VA Form 10-10072 "Supportive Services for Veteran Families (SSVF) Program Application for Supportive Services Grant"

What Is VA Form 10-10072?

This is a legal form that was released by the U.S. Department of Veterans Affairs on August 1, 2013 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2013;
  • The latest available edition released by the U.S. Department of Veterans Affairs;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;

Download a fillable version of VA Form 10-10072 by clicking the link below or browse more documents and templates provided by the U.S. Department of Veterans Affairs.

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Download VA Form 10-10072 "Supportive Services for Veteran Families (SSVF) Program Application for Supportive Services Grant"

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OMB Number: 2900-0757
Estimated burden: 35 hours
Supportive Services for Veteran Families (SSVF) Program
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 35 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 supportive services grants under the SSVF Program and to rate and
rank these applications. Response to this survey 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 eligible applicants for supportive services grants under VA's
SSVF Program. VA will use the collected information to evaluate and select recipients for 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
the regulations (38 CFR Part 62) and the Notice of Fund Availability (NOFA) under which you are submitting
this application. Both documents are included as attachments to this application package and are posted on the
SSVF Program web page (http://www.va.gov/homeless/SSVF.asp). Please note that to be eligible for a grant
under the SSVF Program, the applicant must be either a private nonprofit organization or a consumer
cooperative. See 38 CFR 62.2 and 38 CFR 62.11 for definitions of these and other terms contained throughout
the application.
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
applications will be considered for funding; applications will not be reviewed if incomplete. To be considered
timely, the number of required copies of the 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 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: Information on application workshops can be found on VA's SSVF Program
web page at:
http://www.va.gov/homeless/SSVF.asp.
If you have any questions regarding the SSVF
Program, 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).
10-10072
VA FORM
Page 1 of 10
AUG 2013
OMB Number: 2900-0757
Estimated burden: 35 hours
Supportive Services for Veteran Families (SSVF) Program
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 35 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 supportive services grants under the SSVF Program and to rate and
rank these applications. Response to this survey 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 eligible applicants for supportive services grants under VA's
SSVF Program. VA will use the collected information to evaluate and select recipients for 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
the regulations (38 CFR Part 62) and the Notice of Fund Availability (NOFA) under which you are submitting
this application. Both documents are included as attachments to this application package and are posted on the
SSVF Program web page (http://www.va.gov/homeless/SSVF.asp). Please note that to be eligible for a grant
under the SSVF Program, the applicant must be either a private nonprofit organization or a consumer
cooperative. See 38 CFR 62.2 and 38 CFR 62.11 for definitions of these and other terms contained throughout
the application.
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
applications will be considered for funding; applications will not be reviewed if incomplete. To be considered
timely, the number of required copies of the 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 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: Information on application workshops can be found on VA's SSVF Program
web page at:
http://www.va.gov/homeless/SSVF.asp.
If you have any questions regarding the SSVF
Program, 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).
10-10072
VA FORM
Page 1 of 10
AUG 2013
APPLICATION CHECKLIST
An application must include the following items.
Executive Summary
Section A: Background, Qualifications, Experience, & Past Performance of Applicant and Any Identified
Subcontractors (35 maximum points)
1. Background and Organizational History
2. Organizational Qualifications and Past Performance (Exhibit I)
Section B: Program Concept & Supportive Services Plan (25 maximum points)
1. Need for Program and Outreach/Screening Plan (Exhibit II)
2. Collaboration and Service Delivery Plan
3. Timeline
Section C: Quality Assurance & Evaluation Plan (15 maximum points)
1. Program Evaluation
2. Monitoring and Remediation
Section D: Financial Capability & Plan (15 maximum points)
1. Financial Controls and Estimated Monthly Program Cost Summary (Exhibit III)
2. Summary of Sources of Program Funds
Section E: Area or Community Linkages and Relations (10 maximum points)
1. Area or Community Linkages (Exhibit IV)
2. Coordination with Local Continuum(s) of Care
Section F: Certifications
Exhibits
Exhibit I: Key Personnel Resumes and Hiring Criteria for Proposed Staff
Exhibit II: Eligibility/Screening Tool
Exhibit III: Program Budget (Complete Attached Microsoft Excel Applicant Budget Template)
Exhibit IV: (Optional) Letters of support from Continuums of Care (CoCs) where services are proposed and Relevant MOUs
