Form VA Form 10-10072 VA Form 10-10072 Supportive Services for Veterans Families Program Applic

OMB Number: 2900-0757

Estimated Burden: 35 hours

Expiration Date: XX/XX/XXXX

Supportive Services for Veteran Families (SSVF) Program

APPLICATION FOR SUPPORTIVE SERVICES GRANT

The Paperwork Reduction Act of 1995: This information is collected in accordance with Section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of information is estimated to average 35 hours per response, including the time to review instructions, search existing data sources, gather and maintain data needed, and complete and review the collection of information. Respondents should be aware that we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. This collection of information is intended to assist the SSVF Program Office to determine eligibility to receive supportive services grants under the SSVF Program and to rate and rank these applications. Response to this grant application is voluntary, and failure to participate will have no adverse effect on benefits to which you might otherwise be entitled.

Privacy Act Statement: VA is asking you to provide the information requested in this form under the authority of 38 U.S.C. section 2044 in order for VA to determine your eligibility to receive a supportive services grant under the SSVF Program. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information for: civil or criminal law enforcement; congressional communications; the collection of money owed to the United States; litigation in which the United States is a party or has interest; the administration of VA grant programs, including verification of your eligibility to participate; and personnel administration. You do not have to provide the requested information to VA; but if you do not, VA may be unable to process your request for consideration in this program. If you provide VA with your Employer Identification Number (EIN), VA will use it to obtain information relevant to determining whether to award a grant and to administer your grant, if awarded. This information also may be used for other purposes as authorized or required by law.

Background: This form is to be completed by eligible applicants for supportive services grants under VA's SSVF Program. VA will use the collected information to evaluate and select recipients for 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 the regulations (38 CFR Part 62) and the Notice of Fund Opportunity (NOFO) under which you are submitting this application. Both documents are included as attachments to this application package and are posted on the SSVF Program web page (http://www.va.gov/homeless/SSVF.asp). Please note that to be eligible for a grant under the SSVF Program, the applicant must be either a private nonprofit organization or a consumer cooperative. See 38 CFR 62.2 and 38 CFR 62.11 for definitions of these and other terms contained throughout the application.

Submission: The application must be submitted in accordance with the NOFO. The NOFO specifies the number of copies and format in which the application must be submitted. Only timely and complete applications will be considered for funding; applications will not be reviewed if incomplete. To be considered timely, the number of required copies of the application must be received at the address and by the time and date specified in the NOFO. Applications received after that time and date will not be accepted even if postmarked by the deadline date. Following the 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: Information on application workshops can be found on VA's SSVF Program web page at: http://www.va.gov/homeless/SSVF.asp. If you have any questions regarding the SSVF Program, 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).

APPLICATION CHECKLIST

An application must include the following items.

Executive Summary

Section A: Background, Qualifications, Experience, & Past Performance of Applicant and Any Identified Subcontractors (35 maximum points)

1. Background and Organizational History

2. Organizational Qualifications and Past Performance (Exhibit I)

Section B: Program Concept & Supportive Services Plan (25 maximum points)

1. Need for Program and Outreach/Screening Plan (Exhibit II)

2. Collaboration and Service Delivery Plan

3. Timeline

Section C: Quality Assurance & Evaluation Plan (15 maximum points)

1. Program Evaluation

2. Monitoring and Remediation

Section D: Financial Capability & Plan (15 maximum points)

1. Financial Controls and Estimated Monthly Program Cost Summary (Exhibit III)

2. Summary of Sources of Program Funds

Section E: Area or Community Linkages and Relations (10 maximum points)

1. Area or Community Linkages (Exhibit IV)

2. Coordination with Local Continuum(s) of Care

Section F: Certifications

Exhibits

Exhibit I: Key Personnel Resumes and Hiring Criteria for Proposed Staff

Exhibit II: Executive Director Certification of Community Planning

Exhibit III: Program Budget (Complete Attached Microsoft Excel Applicant Budget Template)

