HomeMy WebLinkAboutApplicant-Certification-revNew York State Emergency Management Office
PRESIDENTIAL DECLARATION
FEMA-________-DR or EM-NY
STATE EMERGENCY MANAGEMENT OFFICE
APPLICANT CERTIFICATION
This is to certify the receipt of the guidelines, and associated documents for the Presidential Declaration as
administered by the State Emergency Management Office (SEMO).
The signature below indicates the intent of the (circle one and PRINT in the name):
County City Town Village State Agency School Fire District Non-profit
of __________________________________________________________________, hereinafter referred
to as the subgrantee, to participate in the Presidential Declaration FEMA-______-DR or EM-NY
The public assistance program is voluntary. It is understood that by choosing to participate in the grant
program, the subgrantee is responsible to: 1) comply with all federal and state laws, regulations, policies,
and procedures; 2) fulfill the eligibility requirements to participate as a subgrantee of the State; and 3)
certify that all figures to be provided in the application are true and correct for costs associated with the
declaration provisions.
If debris removal is authorized, the subgrantee agrees to indemnify and hold harmless the State of New
York and the United States of America for any claims arising from the removal of debris or wreckage for
this disaster. The sub-grantee agrees that debris removal from public and private property will not occur
until all state and federal requirements are met.
The undersigned agrees to participate in this program and certifies that to the best of their knowledge and
belief, all work and costs claimed are eligible in accordance with the grant conditions and all work claimed
has been or will be completed.
SIGNED: ______________________________________ DATE: ____________________________
CHIEF EXECUTIVE OFFICER
NAME: ________________________________________ PHONE NO.: (____)_______-_________
Please type or print name/address
ADDRESS: __________________________________________________________________________
CITY,STATE: _____________________________________________ ZIP CODE: ________________
Designation of the Point of Contact if different from above:
NAME: ________________________________________ PHONE NO.: (____)_______-_________
Please type or print name
TITLE &
ADDRESS: ________________________________________________________________________