and MOAs Demonstrating Area or Community Linkages
Exhibit V: Articles of Incorporation, Corporate Resolutions, Certified Partnership, Joint Venture, or LLC Agreement
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AUG 2013
Executive Summary
A)
Administrative Information. Provide the following information for the applicant:
1.
Applicant's Legal Name (as identified in your Articles of Incorporation):
2.
Other Names under Which Applicant Does Business:
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.
Mailing Address for Contact Person (if different from above):
10. Telephone for Contact Person (where the person can be reached during business hours):
11. Fax for Contact Person:
12. E-mail for Contact Person:
13. Optional: If the applicant would like VA to consider any subcontractors when scoring the applicant,
identify for each subcontractor the following information: name, EIN, business address, mailing address,
contact person (name, title, mailing address, telephone, fax, e-mail). Identify the percentage of work
expected to be subcontracted by applicant to each identified subcontractor.
B)
Amount of Supportive Services Grant Funds Requested. $
C) Number of Unique Participant Households Estimated to be Served.
D) Average total supportive services grant amount request per participant household. $
(This amount should equal total grant amount divided by number of participant households served.)
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E)
Geographic Region Served.
a)
Describe the name(s) of the municipalities, counties (or parishes), or tribal lands that the
proposed program will serve. Indicate the name and number of the Continuum(s) of Care (CoCs) to be
served (see
https://www.hudexchange.info/homelessness-assistance/
for CoC locations).
b)
Provide the Veterans Integrated Service Network (VISN) number in which the proposed program
(see
http://www2.va.gov/directory/guide/division_flsh.asp?dnum=1
for VISN map).
will operate
c)
Identify which of the following geographic regions applies to the primary area or community in
which the proposed program will operate:
Urban community
Rural community
Tribal land
Other:
F)
Compliance with Threshold Requirements (38 CFR 62.21). Check the appropriate box for each of the
following questions.
a. Eligible Entity: Confirm that applicant is either a:
Private Nonprofit Organization (Attached in Exhibit V are one or more of the following: IRS ruling
certifying tax-exempt status under the IRS Code of 1986, as amended; Partnership Agreement;
Articles of Incorporation or By-Laws; and/or Indian Housing Plan Tribal Certification)
Consumer Cooperative (State certification of consumer cooperative status is attached in Exhibit V)
b. Eligible Activities: Applicant proposes to use SSVF funding for eligible activities only (see 38 CFR
62.30- 62.34 for list of eligible activities).
Yes
No
c.
Eligible Participants: Applicant proposes to serve Veteran families who earn less than 50% area median
income and are “occupying permanent housing” as defined in 38 CFR 62.11.
Yes
No
d. Compliance with Final Rule: Applicant agrees to comply with Final Rule.
Yes
No
10-10072
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AUG 2013
e.
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:
f.
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. Describe below:
Identify yes or no and explain in reasonable detail each instance within the past 10 years in which the applicant,
any identified subcontractor, or any principal, partner, director, or officer of the applicant or identified
subcontractor was:
If no, please describe (attach
Item
Yes/No
additional pages if necessary):
Yes
i. Convicted of or pleaded guilty or nolo contendre to a crime (other than a traffic
offense).
No
ii. Subject to an order, judgment, or decree (including as a result of a settlement),
Yes
whether by a court, an administrative agency, or other governmental body, or
No
an arbitral or other alternative dispute resolution tribunal, in any civil
proceeding or action in which fraud, gross negligence, willful misconduct,
misrepresentation, deceit, dishonesty, breach of any fiduciary duty,
embezzlement, looting, conflict of interest, or any similar misdeed was alleged
(regardless of whether any wrongdoing was admitted or proven).
iii. Subject to an action or other proceeding, whether before a court, an
Yes
administrative agency, governmental body, or an arbitral or other alternative
No
dispute resolution tribunal, which, if decided in a manner adverse to the
applicant, identified subcontractor, principal, partner, director, or officer (as
applicable), would reasonably be expected to adversely affect the ability of the
applicant or identified subcontractor to perform its obligations with respect to
the proposed program.
Yes
iv. Debarred, suspended, proposed for debarment, declared ineligible or
voluntarily excluded from transactions by any Federal department or agency.
No
Yes
v. Notified that it is in default of any Federal contract or grant, the reason for the
default, and whether the default was cured.
No
Yes
vi. Had one or more public transactions (Federal, State, or local) terminated for
cause or default.
No
vii. Party to litigation or a formal Alternative Dispute Resolution (ADR) process
Yes
(e.g., binding arbitration) involving a claim in excess of $50,000. For those
No
matters involving a claim equal to or in excess of $500,000, describe in detail
the litigation or ADR process.
10-10072
VA FORM
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AUG 2013