10-318b Renewal Application for Legal Services Grant

OMB Control Number: 2900-XXXX
Estimated burden: 20 hours
Expiration Date: XX/XX/XXXX

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

RENEWAL APPLICATION FOR LEGAL 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 20 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
Homeless Program Office (HPO) to determine eligibility to receive renewal legal services grants under the LSV Program and to rate and rank these applications.
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 HPO to
determine eligibility to receive a legal services grant under the LSV 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 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 grantees applying for renewal for legal services grant. VA will use the collected information to evaluate and
select recipients to renew their legal services grants. Applicants may be asked to provide additional supporting evidence or to quantify details
during the review process.
Definitions and LSV Program Information:
Definitions and LSV Program information can be found in both the regulations (38 CFR Part 79) and the Notice of Funding Opportunity (NOFO)
under which you are submitting this application. Both documents are included as attachments to this renewal application package and posted on
the LSV Program web page (http://www.va.gov/homeless/lsv.asp) Please note that to be eligible for a renewal grant under the LSV Program, the
applicant must have received a legal services grant award in the previous fiscal year. See 38 CFR 79.5 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:
Applications must be submitted by following instructions at www.va.gov/homeless/lsv.asp. Applications may not be submitted in any other way.
Applications must be received by the LSV Program Office no later than 4:00 p.m. Eastern Time on the application deadline date. Applications
must be submitted as a complete package. Materials arriving separately will not be included in the application package for consideration 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 USC 1001. Misrepresentation of material facts may also be the basis for denial of grant assistance by VA.
For Further Information:
Information on application technical assistance can be found on VA's LSV Program. web page at: http://www.va.gov/homeless/lsv.asp. If you
have any questions regarding the LSV Program, please contact the LSV Program Office via e-mail at [email protected].

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RENEWAL APPLICATION CHECKLIST
A renewal application must include the following items:
Complete Sections I-IV.
Section I: Administrative Information
Section II: LSVP Program Outcomes (55 maximum points)
Operational Effectiveness
Number of participants assisted
Demographics of participants (gender, age, race, service era)
A description of the legal services provided to each participant
Participation Satisfaction
Program implementation and progress
Section III: Cost Effectiveness (30 maximum points)
Average Total Grant Cost Per Participant
Program Budget and Expenditures
Section IV: Compliance with Program Goals and Requirements (15 maximum points)
LSV Program Goals
Applicable Laws, Regulations and Guidelines
Grant Agreement
Exhibits:
Exhibit I: Program Budget (Complete Attached Microsoft Excel Applicant Budget Template)
Exhibit II: Detailed Description of Each Line Item Contained in this Budget and the Underlying Assumptions Associated with each line item.
Exhibit III: Certificate of Good Standing
Exhibit IV: Self Certification Statement

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SECTION I. ADMINISTRATIVE INFORMATION
A. 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

4. SAMS NUMBER:

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):

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. EMAIL FOR CONTACT PERSON:

B. COMPLIANCE WITH THRESHOLD REQUIREMENTS (38 CFR 79.30)
1. APPLICATION FILED ON TIME: CONFIRM THAT APPLICATION IS FILED WITHIN THE TIME PERIOD ESTABLISHED IN THE NOFO:
YES

NO

2. APPLICATION IS COMPLETE:
YES

NO

3. ELIGIBLE ACTIVITIES: APPLICANT PROPOSES TO USE LSV FUNDING FOR ELIGIBLE ACTIVITIES ONLY (see 38 CFR 79.20 for list of eligible activities):
YES

NO

4. ELIGIBLE PARTICIPANTS: APPLICANT PROPOSES TO SERVE VETERANS WHO ARE HOMELESS OR AT RISK OF HOMELESSNESS AS DEFINED AT 38 CFR
79.15:
YES

