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

OMB: 2900-0757
Estimated Burden: 10 hours
Exp. Date: XX/XX/XXXX

Department of Veterans Affairs

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 informatin can be found in
both the regulations (38 CFR Part 62) and the Notice of Funding 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 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.

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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).

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RENEWAL APPLICATION CHECKLIST
A renewal application must include the following items.
Executive Summary
Section A: SSVF Program Outcomes (55 maximum points)
Housing Stability
Ending Homelessness
Homelessness Prevention
Participant Satisfaction
Program Implementation and Progress
Community Planning
Section B: Cost Effectiveness (30 maximum points)
Average Total Grant Cost Per Participant Household
Program Budget and Expenditures
Section C: Compliance with Program Goals and Requirements (15 maximum points)
SSVF Program Goals
Applicable Laws, Regulations, and Guidelines
Grant Agreement
Exhibits
Exhibit I: Certificate of Good Standing
Exhibit II: Eligibility/Screening Tool
Exhibit III: Applicant Budget Template Instructions (Microsoft Excel File)
Exhibit IV: Detailed Description of Each Line Item Contained in This Budget and the Underlying
Assumptions Associated with Each Line Item Amount.

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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 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

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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
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: Applicants 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.
C) Amount of Supportive Services Grant Funds Requested:
$

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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.)

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E) Budget
1. Quarterly Budget: Attach as Exhibit III to this application a proposed quarterly budget for the renewal period
using the Microsoft Excel template include as an attachment to this application.
2. Budget Narrative: Attach as Exhibit IV to this application a description of each of the line items contained in
your budget and underlying assumptions associated with each line item amount.
F) Participants
1. Number of unique participant households estimated to be service:
2. Average total supportive services grant amount request per participant household:
3. List the HUD Continuum(s) of Care to be served:
G) 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:

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Please attach responses to Sections A-C. Total narrative for these sections cannot exceed 8 pages. Responses
must be typed in 12 point, Times New Roman font. All pages mush have 1 inch margins. Attached responses
must include question number and heading, for example the response to the first question would begin with
the heading:
SECTION A:
1. Describe how your program's participants made progress in achieving stability during the grant award period.
Please provide both specific examples and data (e.g. HMIS/Repository) using the table below in regards to
permanent housing placements. Additionally, describe how any proposed program modifications will impact
participants housing stability?
____________________________________________________________________________________________
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
Describehow your program's participants made progress in achieving stability during the grant award period.
Please provide both specific examples and data (e.g. HMIS/Repository) using the table below in regards to
permanent housing placements. Additionally, describe how any proposed program modifications will impact
participants housing stability?
Households Served by SSVF Program (from Oct 1st - Sept 30th):
Number of
Number of
households
households exited
enrolled in SSVF
from SSVF

Number of
households
placed in
permanent
housing

Percent housed at
program exit

Homeless
Prevention
Rapid Re-Housing
Total
2. Ending Homelessness
Describe how your program targeted and reduced Literal homelessness among very low-income Veteran families
occupying permanent housing (Category 2 and 3, described in 38 CFR 62.11).
3. Homelessness Prevention
Describe how you targeted and prevented literal 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.

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4. Participant Satisfaction
Describe how you receive and respond to feedback from participants in your program (e.g. exit interviews,
internal surveys, etc.). What is your average number of responses? Describe any changes you have made as a
result of participant feedback.
5. Program Implementation and Progress
Specify the average time between client intake and start of service delivery, average time to placement in
permanent housing, and average length of stay (enrollment to exit). Describe any programmatic or
organizational delays associated with onset of supportive services delivery. Describe the timeline for any
proposed program modifications.
6. Community Planning
How have you coordinated SSVF services with other programs offered in the Continuum(s) of Care (CoC) you
currently serve? Describe your direct involvement in each CoC's Coordinated Assessment efforts and community
plan(s) to end Veteran homelessness.

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____________________________________________________________________________________________
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 justify its
reasonableness. (Note: This figure relates to your previous grant award period and not the proposed renewal
period.)
2. Program Budget and Expenditures
2a.) Please complete the table below specifying last year's budgeted vs. actual spending (Oct 1st through Sept
30th)
Category

Approved Budget Actual Amount
Amount
Spent

% Variance
(actual vs.
budget)

TFA
SERVICES
ADMIN
TOTAL
2b.) Please explain whether your program was implemented consistent with your approved budget in your
previous year of operation (Oct 1st through Sept 30th). Explain any major deviations or variances from original
budget.
2c.) Please provide information on whether your program: a) required an extension in order to expend fully,
and/or b) returned funds. If you have returned funds, explain your plan to fully expend your current grant
amount.

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____________________________________________________________________________________________
SECTION C: Compliant 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.
2. Applicable Laws, Regulations and Guidance
Certify that your program was administered accordance with all applicable laws, regulations and guidance.
Provide the results of your most recent monitoring visit and remediation plan for any findings/concerns
identified in the report.
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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____________________________________________________________________________________________
Exhibit III Applicant Budget Template Instructions (Microsoft Excel File)
Applicants are required to provide a detailed one year program budget in Exhibit III that itemizes on a quarterly
basis the supportive services and administrative costs associated with the proposed program. Applicants must
also provide as Exhibit IV 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
a. Applicant is responsible for filling in yellow cells only.
b. All non-yellow cells are locked and populate automatically.
c. Applicant must complete the following proposed funding information provided in the top portion of the
Excel template: applicant name, total grant funds requested, proposed CoC codes to be served, proposed
counties and states to be served, proposed number of households to be served, and average amount to be spent
per household served.
Provision and Coordination of Supportive Services (Total must be a minimum of 90% of the total SSVF Grant
Amount)
a. Personnel/Labor (Note: If the applicant does not anticipate an even spread of costs across all quarters, 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 subcontractor organization name as applicable).
•# 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
full- time employment.
•Fringe Benefits - input cost of fringe benefits (if any).
•Distribute FTE and Fringe Benefits across all quarters. Priority 1 applicants must budget based on
three-year funding.

b. Temporary Financial Assistance: Input the estimated quarterly 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 general housing stability assistance. (Note: Please reference the NOFA
for limitations on the percentage of the total SSVF grant that can be used for this purpose.)

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____________________________________________________________________________________________
Exhibit III Applicant Budget Template Instructions (Microsoft Excel File) (continued)
____________________________________________________________________________________________
c. 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 quarterly costs
associated with those expenses. (Note: Some mandated training expenses have already been added to the
budget.

d. Lease and Maintenance of Vehicle(s): Per 38 CFR 32.33, 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 quarter associated with these vehicles.
____________________________________________________________________________________________
Administrative Expenses (Total cannot exceed 10% of total SSVF Grant Amount)
List all administrative expenses and the quarterly 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.
END OF FORM

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