Exhibit IV: (Optional) Letters of support from Continuums of Care (CoCs) where services are proposed and Relevant MOUs and MOAs Demonstrating Area or Community Linkages

Exhibit V: Articles of Incorporation, Corporate Resolutions, Certified Partnership, Joint Venture, or LLC Agreement

Executive Summary

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

1. Applicant's Legal Name (as identified in your Articles of Incorporation):

2. Other Names under Which Applicant Does Business:

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. Mailing Address for Contact Person (if different from above):

10. Telephone for Contact Person (where the person can be reached during business hours):

11. Fax for Contact Person:

12. E-mail for Contact Person:

13. Optional: If the applicant would like VA to consider any subcontractors when scoring the applicant, identify for each subcontractor the following information: name, EIN, business address, mailing address, contact person (name, title, mailing address, telephone, fax, e-mail). Identify the percentage of work expected to be subcontracted by applicant to each identified subcontractor.

2. Amount of Supportive Services Grant Funds Requested. $

3. Number of Unique Participant Households Estimated to be Served.

4. Average total supportive services grant amount request per participant household. $

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

5. Geographic Region Served.

   1. Describe the name(s) of the municipalities, counties (or parishes), or tribal lands that the proposed program will serve. Indicate the name and number of the Continuum(s) of Care (CoCs) to be served and projected households to be served for each CoC (see http://www.hudhre.info/index.cfm?do=viewCocmaps for CoC locations).

   2. Provide the Veterans Integrated Service Network (VISN) number in which the proposed program will operate (see http://www2.va.gov/directory/guide/division_flsh.asp?dnum=1 for VISN map).

3. Identify which of the following geographic regions applies to the primary area or community in which the proposed program will operate:

Urban community Rural community Tribal land

Other:

6. Compliance with Threshold Requirements (38 CFR 62.21). Check the appropriate box for each of the following questions.

1. Eligible Entity: Confirm that applicant is either a:

Private Nonprofit Organization (Attached in Exhibit V are one or more of the following: IRS ruling certifying tax-exempt status under the IRS Code of 1986, as amended; Partnership Agreement; Articles of Incorporation or By-Laws; and/or Indian Housing Plan Tribal Certification)

Consumer Cooperative (State certification of consumer cooperative status is attached in Exhibit V)

2. 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

3. 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

4. Compliance with Final Rule: Applicant agrees to comply with Final Rule. Yes

No

5. 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:

6. 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. Describe below:

Identify yes or no and explain in reasonable detail each instance within the past 10 years in which the applicant, any identified subcontractor, or any principal, partner, director, or officer of the applicant or identified subcontractor was:

Item	Yes/No	If no, please describe (attach additional pages if necessary):
i. Convicted of or pleaded guilty or nolo contendre to a crime (other than a traffic offense).	Yes No
ii. Subject to an order, judgment, or decree (including as a result of a settlement), whether by a court, an administrative agency, or other governmental body, or an arbitral or other alternative dispute resolution tribunal, in any civil proceeding or action in which fraud, gross negligence, willful misconduct, misrepresentation, deceit, dishonesty, breach of any fiduciary duty, embezzlement, looting, conflict of interest, or any similar misdeed was alleged (regardless of whether any wrongdoing was admitted or proven).	Yes No
iii. Subject to an action or other proceeding, whether before a court, an administrative agency, governmental body, or an arbitral or other alternative dispute resolution tribunal, which, if decided in a manner adverse to the applicant, identified subcontractor, principal, partner, director, or officer (as applicable), would reasonably be expected to adversely affect the ability of the applicant or identified subcontractor to perform its obligations with respect to the proposed program.	Yes No
iv. Debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from transactions by any Federal department or agency.	Yes No
v. Notified that it is in default of any Federal contract or grant, the reason for the default, and whether the default was cured.	Yes No
vi. Had one or more public transactions (Federal, State, or local) terminated for cause or default.	Yes No
vii. Party to litigation or a formal Alternative Dispute Resolution (ADR) process (e.g., binding arbitration) involving a claim in excess of $50,000. For those matters involving a claim equal to or in excess of $500,000, describe in detail the litigation or ADR process.	Yes No

