Va Form 10 0361 Cg – Fill Out and Use This PDF

Capital Grant and Per Diem Application:

Applicant Summary:

Your Organization's Name:

Name

Phone

Fax

Executive Director/CEO

Person to contact about application

Mailing Address (if different from agency address on form 424):

Veterans Integrated Service Network (VISN):

In what VISN is your proposed project located?(See map in appendix)

Have you coordinated with your VISN Council of Network Homeless Coordinators (CNHC) to ensure your project meets a need in your VISN? If yes, please provide the contact's name in the space provided below. If no, see the VISN CNHC List in the appendix and please contact your CNHC member.

My VISN CNHC Member is:

1.Eligibility to Receive VA Assistance:

Non Profit Organizations must provide documentation of Accounting System Certification and Evidence of Private nonprofit Status. This should be accomplished by the following:

Providing documentation showing the applicant is a certified United Way Member Agency;

OR

Providing certification on letterhead stationery from a CPA or Public Accountant that the organization has a functioning accounting system that is operated in accordance with generally accepted accounting principles or that the organization has designated a qualified entity to maintain a functioning accounting system. If an entity is used their name and address must be included in the certification letter;

AND

Providing evidence of the nonprofit status of the organization by submitting a copy of their IRS ruling providing tax-exempt status under the IRS Code of 1986, as amended.

2.Project Summary:

to create: (check all that apply)

(List building Address)

Our program will request per diem assistance upon completion of the project.

The total project cost is			(This is the amount requested from VA plus the remaining balance of
funds required to complete the project.)

Does your organization have site control of the building proposed for this project: Yes No

Service Provider and Geographic Area: Check all that apply:

A.Target Populations Below is a list of homeless veteran populations. Check those populations that you have targeted to be served as a part of this application. Keep in mind; there is an expectation that if you identify a population to be served, the specific services (including staff) and or housing that meet the needs of the identified populations should be addressed in the project plan section of this application. Failure to do so may decrease the overall score of the application.

B.Innovation of Project Complete this block if you wish for your project to be considered as innovative. (See rules §61.13 (f) for innovative quality of proposal.)

Please consider this project for additional points for innovation because…

C.Beds and Bedroom Breakdown

All applicants must enter the requested information in the “projected level” column below. If this is a new component of an existing project, you must also complete the “current level” column. If this is a new project, please enter “N/A in the “current” column. Estimates should reflect the count when the project is fully operational.

	Projected Bedrooms, Beds, and Participants	(A)		(B)
		Current Level at		Projected
	Beds and Bedroom Categories	the project site		Level
1.	Total number of bedrooms for all homeless persons
2.	Number of bedrooms for just homeless veterans
3.	Total number of beds for all homeless persons (include cribs and
children’s beds)
4.	Number of beds for just homeless veterans
5.	If service center, number of anticipated non-repeat visits per month
(number of different veterans per month)
	Bed and Visit Request	Totals
1.	Therefore, the number of beds we are asking VA to fund is…
2.	Therefore, the number of unique service center visits we are asking VA to
fund is…

D. Project Narrative:

Please provide a brief abstract of the project to include: The project design, supportive services provided, project collaboration with the VA and community, and any special population of homeless that will be served. Please indicate if the program is new or an expansion of current services.

2. Project Summary (cont.)

D.Project Narrative (cont.) (Please answer in the space provided below.)

E.State/Local Government Applicants:

Applicants who are states or local governments must provide a copy of any comments or recommendations by approved state and (area wide) clearinghouses pursuant to Executive Order 12372.

3.Major Milestones (Timeline):

You are reminded that 38 C.F.R. subpart 61.67 Recovery Provisions, paragraph (a) allows VA to recover grant funds from those grantees that withdraw from the program or fail to establish the project for which the grant was made after 3 years from the date of the award. With this in mind…

Please enter the number of estimated days from execution of the agreement that each of the milestones will occur. (e.g., If execution of agreement is 9/30/03 and it will take 30 days for item one, enter: 30 days. Enter N/A if the event is not part of the proposal.

	Milestone	Days from Execution
		of Grant Agreement
1.	Close on purchase of structure or execution of lease
2.	Rehabilitation started
3.	Rehabilitation complete
4.	New construction started
5.	New construction complete
6.	Operations Staff Hired
7.	Residents begin to occupy
8.	Supportive Services Begin

4.Life Safety Code Notice:

If awarded, as a condition of funding all entities receiving grants and or per diem under PL 107-95 must ensure that the project facilities meet the fire and safety requirements applicable under the Life Safety Code of the National Fire Protection Association as well as any local or state codes as required. Failure to meet this requirement may lead to loss of the award. It is suggested you take the cost of LSC improvements into account when preparing your budget and cost estimates for the project.

5.Budget and Leveraging:

In the chart below in column (A) enter the total cost of the project and in column (B) the amount requested from VA. (Note: column (B) amount cannot exceed 65% of column (A).)

Keep in mind that if selected for funding you are required to document cost according to the OMB Grant Management Circulars. The activities listed below are not inclusive of all of the items of cost in the circulars nor does their presence below constitute that they are fully allowable under the circulars’ guidance. They are simply your requests to VA for a specific grant activity. Refer to the proper circular to determine if a cost is allowable.

A. Budget Summary:
Summary of Grant		Enter the amount		(A)	(B)
Funds Requested		requested for each		Total Cost of Project	65% of Total Cost
		activity.			Requested from VA
		1.	Acquisition
		2.	Rehabilitation
		3.	New Construction
		4.	Total

B.Leveraging Summary:

Enter in the chart below the cash value of documented cash and in-kind resources from other public (including Federal and State) and private sources that are committed to the project.

Non-VA		Resource	(A)	(B)
Resources Brought			Cash Value	VA use only
to the Project				(Allowed Value)
	1.	Applicant Cash
	2.	Third Party Cash
	3.	Third Party Non-Cash
	4.	Volunteer Time
	5.	Contribution of Building
	6.	Contributed Building Below
		Market Value
	7.	Contributed Leasehold Interest
	8.	Contributed Materials
		Total of All Leveraging

C.Supporting Documentation: Applicants that list the cash value of leveraged resources in the Leveraging Summary must document these resources on the appropriate organization letterhead stationary as outlined in the Assurances Section of this application (First Submission-pages 38 & 39.)

6.Description of Need:

The information you provide here will assist in the rating of your project. Please provide a short and descriptive narrative responding to each of the following items:

A. How did you identify the need for this project? (Please answer in the space provided below.)

B.Estimate the total number of homeless veterans in your area that could be served by, or be eligible for, this program. (Please answer in the space provided below.)

C. List the sources of this information. Please be specific. (Please answer in the space provided below.)

D.What percentage or portions of this total number of homeless veterans (Question B) will be served by this proposed program? (Please answer in the space provided below.)

E.Describe any special characteristics or need of this group to be served to demonstrate understanding of the population. (Please answer in the space provided below.)