. PROJECTED START DATE 13. PROJECTED COMPLETION DATE 14. TARGET GEOGRAPHIC AREA(S)

15. CATEGORY

INITIAL RENEWAL NON-COMPETITIVE

16. PROGRAM HISTORY

NEW 1-2 YEARS 3-5 YEARS 5+ YEARS

17. DISABILITY GROUPS AMPUTEE

BLIND/VI

SPINAL CORD

INJURY

PTSD

TBI/STROKE

OTHER

18. EXPERIENCE WITH DISABLED VETERANS?

YES NO

19. COMPLEMENTARY FUNDING?

FEDERAL: YES NO AMOUNT:

NON-FEDERAL: YES NO AMOUNT:

20. DOES YOUR ORGANIZATION HAVE EXPERIENCE IN MANAGING FEDERAL FUNDS? YES NO

Program Details

1. Program Past Performance:

Applicant must demonstrate eligibility to receive a grant award in accordance with 38 USC 77(2). Limit response to one written page.

2. Program Specifics:

Applicant must clearly describe specific aspects of the proposed program to include: type of adaptive sport(s) provided (community/national events, introductory/competitive events, local/or requires travel), frequency and duration of occurrence, location(s) of programming, estimated number of unique Veterans/ Service Members served (required to be reported by last name, first name and zip code on quarterly reports), type of disabilities served by the proposed adaptive sport, and benefits of the programming to participants. Limit responses to 2 pages.

VA FORM

FEB 2016 10096

3. TIMELINE OF ACTIVITIES (Check box if you are hosting activities in a given month.)

OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP

4. OUTREACH PROGRAM SPECIFICS (Describe your planned outreach efforts to inform eligible Veterans and members of the Armed Forces about your program)

This application does not constitute a Grant Agreement. Upon approval of the application by VA, an applicant will be required to complete a signed Grant Agreement specifying terms and conditions of an award. The Program Goals and Deliverables (Exhibit A) and Program Budget (Exhibit B) will form the basis of the Grant Agreement as agreed upon by VA and the applicant. Upon full execution of the Grant Agreement, the applicant will perform the services/activities hereto attached in Exhibit A, perform the Program Budget in line with the budget attach hereto in Exhibit B unless otherwise agreed upon by the applicant and VA.

In the event the applicant and VA do not enter into a Grant Agreement for any reason, and/or in the event the applicant and VA are unable to agree on the terms of the Grant Agreement within 60 days after approval of the application by VA, this application will automatically terminate.

SIGNATURE ORGANIZATION NAME

NAME TITLE DATE

5. QUALIFICATIONS OF PERSONNEL

(Include specific experience, education or other qualifications relevant to the grant proposal.)

NAME TITLE QUALIFICATIONS

6. PARTNERING AND COLLABORATING ORGANIZATIONS

(Include signed agreements for partnering or joint activities.)

COLLOBORATING ORGANIZATION

NAME AND POC

LOCATION

(CITY, STATE) COLLABORATIVE ACTIVITIES

VA FORM 10096, FEB 2016, page 2

EXHIBIT A

Program Goal and Deliverables

(Include location, dates, activities, frequency of occurrence and number of Veterans expected to participate) Organization Name:

Program Deliverable

DELIVERABLE SUBCOMPONENTS PROJECTED

START

PROJECT

COMPLETION

BUDGET

ESTIMATE

VA FORM 10096, FEB 2016, page 3

EXHIBIT B

VA ADAPTIVE SPORTS GRANT PROGRAM BUDGET

Program Budget and Expected Expenditures (Grant Funds Only)

CATEGORY

Operations

AMOUNT DESCRIPTION OF EXPENDITURES

PROJECTED SPENDING IN EACH QUARTER ($)

OCT-DEC

(Q1)

JAN-MAR

(Q2)

APR-JUN

(Q3)

JUL-SEPT

(Q4)

Equipment

Travel

Supplies

Administrative

*Personnel (Operational) *Personnel

(Administrative)

Other

Total

BUDGET CATEGORY DEFINITIONS

ONLY include amounts spent against this award. DO NOT report expenditures that are funded by other sources.

