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FEDERAL EMERGENCY MANAGEMENT AGENCY

REQUEST FOR PUBLIC ASSISTANCE

O.M.B. No. 3067-0151 Expires April 30, 2001

STREET ADDRESS 1300 Main Street

CITY Popular

COUNTY

STATE

ZIP CODE

Obtaining a Public Assistance Program Grant

Gotham

OR

MAILING ADDRESS (If different from Physical Location)

STREET ADDRESS

POST OFFICE BOX

CITY

STATE

ZIP CODE

Primary Contact/Applicant s Authorized Agent

Alternate Contact

NAME

NAME

Joe Smith

Laura Wolf

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 jsmith@popular.com

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

DATE SUBMITTED

Did you participate in the Federal/State Preliminary Damage Assessment (PDA)?

Yes

No

Private Non-Profit Organization?

Yes

No

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-

FEMA Form 90-49, SEP 98

  • -

    DR-

  • -

    FIPS #

REPLACES ALL PREVIOUS EDITIONS.

Date Received:

41

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