Form 10-0388-11 MEMORANDUM OF AGREEMENT FOR A GRANT TO CONSTRUCT OR ACQU

OMB Number 2900-0661
Estimated burden: 6 hours

MEMORANDUM OF AGREEMENT FOR A GRANT TO
CONSTRUCT OR ACQUIRE A STATE VETERANS HOME
This Memorandum of Agreement is hereby made by and between The Department of Veterans Affairs

(VA), 810

Vermont Avenue, NW, Washington, D.C. 20420, and
has submitted to VA an application for a grant to

acquire a

construct or

facility for veterans in

Description

Location

The Federal Application Identifier (FAI) Number for this project is

. The parties agree that this

application meets the requirements of Federal Law for this grant. The estimated total cost of
equipment, in which VA will participate, is $

, including

. The VA grant will total up to $

will not exceed sixty-five (65) percent of the actual cost of

, but

as determined at final audit.

In consideration of the foregoing, the parties hereto mutually agree as follows:
certifies that the plans and specifications included in the application meet all

(1)
applicable Federal requirements.

agrees that it will

(2)

construct or

acquire a

(a description of the

, to be completed in accordance with the documentation
project, including number of beds added or replaced)

submitted by the State.
agrees to comply strictly with the assurances contained in the documentation

(3)
submitted by the state.

agrees to enter into a contract to

(4)

construct or

acquire a

(a description of the project, including number of beds added or replaced)

within 90 days of the date on which both parties have signed this agreement.
agrees to periodically inspect the project and certify to the Chief Consultant ,
(5)
Office of Geriatrics and Extended Care, 810 Vermont Avenue, NW, Washington, D.C. 20420, for payment of such sums
which it deems are payable by VA.
VA FORM
MAR 2003

10-0388-11

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(6)

agrees to furnish any additional State funds needed to complete the project.

(7)

agrees that, upon completion of the project, it will provide adequate financial

support to maintain and operate the facility.
(8)

agrees that following completion of the project, it will open at least eight beds

per month until the project area is filled.
(9)

agrees that it will use the facilities principally to furnish veterans (nursing
home care, domiciliary care, adult day health care) and that not more than 25 percent of the bed occupancy at any one time
will consist of residents who are not receiving such level of care as veterans.
(10)

agrees that it will operate and maintain the facility in conformance with State
standards and with all applicable State and local laws, codes, regulations and ordinances, and in conformance with the
standards prescribed by VA.
(11)
agrees that it will make such reports in such form and containing such
information as the Secretary may from time to time reasonably require, and give the Secretary, upon demand, access to the
records upon which such information is based.

The Secretary of the Department of Veterans Affairs hereby approves the project. After
certifies its

construction or

acquition costs as set forth in paragraph (5) above, the Secretary agrees to make partial

payments of the grant to cover the costs certified. VA payments will be limited to the unpaid obligated balance of the grant
for actual incurred costs for this project.
This grant is subject to the recapture provisions stated in 38 CFR 59.100.

IN WITNESS WHEREOF, the parties have hereunto affixed their signature on the dates indicated

Date

Secretary of Veterans Affairs

VA FORM
MAR 2005

10-0388-11

Date

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