SSVF 10-10072C highlighted non-sub changes w-remarks

OMB Number: 2900-0757
Estimated burden: 10 hours

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 tollfree number).
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RENEWAL APPLICATION CHECKLIST
An 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)

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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 identified 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 TaxExempt 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: 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.

C)

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.) $

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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. 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.

F)

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:
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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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?

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.

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.

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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.

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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 its
reasonableness. (Note: This figure relates to your previous grant award period and not the proposed renewal period.)

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.

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.

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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
a.
b.

Applicant is responsible for filling in yellow cells only.
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)
a.

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 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 - cost of fringe benefits as a percentage of annual salary (if any)

b.

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.)

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 monthly costs associated with those expenses. (Note: Some mandated training expenses have
already been added to the budget.)

d.

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.
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