Information Collection

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

IC 28939 under ICR 201404-2900-021 · OMB 2900-0661.

⚠️ Notice: This information collection may be referencing outdated material.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

2023-11-01 - Reinstatement without change of a previously approved collection

Documents and Forms

Document Name Document Type
2900-0661 Forms_Support_List[1].docx Other-Support List for State Home Co
10-0388-1 Documents and Information Required for State Home Constr Form 10-0388-2_20140418.pdf Form and Instruction
10-0388-2 Certification of Compliance with Provisions of the Davis Form 10-0388-2_20140424.pdf Form
10-0388-3 State Home Construction Grant Program Space Program Anal Form 10-0388-3_20140424.pdf Form
10-0388-4 Sate Home Construction Grant Program Space Program Analy Form 10-0388-4_20140424.pdf Form
10-0388-5 Additionall Documents and Information Required for State Form 10-0388-5_20140418.pdf Form
10-0388-6 Certification of State Matching Funds To Qualify for Gro Form 10-0388-6_20140418.pdf Form
10-0388-7 Certification Regarding Debarment, Suspension, and Other Form 10-0388-7_20140418.pdf Form and Instruction
10-0388-8 Certification Regarding Drug-Free Workplace Requirements Form 10-0388-8_20140418.pdf Form
10-388-9 Certification Regarding Lobbying Form 10-0388-9_20140418.pdf Form
10-0388-10 Certification of Compliance With Federal Requirements - Form 10-0388-10_20140418.pdf Form
10-0388-12 Certification Regarding Debarment, Suspension, Ineligibi Form 10-0388-12_20140418.pdf Form and Instruction
10-0388-13 Documents and Information Required for State Home Constr Form 10-0388-13_20140418.pdf 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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Support List for State Home Construction Grant Forms (VA Forms 10-0388-XX)			2900-0661 Forms_Support_List[1].docx	No		Printable Only
Form and Instruction	10-0388-1	Documents and Information Required for State Home Construction and Acquisition Grants - Initial Application	Form 10-0388-2_20140418.pdf	Yes	No	Fillable Printable
Form	10-0388-2	Certification of Compliance with Provisions of the Davis-Bacon Act	Form 10-0388-2_20140424.pdf	Yes	No	Fillable Printable
Form	10-0388-3	State Home Construction Grant Program Space Program Analysis - Nursing Home & Domiciliary	Form 10-0388-3_20140424.pdf	Yes	No	Fillable Printable
Form	10-0388-4	Sate Home Construction Grant Program Space Program Analysis - Adult Day Care	Form 10-0388-4_20140424.pdf	Yes	No	Fillable Printable
Form	10-0388-5	Additionall Documents and Information Required for State Home Construction and Acquisition Grants Application	Form 10-0388-5_20140418.pdf	Yes	No	Fillable Printable
Form	10-0388-6	Certification of State Matching Funds To Qualify for Group 1 on the Priority List	Form 10-0388-6_20140418.pdf	Yes	No	Fillable Printable
Form and Instruction	10-0388-7	Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions	Form 10-0388-7_20140418.pdf	Yes	No	Fillable Printable
Form	10-0388-8	Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals	Form 10-0388-8_20140418.pdf	Yes	No	Fillable Printable
Form	10-388-9	Certification Regarding Lobbying	Form 10-0388-9_20140418.pdf	Yes	No	Fillable Printable
Form	10-0388-10	Certification of Compliance With Federal Requirements - State Home Construction Grant	Form 10-0388-10_20140418.pdf	Yes	No	Fillable Printable
Form and Instruction	10-0388-12	Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions	Form 10-0388-12_20140418.pdf	Yes	No	Fillable Printable
Form	10-0388-13	Documents and Information Required for State Home Construction and Acquisition Grants - Post-Grant Requirements	Form 10-0388-13_20140418.pdf	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: 50	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	50	50
Annual IC Time Burden (Hours)	1,200	1,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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