Information Collection

Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities

IC 28939 under ICR 200802-2900-002 · OMB 2900-0661.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0661 can be found here:

Documents and Forms

Document Name Document Type
Form 10-0388-11 Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities Form and Instruction
10-0388 Forms Support List.pdf www.va.gov/vaforms Instruction
10-0388-2 CERTIFICATION OF COMPLIANCE WITH PROVISIONS OF THE DAVIS 10-0388-2-fillable.pdf www.va.gov/vaforms Form and Instruction
10-0388-3 SPACE PROGRAM ANALYSIS - NURSING HOME & DOMICILIARY 10-0388-3-fillable.pdf www.va.gov/vaforms Form
10-0388-4 ADULT DAY HEALTH CARE 10-0388-4-fillable.pdf www.va.gov/vaforms Form
10-0388-5 ADDITIONAL DOCUMENTS AND INFORMATION REQUIRED FOR STATE 10-0388-5-fillable.pdf www.va.gov/vaforms Form
10-0388-6 CERTIFICATION OF STATE MATCHING FUNDS TO QUALIFY FOR GRO 10-0388-6-fillable.pdf www.va.gov/vaforms Form
10-0388-7 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER 10-0388-7-fillable.pdf www.va.gov/vaforms Form and Instruction
10-0388-8 CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS 10-0388-8-fillable.pdf www.va.gov/vaforms Form and Instruction
10-0388-9 CERTIFICATION REGARDING LOBBYING 10-0388-9-fillable.pdf www.va.gov/vaforms Form and Instruction
10-0388-10 CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS 10-0388-10-fillable.pdf www.va.gov/vaforms Form
10-0388-11 MEMORANDUM OF AGREEMENT FOR A GRANT TO CONSTRUCT OR ACQU 10-0388-11-fillable.pdf www.va.gov/vaforms Form and Instruction
10-0388-12 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBI 10-0388-12-fillable.pdf www.va.gov/vaforms Form and Instruction
10-0388-13 DOCUMENTS AND CERTIFICATION REQUIRED FOR STATE HOME CONS 10-0388-13-fillable.pdf www.va.gov/vaforms Form and Instruction
10-0388-14 CHECKLIST OF MAJOR REQUIREMENTS FOR STATE HOME CONSTRUCT 10-0388-14-fillable.pdf www.va.gov/vaforms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Forms and Regulatons for Grants to States for Construction and Acquisition of State Home Facilities	Agency IC Tracking Number:	2900-0661

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-0388-11	MEMORANDUM OF AGREEMENT FOR A GRANT TO CONSTRUCT OR ACQUIRE A STATE VETERANS HOME	10-0388-11-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form and Instruction	10-0388-12	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS	10-0388-12-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form and Instruction	10-0388-13	DOCUMENTS AND CERTIFICATION REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS - POST-GRANT REQUIREMENTS	10-0388-13-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-0388-14	CHECKLIST OF MAJOR REQUIREMENTS FOR STATE HOME CONSTRUCTION/ACQUISITION GRANTS	10-0388-14-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Instruction			10-0388 Forms Support List.pdf	www.va.gov/vaforms	No		Printable Only
Form and Instruction	10-0388-2	CERTIFICATION OF COMPLIANCE WITH PROVISIONS OF THE DAVIS-BACON ACT	10-0388-2-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-0388-3	SPACE PROGRAM ANALYSIS - NURSING HOME & DOMICILIARY	10-0388-3-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-0388-4	ADULT DAY HEALTH CARE	10-0388-4-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-0388-5	ADDITIONAL DOCUMENTS AND INFORMATION REQUIRED FOR STATE HOME CONSTRUCTION AND ACQUISITION GRANTS APPLICATION	10-0388-5-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-0388-6	CERTIFICATION OF STATE MATCHING FUNDS TO QUALIFY FOR GROUP 1 ON THE PRIORITY LIST	10-0388-6-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form and Instruction	10-0388-7	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS	10-0388-7-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form and Instruction	10-0388-8	CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS	10-0388-8-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form and Instruction	10-0388-9	CERTIFICATION REGARDING LOBBYING	10-0388-9-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-0388-10	CERTIFICATION OF COMPLIANCE WITH FEDERAL REQUIREMENTS	10-0388-10-fillable.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	360	360
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.