NO

5. COMPLIANCE WITH INTERIM FINAL RULE: APPLICANT AGREES TO COMPLY WITH INTERIM FINAL RULE:
YES

NO

6. OUTSTANDING OBLIGATIONS: APPLICANT EITHER
A. 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.
B. 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
A. IS NOT IN DEFAULT BY FAILING TO MEET THE REQUIREMENTS FOR ANY PREVIOUS FEDERAL ASSISTANCE
B. IS IN DEFAULT BY FAILING TO MEET THE REQUIREMENTS FOR PREVIOUS FEDERAL ASSISTANCE. DESCRIBE BELOW:

8. AMOUNT OF LEGAL SERVICE GRANT FUNDS REQUESTED:

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C. CHANGES TO PROPOSED PROGRAM
1. 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.):

D. 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:

E. 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:

SIGNATURE:

DATE (MM/DD/YYYY)

NAME AND TITLE:

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SECTION II: LSV 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.
A. OPERATIONAL EFFECTIVENESS
1. DESCRIBE HOW YOUR PROGRAM'S PARTICIPANTS MADE PROGRESS WITH THEIR LEGAL NEEDS AND THEIR STATUS OF HOUSING STABILITY DURING
THE GRANT AWARD PERIOD:

B. NUMBER OF PARTICIPANTS ASSISTED
1. PROVIDE THE NUMBER OF PARTICIPANTS ASSISTED. DESCRIBE YOUR PROGRAM’S PROGRESS IN ENGAGING THE VETERANS:

C. DEMOGRAPHICS OF PARTICIPANTS (Gender, Age, Race, Service Era)
1. DESCRIBE THE DEMOGRAPHICS OF YOUR PROGRAM’S PARTICIPANTS. DESCRIBE HOW YOUR PROGRAM IS IDENTIFYING ANY DISPARITIES OR
INEQUALITIES OF LEGAL SERVICES PROVIDED:

D. A DESCRIPTION OF THE LEGAL SERVICES PROVIDED TO EACH PARTICIPANT
1. DESCRIBE THE TYPE OF LEGAL SERVICES THAT WERE PROVIDED TO EACH PROGRAM PARTICIPANT AND THE OUTCOME:

E. PARTICIPANT SATISFACTION
1. 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:

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F. PROGRAM IMPLEMENTATION AND PROGRESS
1. SPECIFY THE AVERAGE TIME BETWEEN CLIENT INTAKE AND START OF SERVICE DELIVERY, AVERAGE TIME TO RESOLUTION OF LEGAL ISSUE, AND
AVERAGE LENGTH OF SERVICE (enrollment to exit). DESCRIBE ANY PROGRAMMATIC OR ORGANIZATIONAL DELAYS ASSOCIATED WITH ONSET OF
LEGAL SERVICES DELIVERY. DESCRIBE THE TIMELINE FOR ANY PROPOSED PROGRAM MODIFICATIONS:

SECTION III: 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.
A. COST PER PARTICIPANT
1. AVERAGE TOTAL GRANT COST PER PARTICIPANT:
2. PLEASE PROVIDE AN EXPLANATION OF THIS FIGURE (including number of participants served) AND JUSTIFY ITS REASONABLENESS. (Note: This figure

relates to your previous grant award period and not the proposed renewal period.)

B. PROGRAM BUDGET AND EXPENDITURES
1. 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)

SERVICES
ADMIN
TOTAL
2. 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:

3. 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 IV: COMPLIANCE WITH LSV 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.
A. LSV PROGRAM GOALS
1. DESCRIBE HOW YOUR PROGRAM WAS IMPLEMENTED IN ACCORDANCE WITH VA'S GOALS (as described in the Final Rule and NOFO):

B. APPLICABLE LAWS, REGULATIONS AND GUIDANCE
1. 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:

C. GRANT AGREEMENT
1. CERTIFY THAT YOUR PROGRAM WAS ADMINISTERED IN ACCORDANCE WITH YOUR LEGAL SERVICES GRANT AGREEMENT. IF NOT, EXPLAIN THE
CIRCUMSTANCES:

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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 quarterly basis the legal 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.
Provision and Coordination of Legal Services (Total must be a minimum of 90% of the total LSV 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 LSV-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 LSV-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. Other Non-Personnel Provision and Coordination of Legal 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.
c. Lease & 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 LSV 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.

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