Fillable Printable VA Form 40-0895-11

VA Form 40-0895-11

OMB NUMBER: 2900-0559

Respondent Burden: 2 hours

MEMORANDUM OF AGREEMENT FOR A GRANT TO CONSTRUCT

OR MODIFY A STATE OR TRIBAL GOVERNMENT VETERANS CEMETERY

This Memorandum of Agreement is hereby made by and between The Department of Veterans Affairs (VA),

810 Vermont Avenue, NW, Washington, D.C. 20420, and __________________________________________________

who has submitted to VA an application for a grant to construct or modify a _____________________________

___________________________________________ facility for veterans in ____________________________________

______________________________________________________________.

The Federal Application Identifier (FAI) Number for this project is ______________________. The parties agree that this

application meets the requirements of Federal Law for this grant. The estimated total cost of $__________________,

including equipment, in which VA will participate, is $ ______________. The VA grant will total up to $_____________,

but will not exceed one hundred (100) percent of the actual cost of $_______________ as determined at final audit.

In consideration of the foregoing, the parties hereby mutually agree as follows:

(1) ___________________________________ certifies that the plans and specifications included in the

application meet all applicable Federal requirements.

(2) ___________________________________ agrees that it will construct or acquire a

__________________________________________________________________________________, to be completed in

accordance with the documentation submitted by the State.

(3) ___________________________________ agrees to comply strictly with the assurances contained in

the documentation submitted by the state.

(4) ___________________________________ agrees to enter into a contract to

construct or modify a _________________________________________________________________________

within 90 days of the date on which both parties have signed this agreement.

(5) ___________________________________ agrees to periodically inspect the project and certify to the

Director, State Cemetery Grants Service (41E), 810 Vermont Avenue, NW, Washington, D.C. 20420, for payment of

such sums which it deems are payable by VA.

(Description)

(Location)

(Description of the project)

(Description of this project)

(Continued on next page)

VA FORM

OCT 2010

40-0895-11

(6) ___________________________________ agrees to furnish any additional State funds needed to

complete the project.

(7) ___________________________________ agrees that, upon completion of the project, it will provide

adequate financial support to maintain and operate the facility.

(8) ___________________________________ agrees that it will operate and maintain the facility in

conformance with State standards and with all applicable State and local laws, codes, regulations and ordinances, and in

conformance with NCA Shrine standards prescribed by VA.

(9) ___________________________________ agrees that it will make such reports in such form and

containing such information as the Secretary may from time to time reasonably require, and give the Secretary, upon

demand, access to the records upon which such information is based.

The Secretary of the Department of Veterans Affairs hereby approves the project. After _____________________

certifies its construction or modification costs as set forth in paragraph (5) above, the Secretary agrees to make

partial payments of the grant to cover the costs certified. VA payments will be limited to the unpaid obligated balance of

the grant for actual incurred costs for this project. If all funds have not been used by the State for the purpose of the project

within three years after being so made available, the United States shall be entitled to recover any such unused funds from

the State. This project is subject to the recapture provisions stated in 38 CFR 39.10.

IN WITNESS WHEREOF, the parties have hereunto affixed their signature on the dates indicated:

(State or Tribal Government Authorizing Official) (Date)

(Director, State Cemetery Grants Service)

(Date)

Respondent Burden: Public reporting burden for this collection of information is estimated to average 2 hours. Statutory authority for

a State Cemetery Grant is 38 U.S.C. 2408. The information requested is necessary to ensure that State or Tribal government identify

the parties (VA and applicant), identify the scope of the project and indicate how the grant award funds will be reimbursed to the

applicant. VA may not conduct or sponsor and you are not required to respond to this collection of information unless it displays a

valid OMB number. Respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspects of this

collection of information, including suggestions for reducing the burden to VA Clearance Officer (005R1B), 810 Vermont Avenue

NW, Washington, DC 20420. SEND COMMENTS ONLY. Please do not send applications for a grant to this address.

VA FORM 40-0895-11, OCT 2010, PAGE 2 OF 2