Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion (VA Form 26-0967) & Specially Adaptive Housing Assist. Tech. Grants Criteria and Response (VA Form 26-0967a)

Forms and Documents

Document Name	Status
Form 26-0967 VA Form 26-0967, Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion, and VA Form 26-0967a, Specially Adaptive Housing Assistive Technology Grants Criteria and Respons Form and Instruction	Modified
30-DAY (published) 2900-0903.pdf Supplementary Document	2025-01-02
2900-0903 VA Form 26-0967 FRN.pdf Supplementary Document	2024-10-29
OMB 2900-0903 26-0967 & 26-0967a Support Stmt FINAL 12262024 (2).docx Supporting Statement A	2025-01-02

IC Document Collections

IC ID	Document Title	Status
249464	VA Form 26-0967, Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion, and VA Form 26-0967a, Specially Adaptive Housing Assistive Technology Grants Criteria and Respons Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0903	ICR Reference No: 202407-2900-011
Status: Received in OIRA	Previous ICR Reference No: 202109-2900-008
Agency/Subagency: VA	Agency Tracking No: VBA-LGY-KM
Title: Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion (VA Form 26-0967) & Specially Adaptive Housing Assist. Tech. Grants Criteria and Response (VA Form 26-0967a)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/02/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2025
Responses	20	20
Time Burden (Hours)	40	40
Cost Burden (Dollars)	0	0

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Abstract: Section 203 of the Veterans’ Benefits Act of 2010, Public Law 111-275, amended chapter 21, title 38, United States Code, to establish the Specially Adapted Housing (SAH) Assistive Technology Grant program. 38 U.S.C. 2108 states that a person or entity seeking an SAH technology grant shall submit an application for the grant in such form and manner as the Secretary shall specify. VA published regulations to outline the process, the criteria, and the priorities relating to the award of these research and development grants. 36 C.F.R. 4412(d)(2) requires applicants to submit VA Form 26-0967, Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion and VA Form 26-0967a, Specially Adaptive Housing Assistive Technology Grants Criteria and Responses. 36 C.F.R. 4412(d)(3) require applicants to provide statements addressing six scoring criteria for grant awards as part of their application. Lastly, 36 C.F.R. 4412(d)(1) require that applicants submit Standard Form 424, Application for Federal Assistance, which is covered under an existing information collection (OMB Number: 4040-0004). The final rule was published on September 17, 2015 (80 FR 55763-55766).

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Authorizing Statute(s): US Code: 38 USC 2108 Name of Law: Specially Adapted Housing (SAH) Assistive Technology Grant
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 85587	10/28/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 126	01/02/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
VA Form 26-0967, Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion, and VA Form 26-0967a, Specially Adaptive Housing Assistive Technology Grants Criteria and Respons	26-0967, 26-0967	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion ,   Scoring Criteria for SAH Assistive Technology Grants

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	20	20	0	0	0	0
Annual Time Burden (Hours)	40	40	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $2,486

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/02/2025

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