10-0388-2 Certification Of Compliance With Provisions Of The Davis

OMB Number: 2900-0661
Estimated Burden: 6 hours

CERTIFICATION OF COMPLIANCE
WITH PROVISIONS OF THE DAVIS-BACON ACT
(40 U.S.C. Sections 276a to 276a-7)
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 this Act. The public reporting burden for this collection of information is estimated to average 6 hours per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. We may not collect or sponsor and you are not required to respond to, a collection unless it has a valid OMB Control
Number. This collection of information is collected under the authority of 38 U.S. Code Sections 8133(a) and 8135(a). VA will use this information,
along with other documents submitted by the States to determine the feasibility of the projects for VA participation, to meet VA requirements for a
grant award and to rank the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will be unable to authorize
a grant without a complete package. Your failure to furnish this information will have no effect on any of other benefits to which you are entitled.

I certify that I have obtained the latest prevailing wage rates from the U.S. Department of Labor for the State Home project
located at

Project FAI (Federal Application Identifer) Number

and that these rates have been incorporated into the construction contract for the proposed State Veterans Home project
in compliance with the Davis-Bacon Act.

TITLE 38 U.S.C. 8135(A) 8
NAME OF AUTHORIZED STATE OFFICIAL

SIGNATURE

VA FORM
MAR 2005

10-0388-2

TITLE OF AUTHORIZED STATE OFFICIAL

DATE (mm/dd/yyyy)