G. Summary Grant Information

1. Identify in the table below which of the following other public benefits the applicant will either provide directly and/or assist participants in obtaining through referrals to other organizations:

Type of Benefit/Service (See 38 CFR 62.33 for definitions of these services)*	Applicant will provide benefit directly (Yes/No)		Applicant will assist participants in obtaining benefit through referrals to other organizations (Yes/No)
Health care services	Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes	No No No No No No No No No No No No	Yes Yes Yes	No No No No
Daily living services
Personal financial planning services
Transportation services**			Yes
Income support services			Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Fiduciary and representative payee services
Legal services
Child care
Housing counseling, housing search
Other:
Other:
Other:

*Note: 38 CFR 62.33 requires grantees to assist participants to obtain, and coordinate the provision of, the above-listed public benefits if they are being provided by Federal, State, local, or tribal government agencies, or any eligible entity in the area or community served by the grantee by referring the participant to and coordinating with such entity. With the exception of health care services and daily living services, grantees may also elect to provide directly to participants the listed public benefits in accordance with the requirements set forth in 38 CFR 62.34.

2. Identify below which of the following other supportive services (if any) will be offered to participants (see 38 CFR 62.33 and 38 CFR 62.34 for descriptions of these supportive services):

Rental Assistance

Utility-Fee Payment Assistance Security or Utility Deposit Assistance Moving Costs Assistance

General Housing Stability Assistance

Child Care Financial Assistance Transportation

Emergency Housing Assistance Other:

Other:

Please attach responses to Sections A-F. Total narrative for these sections cannot exceed 8 pages. Responses must be typed in 12 point, Times New Roman font. All pages must 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:

a) Describe your organizational experience and effectiveness in working with individuals and families who are homeless and at imminent risk of homelessness, noting experience working with Veterans. If you plan on using subcontractors, detail their experience in the work that they will be subcontracted to perform.

SECTION A: Background, Qualifications, Experience, & Past Performance of Applicant and Any Identified Subcontractors

In scoring the application, VA will award up to 35 points based on the applicant's responses to questions contained in this section.

1. Describe your organizational experience and effectiveness in working with individuals and families who are homeless and at imminent risk of homelessness, noting experience working with Veterans. If you plan on using subcontractors, detail their experience in the work that they will be subcontracted to perform.

2. What staff do you intend to hire, indicating their background and expected caseload? Provide resumes for key personnel (including case managers and other direct service staff) that will be involved in operating the proposed program in Exhibit I. If the majority of the staff for the propose program will need to be hired, provide minimum hiring criteria in Exhibit I.

SECTION B: Program Concept & Supportive Services Plan

In scoring the application, VA will award up to 25 points based on the applicant's responses to questions contained in this section. Applicants should reference the requirements set forth in the NOFO in preparing these responses. Applicants are required to use eligibility/screening tool attached in Exhibit II.

1. Estimate the need for SSVF services. Include the basis for this estimate, highlighting areas of unmet need (for instance, overall numbers of homeless or at-risk Veteran families might be relatively low, but there may be few available services to meet these needs). How many household participants do you expect to serve and how do you expect to engage them? The screening tool provided in Exhibit II identifies eligibility criteria for program participation. For those Veteran families who are eligible, using Stage 2 of Exhibit II, what threshold (point score) do you plan to use for targeting Category 1 (prevention) participants?

2. How will you coordinate services with the VA and other providers in the Continuum(s) of Care where you plan to deliver services, describing how all of the required services will be delivered? Describe which optional services you also plan to provide (such as temporary financial assistance).

