FEDERAL EMERGENCY MANAGEMENT AGENCY
REQUEST FOR PUBLIC ASSISTANCE
O.M.B. No. 3067-0151 Expires April 30, 2001
STREET ADDRESS 1300 Main Street
Obtaining a Public Assistance Program Grant
MAILING ADDRESS (If different from Physical Location)
POST OFFICE BOX
Primary Contact/Applicant s Authorized Agent
TITLE City Engineer
TITLE City Planner
BUSINESS PHONE (555)555-5555
BUSINESS PHONE (444)444-5454
FAX NUMBER (555)555-1212
FAX NUMBER Same
HOME PHONE (Optional) (555)123-4567
HOME PHONE (Optional) (555)234-6789
CELL PHONE (555)501-1111
CELL PHONE (555)501-2222
E-MAIL ADDRESS firstname.lastname@example.org
E-MAIL ADDRESS Lwolf@popular.com
PAGER & PIN NUMBER (555)312-1312
PAGER & PIN NUMBER (555)312-6789
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 10 minutes. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing and submitting the forms. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of the forms. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (3067-0151). NOTE: Do not send your completed form to this address.
COUNTY (Location of Damages. If located in multiple counties, please indicate.) Gotham County
APPLICANT PHYSICAL LOCATION
APPLICANT (Political subdivision or eligible applicant.) City of Popular
Did you participate in the Federal/State Preliminary Damage Assessment (PDA)?
Private Non-Profit Organization?
If yes, which of the facilities below best describe your organization?
Title 44 CFR, part 206.221(e) defines an eligible private non-profit facility as: “… any private non-profit educational, utility, emergency, medical or custodial care facility, including a facility for the aged or disabled, and other facility providing essential governmental type services to the general public, and such facilities on Indian reservations.” “Other essential governmental service facility” means museums, zoos, community centers, libraries, homeless shelters, senior citizen centers, rehabilitation facilities, shelter workshops and facilities which provide health and safety services of a governmental nature. All such facilities must be open to the general public.
Private Non-Profit Organizations must attach copies of their Tax Exemption Certificate and Organization Charter or By-Laws. If your organization is a school or educational facility, please attach information on accreditation or certification.
Official Use Only:
FEMA Form 90-49, SEP 98
REPLACES ALL PREVIOUS EDITIONS.