For further information regarding allowable costs, please reference OMB guidance (2 CFR 200 and 38 CFR 77).

Operations - Expenditures associated with implementing this grant program such as coaching fees, lift tickets and facility fees.

Equipment - Sport equipment purchased to meet program objectives. To be categorized as equipment must have a useful life of more than one year and a unit price equal to or greater than $5,000. Equipment expenditures must be identified in your Grant Application and listed on Exhibit C.

Travel - Expenses for transportation, lodging, subsistence, and related items incurred to meet program objectives. Costs must be consistent with those allowed in like circumstances in your organization's other activities. Travel costs must comply with GSA lodging and subsistence rates for designated locations which can be found at http://www.gsa.gov/portal/category/100120.

Supplies - Consumable items in direct support of carrying out the award or equipment purchases with a per-unit value less than $5,000.

Administrative (non-Personnel) - Sum of Administrative and In-Direct Costs that do not include Personnel (Administrative). When combined with Personnel (Administrative) costs, may not exceed 5% of the total award. Costs must be clearly identified and associated with the implementation and tracking of the award.

*Personnel (Operational) - Includes both Personnel and Fringe Benefit expenses that should be based on documented payrolls approved by a responsible official(s) of the organization. Reports need to reflect the distribution of activity for those whose compensation is charged, in whole or in part, directly to this award. Operational activities are identified as "time spent by such employee directly providing coaching or training for participants" per 38 CFR 77.14(c)(2). The reports must reflect an after-the-fact determination of the actual activity worked on the program. Reports must account for the total activity for which employees are compensated.

*Personnel (Administrative) - Includes both Personnel and Fringe Benefits expenses that should be based on documented payrolls approved by a responsible official(s) of the organization. Reports need to reflect the distribution of activity for those whose compensation is charged, in whole or in part, directly to this award. Administrative activities are identified as all personnel activities that are not "time spent by such employee directly providing coaching or training for participants" per 38 CFR 77.14(c)(2). The reports must reflect an after-the-fact determination of the actual activity worked on the program. Reports must account for the total activity for which employees are compensated.

VA FORM 10096, FEB 2016, page 4 http://www.gsa.gov/portal/category/100120

EXHIBIT C

EQUIPMENT PURCHASES

Organization Name:

Equipment Purchases

*Report the purchase of single units/pieces of equipment equal to or in excess of $5,000. This is only for equipment purchases using this award.

TYPE OF EQUIPMENT MAKE AND MODEL APPROXIMATE

VALUE QUANTITY

EXHIBIT D

ADAPTIVE SPORTS OFFERED

Please indicate the type of adaptive sport activity: introductory, participatory, or competitive.

SPORT INTRODUCTORY PARTICIPATION COMPETITION

VA FORM 10096, FEB 2016, page 5

VA Form 10096, ADAPTIVE SPORT GRANT APPLICATION Missie Vaccaro-Palomaki December 2014 February 2016 Matt Bristol/Joshua McCoy (002)

10096, ADAPTIVE, SPORT, GRANT, APPLICATION

OMB Number: 2900-0820 Exp. Date: Feb., 2019 Respondent Burden: 20 minutes O M B Number: 2900-0820 Exp. Date: Feb, 2019 Respondent Burden: 20 minutes Department of Veterans Affairs logo

ADAPTIVE SPORT GRANT APPLICATION

PRIVACY ACT: The information requested on this form is solicited under the authority of Title 38, U.S.C., and Sections 1710, 1712, and 1722. It is being collected to enable us to determine your eligibility for benefits and will be used for that purpose. The information you supply may be verified through a computer matching program at any time and information may be disclosed outside the VA as permitted by law. VA may make a routine use disclosure of the information as outlined in the Privacy Act system of records identified as 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary; however, the information is required in order for us to determine your eligibility for the benefit for which you have applied. Failure to furnish the information will have no adverse affect on any other benefits to which you may be entitled.

RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this application will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.

SECTION A - ORGANIZATION AND GRANT INFORMATION

1. ORGANIZATION AND MAILING ADDRESS

2. PROGRAM NAME AND TITLE

3. GRANT AMOUNT

REQUESTED

SECTION B - CONTACT INFORMATION

4. PRIMARY CONTACT

5. PRIMARY PHONE NUMBER

6. ALTERNATE PHONE NUMBER

7. EMAIL

SECTION C - PROGRAM AND OTHER INFORMATION

8. DUNS NUMBER (Must provide a DUNS number before any payment is disbursed)

9. CONGRESSIONAL DISTRICT

10. SAM CAGE CODE NUMBER

11. EIN NUMBER

12. PROJECTED START DATE

13. PROJECTED COMPLETION DATE

14. TARGET GEOGRAPHIC AREA(S)

15. CATEGORY

16. PROGRAM HISTORY

17. DISABILITY GROUPS

18. EXPERIENCE WITH DISABLED VETERANS?

19. COMPLEMENTARY FUNDING?

FEDERAL:

AMOUNT:

NON-FEDERAL:

AMOUNT:

20. DOES YOUR ORGANIZATION HAVE EXPERIENCE IN MANAGING FEDERAL FUNDS?

Program Details

1. Program Past Performance:

Applicant must demonstrate eligibility to receive a grant award in accordance with 38 USC 77(2). Limit response to one written page.

2. Program Specifics:

Applicant must clearly describe specific aspects of the proposed program to include: type of adaptive sport(s) provided (community/national events, introductory/competitive events, local/or requires travel), frequency and duration of occurrence, location(s) of programming, estimated number of unique Veterans/ Service Members served (required to be reported by last name, first name and zip code on quarterly reports), type of disabilities served by the proposed adaptive sport, and benefits of the programming to participants. Limit responses to 2 pages.

VA FORM FEB 2016

V A FORM 1 0 0 9 6, FEBRUARY 2016

10096

3. TIMELINE OF ACTIVITIES (Check box if you are hosting activities in a given month.)

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

4. OUTREACH PROGRAM SPECIFICS (Describe your planned outreach efforts to inform eligible Veterans and members of the Armed Forces about your program) This application does not constitute a Grant Agreement. Upon approval of the application by VA, an applicant will be required to complete a signed Grant Agreement specifying terms and conditions of an award. The Program Goals and Deliverables (Exhibit A) and Program Budget (Exhibit B) will form the basis of the Grant Agreement as agreed upon by VA and the applicant. Upon full execution of the Grant Agreement, the applicant will perform the services/activities hereto attached in Exhibit A, perform the Program Budget in line with the budget attach hereto in Exhibit B unless otherwise agreed upon by the applicant and VA.

In the event the applicant and VA do not enter into a Grant Agreement for any reason, and/or in the event the applicant and VA are unable to agree on the terms of the Grant Agreement within 60 days after approval of the application by VA, this application will automatically terminate.

SIGNATURE

ORGANIZATION NAME

NAME

TITLE

DATE

5. QUALIFICATIONS OF PERSONNEL

(Include specific experience, education or other qualifications relevant to the grant proposal.)

NAME

TITLE

QUALIFICATIONS

6. PARTNERING AND COLLABORATING ORGANIZATIONS

(Include signed agreements for partnering or joint activities.)

