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

OMB Control Number: 2900-0757

Estimated Burden: 10 hours

Expiration Date: XX/XX/XXXX

Supportive Services for Veteran Families (SSVF) Program

RENEWAL 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 10 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 renewal supportive services grants under the SSVF Program. Response to this grant renewal 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 renewal 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 renewal 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 grantees applying for renewal of a supportive services grant. VA

will use the collected information to evaluate and select recipients to renew their SSVF 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 Funding Opportunity (NOFO) 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 NOFO. The NOFO 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 NOFO. 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

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: Executive Director Certificate

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.

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:
Applicant uses subcontractors to implement the SSVF program. Yes No Applicant’s SSVF program is currently CARF ,COA or TJC 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: 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.

2. Amount of Supportive Services Grant Funds Requested:

$

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 NOFO for additional details. You are not required to make any changes to your proposed program.)

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 and projected numbers of households to be served per COC

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:

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 households enrolled in SSVF	Number of households exited from SSVF	Number of households placed in permanent housing	Percent housed at program exit
	Homeless Prevention
	Rapid Re-Housing
	Total
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). 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.

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.

4. 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.

4. 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.

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.
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.) 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 Amount	Actual 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.

VA Form

10-10072C

Renewal Application Page 10 of 13

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 NOFO) 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.

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

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

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

3. 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)

1. 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.

2. 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 NOFO for limitations on the percentage of the total SSVF grant that can be used for this purpose.)

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

VA Form NOV ²⁰²¹

Renewal Application

Page 1 of 13

10-10072C