Form 10-319a Quarterly Grantee Performance Report

OMB Control Number: 2900-XXXX
Estimated burden: 30 minutes
Expiration Date: XX/XX/XXXX

Legal Services for Homeless Veterans and Veterans At-Risk for
Homelessness (LSV) Grant Program

QUARTERLY GRANTEE PERFORMANCE REPORT

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 30 minutes 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 VA's
Homeless Program Office (HPO) in monitoring grantee performance and compliance with the requirements for legal services grants under the LSV Program.
Response to this quarterly grantee performance certification is voluntary, but required for participation in this program; however, 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
monitor your performance pursuant to a legal services grant under the HPO 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. This information also may be used for other purposes as authorized or required by law.

INSTRUCTIONS: Please complete the following form and email, along with your Quarterly Financial Report (Attachment 1), to the LSV
Program web page (http://www.va.gov/homeless/lsv.asp). Please clearly mark any information that is confidential to individual participants
SECTION I: GRANT INFORMATION
1. GRANTEE NAME:

2. GRANT AWARD NUMBER:

3. GRANT AMOUNT:

4. NAME AND TITLE OF CONTACT COMPLETING FORM:
5. CONTACT EMAIL:

SECTION II: FINAL RULE
1. I CERTIFY THAT THIS LSV PROGRAM IS IN COMPLIANCE WITH THE FINAL RULE (38 CFR part 62).
YES

NO

2. I CERTIFY THAT I AM OPERATING IN COMPLIANCE WITH MY SIGNED GRANT AGREEMENT.
YES

NO

SECTION III: DATA QUALITY
1. I CERTIFY THAT I AM REVIEWING THE MONTHLY DATA QUALITY SUMMARY REPORTS.
YES

NO

2. I CERTIFY THAT DATA AND REPORTS GIVEN TO THE VA ACCURATELY REPRESENTS OUR PROGRAM PERFORMANCE.
YES

NO

2A. IF THE ANSWER TO THE PREVIOUS QUESTION WAS NO, PLEASE OUTLINE YOUR PLAN TO IMPROVE UPLOAD QUALITY INCLUDING TIMELINES/DATES:

3. I CERTIFY THAT OUR PROGRAM IS ACTIVELY WORKING TO IMPROVE DATA QUALITY.
YES

NO

4. I CERTIFY THAT OUR PROGRAM IS ADDRESSING ALL ERRONEOUS RECORDS INDICATED IN OUR MONTHLY DATA QUALITY/DATA SUMMARY REPORTS.
YES
VA FORM
XXXX

NO

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SECTION IV: LEGAL SERVICES
GRANTEE/PROGRAM
PROVIDED SERVICE
DIRECTLY

TYPE OF LEGAL SERVICES PROVIDED

(Yes/No)

GRANTEE/PROGRAM ASSISTED
PARTICIPANTS IN OBTAINING SERVICES
THROUGH REFERRALS TO OTHER
ORGANIZATIONS

(Yes/No)

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

SECTION V: TRAININGS AND WEBINARS
1. I CERTIFY THAT LSV PROGRAM STAFF (NEW AND EXISTING) REVIEW ALL TRAININGS/WEBINARS PROVIDED BY THE LSV PROGRAM OFFICE.
YES

NO

2. I CERTIFY THAT LSV PROGRAM HAS A PLAN FOR ENSURING THAT STAFF AND ANY SUBCONTRACTORS ARE APPROPRIATELY TRAINED, AND STAY
INFORMED OF INDUSTRY TRENDS AND THE REQUIREMENTS OF THIS GRANT.
YES

NO

SECTION VI: BUDGET
1. I CERTIFY THAT PAYMENT REQUESTS FROM HHS PAYMENT MANAGEMENT SYSTEM REFLECT ACTUAL SPENDING.
YES

NO

2. I CERTIFY THAT ALL EXPENDITURES ARE FOR COSTS APPROVED ON THE LSV BUDGET.
YES

NO

2. I CERTIFY THAT ALL EXPENDITURES ARE FOR COSTS APPROVED ON THE LSV BUDGET.
YES

NO

3. I CERTIFY THAT I HAVE RECEIVED APPROVAL FROM THE LSV PROGRAM OFFICE FOR ANY MODIFICATIONS MADE TO MY APPROVED LSV GRANT
BUDGET.
YES

NO

4. I CERTIFY THAT ALL SPENDING IS IN COMPLIANCE WITH ALL OMB REGULATIONS.
YES

NO

5. ADDITIONAL FEEDBACK FOR LSV COMPLIANCE OFFICE:

SECTION VII: CERTIFICATION AND SUBMISSION
I certify that I am authorized to submit this response on behalf of this LSV program. Please note: Documentation supporting all certifications must
be maintained by the grantee and made available for monitoring visits and audits.
SIGNATURE:

VA FORM 10-319a, XXXX

DATE (MM/DD/YYYY)

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