Va Form 10-0388-4 - State Home Construction Grant Programadult Day Health Care Page 4
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4The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of section 3507 of this Act. The public reporting burden for this collection of information is estimated to average 6
hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. We may not collect or sponsor and you are not required
to respond to, a collection unless it has a valid OMB Control Number. This collection of information is collected under the
authority of 38 U.S. Code Sections 8133(a) and 8135(a). VA will use this information, along with other documents submitted by
the States to determine the feasibility of the projects for VA participation, to meet VA requirements for a grant award and to rank
the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will be unable to authorize a
grant without a complete package. Your failure to furnish this information will have no effect on any of other benefits to which
you are entitled.
VA FORM
Pa ge 4 of 4
10-0388-4
MAR 2005
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