Form FEMA Form 90-121 FEMA Form 90-121 PNP Facility Questionaire

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
PNP FACILITY QUESTIONNAIRE

O.M.B. NO. 1660-0017
Expires October 31, 2008

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 30 minutes 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, Paperwork Reduction Project (1660-0017). Please do not send your completed survey
to the above address.
FEMA and State personnel will use this questionnaire to determine the eligibility of specific facilities of an approved Private Non-Profit (PNP) organization (See 44 CFR 206.221). Owners of critical
facilities (i.e., power, water (including providing by an irrigation organization or facility, if it is not provided solely for irrigation purposes), sewer, wastewater treatment, communications and
emergency medical care) can apply directly to FEMA for assistance for emergency work (debris removal and emergency protective measures) and permanent work (repair, restore or replace a
damaged facility). Owners of non-critical facilities can apply directly to FEMA for assistance for emergency work, but must first apply to the U. S. Small Business Administration (SBA) for
assistance for permanent work. If the owner of a non-critical facility does not qualify for an SBA loan or the cost to repair the damaged facility exceeds the SBA loan amount, the owner may apply
to FEMA for assistance.
1. Name of PNP Organization
2. Name of the damaged facility and location

3. What was the primary purpose of the damaged facility
4. Is the facility a critical facility as described above?

Yes

No

Yes

No

Yes

No

Yes

No

5. Who may use the faciltiy
6. What fee, if any, is charged for the use of the faciltiy
7. Was the facility in use at the time of the disaster?
8. Did the facility sustain damage as a direct result of the disaster?
9. What type of assistance is being requested?
10. Does the PNP organization own the facility?
11. If "Yes" obtain proof of owbership; check here if attached.
12. Does the PNP organization have the legal responsibility to repair the facility?

Yes

13. If "Yes", provide proof of legal responsibility; check here if attached.

Yes

No

14. Is the facility insured?

Yes

No

No

15. If "Yes", obtain a copy of the insurance policy; check here if attached.
Additional information or comments:

CONTACT PERSON

FEMA Form 90-121, FEB 06

DATE