Form 116-0-1 Promissory Note

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

PROMISSORY NOTE
PAPERWORK BURDEN DISCLOSURE NOTICE

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

Public reporting burden for this form is estimated to average 4 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 this burden to: Information
Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington,
DC, 20472, and Paperwork Reduction Project (1660-0083). Note: Do not send your completed form to this address.
PART I: COMMUNITY DISASTER LOAN
1. NAME AND ADDRESS OF BORROWER

2. TELEPHONE NUMBER
3. LOAN NUMBER

DATE

,

(herein called "Borrower") promises to pay to the Order of the United States of America, acting through the Federal Emergency
Management Agency, (herein called the "Government") at its office in
The principle sum
of
rate of

dollars ($
percent (

), plus interest on the unpaid principal balance at the

%) per annum. The principal and interest less such as may be canceled

pursuant to Section 417 of the Stafford Disaster Relief and Emergency Assistance Act, Public Law 93-288, as amended and
implementing regulations are due on

unless the term of this note is extended in the sole

discretion of the Government, except that prepayments may be made as provided below.
The loan shall be paid in increments to Borrower as requested by Borrower and approved by Government. Interest shall be
charged on each loan increment from the actual date of payment by the Government.
Every repayment made on this loan shall be applied first to interest and then to principal.
Prepayments of scheduled installments, or any portion thereof, may be made at any time at the option of Borrower. Such
payments shall be applied to the installments last to become due under this note and shall not affect the obligation of Borrower to
pay the remaining installments.
Any cost incurred by the government in collecting this note shall be added to the unpaid balance of the loan, bear interest at the
same rate as this loan, and are immediately due without demand.
The government may extend, or renew, this note without affecting any other rights it has against the Borrower or any other party.
Borrower agrees to use this loan solely for purposes authorized by the Government.
In the event of default on this note by the Borrower, the Federal Emergency Management Agency will take action to recover the
outstanding principal plus related interest under Federal Debt collection authorities, including administrative offset against other
Federal funds due the Borrower and/or referral to the Department of Justice for Judicial enforcement and collection.

FEMA Form 90-6, JUN 07

DEFAULT hereunder shall constitute default under any other instrument evidencing a debt of borrower owing to or insured by the
Government or securing or otherwise relating to such a debt; and default under any such other instrument shall constitute default
hereunder. UPON ANY SUCH DEFAULT, the Government at its option may declare all or part of such indebtness immediately due and
payable.
This note is given as evidence of a loan to Borrower made by the Government pursuant to section 417 of the Stafford Act (Public Law
93-288, as amended) and Federal Emergency Management Agency Regulation 44 CFR 206, Subpart K.

(SEAL)
ATTEST:
(Signature of Attesting Official)

(Name of Borrower)

(Title of Attesting Official)

(Signature of Executive Official)
(Title of Executive Official)
(Post Office Box No. or Street Address)
(City, State, and Zip Code)
PART II - STATE CO-SIGNER

Is State co-signing this note?

Yes

If Yes, State must complete Part II.

No

If No, attach FEMA Form 90-100, Collateral Security.

ATTEST:

(Signature of Attesting Official)

Name of State Co-Signer)

(Title of Attesting Official)

(Signature of Co-Signer)

(Title of State Official)

SEAL:

PART III - SCHEDULE OF LOAN INCREMENTS TO BE DISBURSED TO BORROWER
AMOUNT

DATE

AMOUNT

(1) $

(6) $

(2) $

(7) $

(3) $

(8) $

(4) $

(9) $

(5) $

(10) $
TOTAL

PAY TO THE ORDER OF:
PART IV - RECOVERY DIVISION, PUBLIC ASSISTANCE BRANCH AUTHORIZATION
TYPED NAME AND TITLE (Authorizing Official)

SIGNATURE

DATE