VA Form 10-10072c Renewal Application for Supportive Services Grant

OMB Control Number: 2900-0757

Estimated Burden: 10 hours

U.S. Department of Veterans Affairs (VA)

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 [email protected] or via phone at 1-877-737-0111 (this is a toll-free number).

RENEWAL APPLICATION CHECKLIST

A renewal 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)

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.

1. Administrative Information. Provide the following information for the applicant:

1. Applicant Organization’s Legal Name (as stated 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

2. 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

3. 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

4. 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

5. Compliance with Final Rule: Applicant agrees to comply with Final Rule.

 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.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

3. 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.) $_______________

4. 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.)

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5. Budget.

1. Monthly Budget: Attach as Exhibit II to this application a proposed monthly budget for the renewal period using the Microsoft Excel template included as an attachment to this application. As noted previously, your budget cannot vary more than 40% of your current grant award amount.

2. Budget Narrative: Attach as Exhibit III to this application a description of each of the line items contained in your budget and the underlying assumptions associated with each line item amount.

6. Participants.

1. Number of unique participant households estimated to be served: ___________

2. Average total supportive services grant amount request per participant household: _________

(Note: This amount should equal total grant amount divided by number of participant households served.)

3. List the Continuum(s) of Care to be served: _________________________________________

7. Certification. By submitting this application, the applicant certifies that the facts stated and the certifications and representations made in this application are true, to the best of the applicant’s knowledge and belief after due inquiry, and that the applicant has not omitted any material facts. The undersigned is an authorized representative of the applicant.

Applicant: ____

Signed: ____

Name and Title: ____

Date: ____

SECTION A: SSVF Program Outcomes

The information requested below should be typed into the boxes following each question in the application form. Limit your responses to the space provided. In scoring this section of the application, VA will award up to 55 points.

1. Housing Stability. Describe how your program’s participants made progress in achieving housing stability during the grant award period. Please provide specific examples and numbers wherever possible. How will any proposed program modifications impact participants housing stability?

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2. Participant Satisfaction. Describe how you responded to the feedback you received from participants in your program.

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3. Program Timeline. Describe the timeframe within which the program was implemented (i.e. note when program setup, hiring, outreach, case management, etc. began and/or ended). Specify the amount of time between when intake occurs and service delivery begins. Describe any programmatic/organizational delays associated with onset of supportive services delivery. Describe the timeline for any proposed program modifications.

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4. Homelessness Prevention.

Describe how you targeted and prevented homelessness among those very low-income Veteran families occupying permanent housing (Category 1, described in 38 CFR 62.11(1)) who were most at risk. Provide an estimate of the quantity of households who were diverted from homelessness.

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5. Ending Homelessness.

a. Describe how your program targeted and reduced homelessness among very low-income Veteran families occupying permanent housing. Provide an estimate of the number of households who were transitioned from homelessness to permanent housing through the SSVF Program.

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b. How have you coordinated SSVF services with other programs offered in the Continuum(s) of Care (CoC) you currently serve? Describe your involvement in the CoC’s Coordinated Assessment efforts.

SECTION B: Cost-Effectiveness

The information requested below should be typed into the boxes following each question in the application form. Limit your responses to the space provided. In scoring this section of the application, VA will award up to 30 points.

1. Average Total Grant Cost Per Participant Household. $______________

Please provide an explanation of this figure (including number of households served) and its reasonableness. (Note: This figure relates to your previous grant award period and not the proposed renewal period.)

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2. Last Year’s Budget. Please explain whether your program was implemented consistent with your approved budget in your previous year of operation. Explain any major deviations. (Note: This question only applies to programs with at least one full year of operation at the time of application.) If you have requested additional funds and were unable to spend at 98% of your Fiscal Year 2011 Budget, explain how your program will be able to manage and spend these additional funds.

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SECTION C: Compliance with SSVF Program Goals and Requirements

The information requested below should be typed into the boxes following each question in the application form. Limit your responses to the space provided. In scoring this section of the application, VA will award up to 15 points.

1. SSVF Program Goals. Describe how your program was implemented in accordance with VA’s goals (as described in the Final Rule and NOFA) for the SSVF Program.

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2. Applicable Laws, Regulations and Guidance. Certify that your program was administered in accordance with all applicable laws, regulations and guidance. If not, explain the circumstances.

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3. Grant Agreement. Certify that your program was administered in accordance with your supportive services grant agreement. If not, explain the circumstances.

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Exhibits III and IV. Applicant Budget Template (Microsoft Excel File) and Budget Narrative

Applicants are required to provide a detailed one year program budget in Exhibit II that itemizes on a monthly basis the supportive services and administrative costs associated with the proposed program. Applicants must also provide as Exhibit III to this application a detailed description of each line item contained in this budget and the underlying assumptions associated with each line item amount.

The program budget must be completed in the Microsoft Excel template provided. Instructions on the use of this template are as follows:

General

1. Applicant is responsible for filling in yellow cells only.

2. All non-yellow cells are locked and populate automatically.

Provision and Coordination of Supportive Services (Total must be a minimum of 90% of the total

SSVF Grant Amount)

1. Personnel/Labor (Note: The spreadsheet will spread these costs evenly across all 12 months. If the applicant does not anticipate an even spread of costs, this should be explained in the narrative.):

   • Title and Organization – input the titles of all SSVF-funded personnel (e.g., Program Director, Case Manager, Employment Specialist, etc.) and the organization at which they are or will be employed (i.e., list applicant organization or member organization name as applicable). Contact [email protected] if additional lines to the spreadsheet are necessary.

   • # of Full-Time Employees (FTE) – input the number of FTE who will hold the specified title at the specified organization.

   • % FTE – input the percentage of time the staff member will devote to the SSVF-funded program (e.g., full-time staff would be shown at 100%).

   • Base Annual Salary / Wage – input the annual salary of the specified personnel, assuming fulltime employment.

   • Fringe Benefits – cost of fringe benefits as a percentage of annual salary (if any)

2. Temporary Financial Assistance: Input the estimated cost of temporary financial assistance, which includes time-limited payments to third parties for rent, utilities, moving expenses, security and utility deposits, transportation, child care and emergency supplies. (Note: Please reference the NOFA for limitations on the percentage of the total SSVF grant that can be used for this purpose.)

3. Other Non-Personnel Provision and Coordination of Supportive Services Expenses: List any other expenses related to the provision and coordination of supportive services expenses in this section and the monthly costs associated with those expenses.\

4. Lease & Maintenance of Vehicle(s): Per 38 CFR 62.33, if public transportation options are not sufficient within an area or community, costs related to the lease of vehicle(s) may be included in the application. Specify the number of vehicles to be leased and the cost per month associated with these vehicles.

Administrative Expenses (Total cannot exceed 10% of total SSVF Grant Amount)

List all administrative expenses and the monthly costs associated with each expense. Per 38 CFR

62.70, administrative expenses are defined as all direct and indirect costs associated with the management of the program. These costs will include the administrative costs, both direct and indirect, of subcontractors. A line item of “administrative costs” is not sufficiently descriptive. Administrative costs must be broken down into multiple line items by category.

10-10072C

VA Form AUG 2012

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