VA Form 10-10072C Renewal Application for Supportive Services Grant - Supportive Services for Veteran Families (Ssvf) Program

VA Form 10-10072C or the "Renewal Application For Supportive Services Grant - Supportive Services For Veteran Families (ssvf) Program" is a form issued by the United States Department of Veterans Affairs.

The form was last revised on August 1, 2012 - an up-to-date fillable PDF VA Form 10-10072C down below or find it on the Veterans Affairs Forms website.

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OMB Number: 2900-0757
Estimated burden: 10 hours
Supportive Services for Veteran Families (SSVF) Program
RENEWAL APPLICATION FOR SUPPORTIVE SERVICES GRANT
We are required to notify you that this information collection is in accordance with the clearance requirements
of Section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of
information is estimated to average 10 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining data needed, and completing and reviewing the
collection of information. Respondents should be aware that notwithstanding any other provision of law, no
person will be subject to any penalty for failing to comply with a collection of information if it does not display
a currently valid OMB control number. This collection of information is intended to assist the SSVF Program
Office to determine eligibility to receive renewal supportive services grants under the SSVF Program and to
rate and rank these applications. Response to this application is voluntary and failure to participate will have
no adverse effect on benefits to which you might otherwise be entitled.
Background: This form is to be completed by grantees applying for renewal of a supportive services grant.
VA will use the collected information to evaluate and select recipients to renew their supportive services
grants. Applicants may be asked to provide additional supporting evidence or to quantify details during the
review process.
Definitions and SSVF Program Information: Definitions and SSVF Program information can be found in
both the regulations (38 CFR Part 62) and the Notice of Fund Availability (NOFA) under which you are
submitting this application. Both documents are posted on the SSVF Program web page
(http://www.va.gov/HOMELESS/SSVF.asp). Please note that to be eligible for a renewal grant under the
SSVF Program, the applicant must have received a supportive services grant award in the previous fiscal year.
See 38 CFR 62.2 and 38 CFR 62.11 for definitions of the terms contained throughout the application.
Instructions: Please answer the application questions in the space provided on each page of the form.
Submission: The application must be submitted in accordance with the NOFA. The NOFA specifies the
number of copies and format in which the application must be submitted. Only timely and complete renewal
applications will be considered for funding; applications will not be reviewed if incomplete. To be considered
timely, the number of required copies of the renewal application must be received at the address and by the
time and date specified in the NOFA. Applications received after that time and date will not be accepted even
if postmarked by the deadline date. Following the renewal application deadline, applicants will be notified that
their applications have been received. To be considered complete, all items requested in this grant application
must arrive as a single application package. Materials arriving separately will not be considered and may result
in the application being rejected or not funded.
Documentation and Public Access Requirements: VA will ensure that documentation and other information
regarding each application submitted are sufficient to indicate the basis upon which assistance was provided or
denied. This material will be made available for public inspection for a five-year period beginning not less
than 30 days after the grant award. Material will be made available in accordance with the Freedom of
Information Act (5 U.S.C. 552).
Warning: It is a crime to knowingly make false statements to a Federal agency. Penalties upon conviction can
include a fine and imprisonment. For details see 18 U.S.C. 1001. Misrepresentation of material facts may also
be the basis for denial of grant assistance by VA.
For Further Information: If you have any questions regarding the SSVF Program or this application, please
contact the SSVF Program Office via e-mail at
SSVF@va.gov
or via phone at 1-877-737-0111 (this is a toll-
free number).
10-10072C
VA FORM
Page 1 of 14
AUG 2012
OMB Number: 2900-0757
Estimated burden: 10 hours
Supportive Services for Veteran Families (SSVF) Program
RENEWAL APPLICATION FOR SUPPORTIVE SERVICES GRANT
We are required to notify you that this information collection is in accordance with the clearance requirements
of Section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of
information is estimated to average 10 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining data needed, and completing and reviewing the
collection of information. Respondents should be aware that notwithstanding any other provision of law, no
person will be subject to any penalty for failing to comply with a collection of information if it does not display
a currently valid OMB control number. This collection of information is intended to assist the SSVF Program
Office to determine eligibility to receive renewal supportive services grants under the SSVF Program and to
rate and rank these applications. Response to this application is voluntary and failure to participate will have
no adverse effect on benefits to which you might otherwise be entitled.
Background: This form is to be completed by grantees applying for renewal of a supportive services grant.
VA will use the collected information to evaluate and select recipients to renew their supportive services
grants. Applicants may be asked to provide additional supporting evidence or to quantify details during the
review process.
Definitions and SSVF Program Information: Definitions and SSVF Program information can be found in
both the regulations (38 CFR Part 62) and the Notice of Fund Availability (NOFA) under which you are
submitting this application. Both documents are posted on the SSVF Program web page
(http://www.va.gov/HOMELESS/SSVF.asp). Please note that to be eligible for a renewal grant under the
SSVF Program, the applicant must have received a supportive services grant award in the previous fiscal year.