3. 
   Describe your timeline for implementing services.

SECTION C: Quality Assurance & Evaluation Plan

In scoring the application, VA will award up to 15 points based on the applicant's responses to questions contained in this section.

1. Programs are expected to place over 80 percent of category 2 and 3 participants in permanent housing and maintain over 90 percent of category 1 participants in their current housing (this may be adjusted up or down based on complexity). It is expected that once placed, participants will be able to sustain themselves in housing. How will you monitor your ability to meet this goal as well as achieving the goal of preventing homelessness?

2. 
   How will you monitor work, including the work of any subcontractor? If you identify problems with services delivered by you or your subcontractor, what process is in place to create remediation plans?

SECTION D: Financial Capability & Plan

Exhibit III below must also be provided in the Microsoft Excel template. In scoring the application, VA will award up to 15 points based on the applicant's responses to questions contained in this section.

1. Describe financial controls in place to ensure that program funds are used appropriately. Using the attached template, provide a detailed one-year program budget that is itemized on a monthly basis. Include a detailed description of each of the line items contained in the budget template and the underlying assumptions associated with each line item amount.

2. 
   Specify all sources of funds to be used to operate the proposed program. Identify each source in a separate line item and the status of the funding, whether the funding is requested, committed, or received.

SECTION E: Area or Community Linkages and Relations

In scoring the application, VA will award up to 10 points based on the applicant's responses to questions contained in this section.

1. Describe how community relationships with area providers, governmental agencies, VA, and consumer groups will assist in the delivery of SSVF services. Reference specific entity names, attaching Memorandums of Agreement or other evidence of relevant, formal agreements (Exhibit IV).

2. 
   Describe your current efforts to coordinate services in the Continuum(s) of Care (CoC) where you plan to deliver services. Describe your involvement in the CoC's Coordinated Assessment efforts.

SECTION F: Applicant Certifications & Assurances

The following items require a single certification on the following page by an authorized representative of the applicant requesting a supportive services grant. The list below should be included in the application packet with responses attached and numbered to correspond to the relevant item. VA may require that applicants provide documentation of these certifications.

1. Compliance. Applicant assures that the applicant and any subcontractors will comply with all requirements of 38 CFR Part 62. If the applicant intends to request waivers to any requirements included in the preceding citation, please explain.

2. Accuracy of Application Information. All information submitted with this application is accurate, and does not contain any false, fictitious or fraudulent statement or entry.

3. Non-Delinquency. The applicant further certifies that the applicant is not currently in default or delinquent on any debt or loans provided or guaranteed by the Federal Government.

4. Debarment. The applicant further certifies that the applicant has not been in the preceding three years:

   1. debarred, suspended or declared ineligible from participating in any Federal program; b) formally proposed for debarment, with a final determination still pending; c) voluntarily excluded from participation in a Federal transaction; or d) indicted, convicted, or had a civil judgment rendered against it for any of the offenses listed in the Regulations Governing Debarment and Suspension (Governmentwide Nonprocurement Debarment and Suspension Regulations: 49 CFR Part 29).

5. Reports and Record Retention. If this supportive services grant is awarded, applicant assures that any and all reports required by VA will be made available in such form and contain such information as VA may require. Applicant further assures that upon demand, VA has access to the records upon which such information is based.

6. Fiscal Control. If this supportive services grant is awarded, applicant assures that it will establish and maintain such procedures for fiscal control and fund accounting as may be necessary to ensure proper disbursement and accounting with respect to the supportive services grant.

7. Civil Rights. Applicant certifies that this program will comply with all provisions of Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.). If applicant does not certify this, applicant has provided information explaining any exceptions to this certification.

8. Lobbying. The undersigned certified, to the best of their knowledge and belief, that:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard FormsLLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31 U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than

$100,000 for each such failure.

Signature: 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:

Exhibit III Applicant Budget Template (Microsoft Excel File)

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

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 NOFO 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. (Note: Some mandated training expenses have already been added to the budget.)

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.

VA FORM NOV 2021

10-10072

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