Form 10-367b Quarterly Grantee Performance Report - LSV-A Grant

OMB Control Number: 2900-XXXX
Estimated burden: 60 minutes
Expiration Date: XX/XX/20XX

Legal Services for Veterans -- Legal Assistance for Access to VA
Programs (LSV-A) Grant Program

QUARTERLY GRANTEE PERFORMANCE REPORT

VA Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 2900-XXXX, and it expires XX/XX/20XX. Public reporting burden for this
collection of information is estimated to average 60 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other
aspects of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected].
Please refer to OMB Control Number 2900-XXXX in any correspondence. Do not send your completed VA Form 10-367b to this email address.
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. Please redact information protected by
attorney-client privilege, unless that privilege has been waived by the client. See 38 CFR 81.xx.

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

6. GRANT PERFORMANCE REVIEW PERIOD

SECTION II: FINAL RULE
1. I CERTIFY THAT THIS LSV-A PROGRAM IS IN COMPLIANCE WITH 38 CFR PART 81.
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 DATA AND REPORTS GIVEN TO THE VA ACCURATELY REPRESENTS OUR PROGRAM PERFORMANCE.
YES

NO

1A. IF THE ANSWER TO THE PREVIOUS QUESTION WAS NO, PLEASE OUTLINE YOUR PLAN TO IMPROVE UPLOAD QUALITY INCLUDING TIMELINES/DATES:

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

NO

3. I CERTIFY THAT OUR PROGRAM IS ADDRESSING ALL ERRONEOUS RECORDS OR REPORTING ISSUES AS IDENTIFIED BY THE LSV PROGRAM OFFICE.
YES

VA FORM
SEP 2024

NO

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SECTION IV: TRAININGS AND WEBINARS
1. I CERTIFY THAT THE PROGRAM STAFF AT OUR ORGANIZATION FUNDED BY THE LSV GRANT REVIEW ALL TRAININGS/WEBINARS PROVIDED BY THE
VHA LSV PROGRAM OFFICE.
YES

NO

2. I CERTIFY THAT THE PROGRAM OPERATING WITH LSV GRANT FUNDS HAS A PLAN FOR ENSURING THAT STAFF AND ANY SUBCONTRACTORS ARE
APPROPRIATELY TRAINED, THAT ATTORNEYS PROVIDING SERVICES ARE IN GOOD STANDING WITH ALL STATE BARS IN WHICH THEY ARE PROVIDING
GRANT FUNDED LEGAL SERVICES AND STAY INFORMED OF INDUSTRY TRENDS AND THE REQUIREMENTS OF THIS GRANT.
YES

NO

SECTION V: 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-A BUDGET.
YES

NO

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

NO

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

NO

5. I CERTIFY THAT AT LEAST 10 PERCENT OF LSV GRANT FUNDS ARE PROJECTED TO BE USED FOR THE PROVISION OF LEGAL SERVICES FOR WOMEN
VETERANS BY THE END OF THE GRANT CYCLE.
YES

NO

SECTION VI: LEGAL SERVICES

(Provide the # of Veterans that fit the following descriptions)
VETERANS SCREENED
AND REFERRED
ELSEWHERE

1. LEGAL NEEDS OUTSIDE SCOPE OF THE GRANT

4. NOT ELIGIBLE

2. CONFLICT OF INTEREST

5. DECLINED/DID NOT ENGAGE

3. NEED EXCEEDED CAPACITY OF THE GRANTEE

6. OTHER

THE FOLLOWING SECTIONS ARE SPECIFIC TO THE VETERANS SERVED USING LSV-A GRANT FUNDS
UNIQUE VETERANS
SERVED

AGE

1. FEMALES

4. TRANSGENDER MALES

2. MALES

5. GENDER NON-CONFIRMING

3. TRANSGENDER FEMALES
1. UNDER 20

6. 60-69

2. 20-29

7. 70-79

3. 30-39

8. 80-89

4. 40-49

9. OVER 90

5. 50-59
HOUSING STATUS UPON
SCREENING

1. HOMELESS

2. AT-RISK FOR HOMELESSNESS

1. HOUSING - i.e. eviction defense, representation in landlord-tenant cases, and representation in foreclosure cases
2. FAMILY - i.e. assistance in court proceedings for child support and custody, divorce, estate planning, and family
reconciliation
3. INCOME - assistance in obtaining public benefits or VA benefits

PRESENTING LEGAL
PROBLEMS

4. ASSIST WITH UPGRADE THE CHARACTERIZATION OF DISCHARGE OR DISMISSAL OF A FORMER
MEMBER OF THE ARMED FORCES
5. CRIMINAL DEFENSE - in matters symptomatic of homelessness such as outstanding warrants, fines, and driver's
license revocation, and citations (to reduce recidivism and facilitate the overcoming of reentry obstacles in

employment or housing, covered legal services relating to criminal defense also include legal assistance with
requests to expunge or seal a criminal record)

6. MATTERS R/T DV OR IPV
7. DEBT COLLECTION/FRAUD/FINANCIAL EXPLOITATION
8. ASSIST WITH ACCESS TO HEALTHCARE/TREATMENT SERVICES
1. LEGAL INFORMATION/REFERAL/EDUCATION
2. COUNSEL & ADVICE
LEVEL OF LEGAL
SERVICES PROVIDED

3. LIMITED ACTION
4. REPRESENTATION
5. GROUP EDUCATION/CLASS (List # of classes, not # of Veterans)
6. AVERAGE # OF VETERANS PER GROUP EDUCATION/CLASS (Only if group education/class provided)

VA FORM 10-367b, FEB 2024

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SECTION VI: LEGAL SERVICES (Continued)
(Provide the # of Veterans that fit the following descriptions)

TYPES OF LEGAL
SERVICE PROVIDED

1. HOUSING

6. PROTECTIVE ORDERS R/T DV OR IPV

2. FAMILY LAW

7. CONSUMER LAW

3. INCOME SUPPORT

8. EMPLOYMENT LAW

4. DISCHARGE OR DISMISSAL UPGRADE

9. ACCESS TO HEALTHCARE

5. CRIMINAL DEFENSE
LEGAL CASE STATUS

3. PENDING CASES

1. OPEN CASES
2. CLOSED CASES
1. SCREEN HOMELESS, NOW HOUSED

2. SCREENED HOMELESS, NOW IN PROCESS OF ACCESSING HOUSING
HOUSING STATUS AT
EXIT

3. SCREENED HOMELESS, HOUSING STATUS NOT IMPROVED
4. SCREENED AT-RISK, NO LONGER AT-RISK
5. SCREENED AT-RISK, STILL HOUSED BUT STILL AT-RISK
6. SCREENED AT-RISK, NOW HOMELESS

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-A program. Please note: Documentation supporting all certifications
must be maintained by the grantee and made available for monitoring visits and audits.
SIGNATURE

VA FORM 10-367b, FEB 2024

DATE (MM/DD/YYYY)

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