HomeMy WebLinkAboutRequest for PADEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
REQUEST FOR PUBLIC ASSISTANCE
FEMA Form 90-49 AUG 10 REPLACES ALL PREVIOUS EDITIONS
STREET ADDRESS
DATE SUBMITTED
O.M.B. NO. 1660-0017
Expires April 30, 2013
CITY STATE
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 10 minutes. Burden means the time, effort and financial resources
expended by persons to generate, maintain, disclose, or to provide information to us. You may send comments regarding the
burden estimate or any aspect of the collection, including suggestions for reducing the burden to: Information Collections Management,
Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472,
Paperwork Reduction Project (OMB Control Number 1660-0017). You are not required to respond to this collection of information
unless it displays a valid OMB number. NOTE: Do not send your completed questionnaire to this address.
APPLICANT PHYSICAL LOCATION
MAILING ADDRESS (If different from Physical Location)
Primary Contact/Applicant's Authorized Agent
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 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.
APPLICANT (Political subdivision or eligible applicant)
COUNTY (Location of Damages. If located in multiple counties, please indicate)
COUNTY ZIP CODE
STREET ADDRESS
POST OFFICE BOX STATECITY ZIP CODE
Alternate Contact
NAME NAME
TITLETITLE
FAX NUMBERFAX NUMBER
BUSINESS PHONEBUSINESS PHONE
HOME PHONE (Optional)HOME PHONE (Optional)
CELL PHONECELL PHONE
E-MAIL ADDRESS
PAGER & PIN NUMBERPAGER & PIN NUMBER
E-MAIL ADDRESS
Did you participate in the Federal/State Preliminary Damage Assessment (PDA)?YES NO
NOYESPrivate Non-Profit Organization?
If yes, which of the facilities identified below best describe your organization?
OFFICIAL USE ONLY: FEMA --DR--FIPS#DATE RECEIVED
DUNS NUMBER