Get Va 10-0430 2007-2025

Completing the VA 10-0430 form online is essential for state homes seeking assistance in hiring and retaining nurses. This guide provides clear, step-by-step instructions to help users navigate the process smoothly.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the VA 10-0430 form and open it for editing.
2. Begin by filling in the name, street address, city, state, and ZIP code of the state home in the first section. Ensure the phone number is accurately entered.
3. In the second section, provide the name of the designated state representative along with their phone, fax, and email details. Remember to include a copy of the delegation of authority.
4. Proceed to the next section to document the state home administrator’s contact information, particularly their phone number.
5. Check the appropriate program(s) for which the facility is receiving per diem payments by selecting from the provided options: domiciliary, nursing home, hospital, and adult day health.
6. Describe and provide documentation of the nursing shortage. Include credible evidence such as records showing vacancies or the necessity of utilizing overtime.
7. Provide a detailed explanation of the employee incentive scholarship program or other employee incentive programs requesting payment. Attach relevant documentation, including program costs.
8. Indicate the amount you are applying for, ensuring it does not exceed 2 percent of the total estimated per diem payments for the fiscal year.
9. Describe the availability of matching funds, confirming that at least 50% of the funding for the employee incentive program is sourced from non-VA funds. Attach a letter from an authorized state budget official certifying the availability of state funds.
10. Outline the measures to ensure that an individual receiving employee incentive benefits will work at the state home as a nurse for a specified period. Attach documentation to support your explanation.
11. Describe how the employee incentive program will address the nursing shortage at the state home and estimate the time required to achieve this goal. Attach relevant documentation.
12. Indicate whether the state home has received a refund payment from an employee in breach of an assistance agreement. If yes, provide details and attach documentation.
13. Confirm if the refund payment has been returned to the incentive program account as a non-federal funding source.
14. Complete the form by providing the date and ensure the signature of the state representative is included.
15. After completing all sections, review the form for accuracy. Save any changes, and consider downloading, printing, or sharing the finished form as needed.

Complete the VA 10-0430 form online to ensure timely assistance for your state home.