COLLOBORATING ORGANIZATION

NAME AND POC

LOCATION

(CITY, STATE)

COLLABORATIVE ACTIVITIES

VA FORM 10096, FEB 2016, page 2 V A FORM 1 0 0 9 6, FEBRUARY 2016, page 2

EXHIBIT A

Program Goal and Deliverables (Include location, dates, activities, frequency of occurrence and number of Veterans expected to participate) Organization Name:

Program Deliverable

DELIVERABLE SUBCOMPONENTS

PROJECTED

START

PROJECT

COMPLETION

BUDGET

ESTIMATE

VA FORM 10096, FEB 2016, page 3 V A FORM 1 0 0 9 6, FEBRUARY 2016, page 3

EXHIBIT B

VA ADAPTIVE SPORTS GRANT PROGRAM BUDGET

Program Budget and Expected Expenditures (Grant Funds Only)

CATEGORY

Operations

AMOUNT

DESCRIPTION OF EXPENDITURES

PROJECTED SPENDING IN EACH QUARTER ($)

OCT-DEC

(Q1)

JAN-MAR

(Q2)

APR-JUN

(Q3)

JUL-SEPT

(Q4) Equipment Travel Supplies Administrative *Personnel (Operational) *Personnel (Administrative) Other Total

BUDGET CATEGORY DEFINITIONS

ONLY include amounts spent against this award. DO NOT report expenditures that are funded by other sources.

For further information regarding allowable costs, please reference OMB guidance (2 CFR 200 and 38 CFR 77).

Operations - Expenditures associated with implementing this grant program such as coaching fees, lift tickets and facility fees.

Equipment - Sport equipment purchased to meet program objectives. To be categorized as equipment must have a useful life of more than one year and a unit price equal to or greater than $5,000. Equipment expenditures must be identified in your Grant Application and listed on Exhibit C.

Travel - Expenses for transportation, lodging, subsistence, and related items incurred to meet program objectives. Costs must be consistent with those allowed in like circumstances in your organization's other activities. Travel costs must comply with GSA lodging and subsistence rates for designated locations which can be found at http://www.gsa.gov/portal/category/100120.

Supplies - Consumable items in direct support of carrying out the award or equipment purchases with a per-unit value less than $5,000.

Administrative (non-Personnel) - Sum of Administrative and In-Direct Costs that do not include Personnel (Administrative). When combined with Personnel (Administrative) costs, may not exceed 5% of the total award. Costs must be clearly identified and associated with the implementation and tracking of the award.

*Personnel (Operational) - Includes both Personnel and Fringe Benefit expenses that should be based on documented payrolls approved by a responsible official(s) of the organization. Reports need to reflect the distribution of activity for those whose compensation is charged, in whole or in part, directly to this award. Operational activities are identified as "time spent by such employee directly providing coaching or training for participants" per 38 CFR 77.14(c)(2). The reports must reflect an after-the-fact determination of the actual activity worked on the program. Reports must account for the total activity for which employees are compensated.

*Personnel (Administrative) - Includes both Personnel and Fringe Benefits expenses that should be based on documented payrolls approved by a responsible official(s) of the organization. Reports need to reflect the distribution of activity for those whose compensation is charged, in whole or in part, directly to this award. Administrative activities are identified as all personnel activities that are not "time spent by such employee directly providing coaching or training for participants" per 38 CFR 77.14(c)(2). The reports must reflect an after-the-fact determination of the actual activity worked on the program. Reports must account for the total activity for which employees are compensated.

VA FORM 10096, FEB 2016, page 4 V A FORM 1 0 0 9 6, FEBRUARY 2016, page 4

EXHIBIT C

EQUIPMENT PURCHASES

Organization Name:

Equipment Purchases *Report the purchase of single units/pieces of equipment equal to or in excess of $5,000. This is only for equipment purchases using this award.

TYPE OF EQUIPMENT

MAKE AND MODEL

APPROXIMATE

VALUE

QUANTITY

EXHIBIT D

ADAPTIVE SPORTS OFFERED

Please indicate the type of adaptive sport activity: introductory, participatory, or competitive.

SPORT

INTRODUCTORY

PARTICIPATION

COMPETITION

VA FORM 10096, FEB 2016, page 5 V A FORM 1 0 0 9 6, FEBRUARY 2016, page 5