See 38 CFR 62.2 and 38 CFR 62.11 for definitions of the terms contained throughout the application.
Instructions: Please answer the application questions in the space provided on each page of the form.
Submission: The application must be submitted in accordance with the NOFA. The NOFA specifies the
number of copies and format in which the application must be submitted. Only timely and complete renewal
applications will be considered for funding; applications will not be reviewed if incomplete. To be considered
timely, the number of required copies of the renewal application must be received at the address and by the
time and date specified in the NOFA. Applications received after that time and date will not be accepted even
if postmarked by the deadline date. Following the renewal application deadline, applicants will be notified that
their applications have been received. To be considered complete, all items requested in this grant application
must arrive as a single application package. Materials arriving separately will not be considered and may result
in the application being rejected or not funded.
Documentation and Public Access Requirements: VA will ensure that documentation and other information
regarding each application submitted are sufficient to indicate the basis upon which assistance was provided or
denied. This material will be made available for public inspection for a five-year period beginning not less
than 30 days after the grant award. Material will be made available in accordance with the Freedom of
Information Act (5 U.S.C. 552).
Warning: It is a crime to knowingly make false statements to a Federal agency. Penalties upon conviction can
include a fine and imprisonment. For details see 18 U.S.C. 1001. Misrepresentation of material facts may also
be the basis for denial of grant assistance by VA.
For Further Information: If you have any questions regarding the SSVF Program or this application, please
contact the SSVF Program Office via e-mail at
SSVF@va.gov
or via phone at 1-877-737-0111 (this is a toll-
free number).
10-10072C
VA FORM
Page 1 of 14
AUG 2012
RENEWAL APPLICATION CHECKLIST
An application must include the following items.
Executive Summary
Section A: SSVF Program Outcomes (55 maximum points)
Housing Stability
Participant Satisfaction
Program Timeline
Homelessness Prevention
Reduction in Homelessness
Section B: Cost-Effectiveness (30 maximum points)
Cost per Household
Program Budget
Section C: Compliance with Program Goals and Requirements (15 maximum points)
SSVF Program Goals
Laws, Regulations and Guidelines
Grant Agreement
Exhibits
Exhibit I: Certificate of Good Standing
Exhibit II: Eligibility/Screening Tool
Exhibit III: Monthly SSVF Program Budget (Excel Template)
Exhibit IV: Budget Narrative (applicant can attach as a Word or PDF document)
10-10072C
VA FORM
Page 2 of 14
AUG 2012
Executive Summary
The information requested below should be typed into the space following each question in the application
form. Limit your responses to the space provided.
A)
Administrative Information. Provide the following information for the applicant:
1.
Applicant Organization's Legal Name (as identified in your Articles of Incorporation):
2.
Applicant's Program Number (as provided by VA):
3.
Employer Identification Number (EIN) that Corresponds to the Applicant's IRS Ruling Certifying Tax-
Exempt Status under the IRS Code of 1986 (Note: EIN will be used to determine whether applicant is
delinquent or in default on any Federal debt, in accordance with 31 U.S.C. 3701, et seq. and 5 U.S.C.
552a at note):
4.
DUNS Number:
5.
Business Address:
6.
Mailing Address (if different from above) - include both U.S. mailing address and courier (i.e., no P.O.
Box) address:
7.
Contact Person Name:
8.
Contact Person Title:
9.
Telephone for Contact Person (where the person can be reached during business hours):
10. Fax for Contact Person:
11. E-mail for Contact Person:
12. Applicant uses subcontractors to implement the SSVF program.
Yes
No
13. Applicant's SSVF program is currently CARF or COA accredited and wishes to be considered for an
additional year of grant funding (attach copy of certification).
Yes
No
10-10072C
VA FORM
Page 3 of 14
AUG 2012
B)
Compliance with Threshold Requirements (38 CFR 62.21). Check the appropriate box for each of the
following questions.
1.
Application Completeness: Application is complete. It contains each of required application sections
(see pg. 3 of application for a checklist).
Yes
No
2.
Eligible Entity: Confirm that applicant remains either a:
Private Nonprofit Organization (Attached in Exhibit I is a Certificate of Good Standing)
Consumer Cooperative
Eligible Activities: Applicant proposes to use SSVF funding for eligible activities only (see 38 CFR
3.
62.30- 62.34 for list of eligible activities).
Yes
No
Eligible Participants: Applicant proposes to serve Veteran families who earn less than 50% area median
4.
income and are “occupying permanent housing” as defined in 38 CFR 62.11.
Yes
No
Compliance with Final Rule: Applicant agrees to comply with Final Rule.
5.
Yes
No
6.
Outstanding Obligations: Applicant either:
Does not have an outstanding obligation to the Federal government that is in arrears and does not
have an overdue or unsatisfactory response to an audit.
Has an outstanding obligation to the Federal government that is in arrears and/ or an overdue or
unsatisfactory response to an audit. Describe below:
7.
Default: Applicant either:
Is not in default by failing to meet the requirements for any previous Federal assistance.
Is in default by failing to meet the requirements for previous Federal assistance.
C)
Amount of Supportive Services Grant Funds Requested (Note: Request cannot be greater than
your current grant award amount in order to submit a renewal application. Please refer to the
NOFA for the maximum allowable grant size.) $
10-10072C
VA FORM
Page 4 of 14
AUG 2012
D)
Changes to Proposed Program. Please describe any changes that you would like to make to your
proposed program. (Note: In order to be eligible for renewal, your program must remain substantially
the same as the program concept you proposed during the initial application. Please refer to the NOFA
for additional details. You are not required to make any changes to your proposed program.)
10-10072C
VA FORM
Page 5 of 14
AUG 2012

Download VA Form 10-10072C Renewal Application for Supportive Services Grant - Supportive Services for Veteran Families (Ssvf) Program

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