Form FF-090-0-1 Certification of Eligibility for Community Disaster Loan

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

CERTIFICATION OF ELIGIBILITY FOR COMMUNITY DISASTER LOANS

O.M.B. No 1660-0083
Expires June 30, 2009

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 2.5 hours per response. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing and submitting the form.
You are not required to respond to this collection of information unless it displays a valid OMB control number. Send comments regarding the
accuracy of the burden estimate and any 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
(1660-0083). NOTE: Do not send your completed form to this address
YES

1. Does State law prohibit your municipality from incurring the indebtedness from a federal loan?
2. Has the disaster caused revenue loss greater that 5% of total revenue estimated for the fiscal year of the
disaster or the following fiscal year?
3. Has the loss of revenue or the increase in disaster-related un-reimbursable expenses adversely affected the
level and/or the categories of essential municipal services provided prior to the disaster? If yes, explain.

4. Are there insufficient funds to meet current fiscal year operating requirements? If yes, what measures are
you taking to meet financial obligations?

5. Is cash or other liquid assets available from the previous fiscal year? If yes, how long will the cash or liquid
asset last given your current financial projections?

6. Were revenue producing businesses displaced due to property destruction?
7. Have you reduced or eliminated essential municipal services? If no, do you plan on doing this? If so, when?

8. Are you in danger of municipal insolvency?
By signing this certificate, the applicant representative hereby confirms the following:
- All statements are made truthfully, as fairly and accurately as possible.
- All statements are in accordance with any federal, state, and local laws, standards, and regulations.
SIGNATURE OF APPLICANT REPRESENTATIVE

DATE

NAME OF APPLICANT REPRESENTATIVE

TITLE

NAME OF APPLICANT PARISH/COUNTY

STATE

APPLICANT REPRESENTATIVE CONTACT EMAIL

PHONE

FEMA Form 90-143, JUN 07

NO