Form 516-0-1 Federal Hotel and Motel Fire Safety Declaration Form

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. NO. 1660-0068
Expires April 30, 2012

FEDERAL HOTEL AND MOTEL FIRE SAFETY DECLARATION FORM

Use this form to report your property's compliance with the Hotel and Motel Fire Safety Act of 1990 (P.L. 101-391).
Compliant properties will be added to the National Master List (NML).
This form is being submitted to (Check one):
Add a previously unlisted property

Change listing

Property type (Check one):

Hotel/Motel

Delete listing

FEMA # :
Bed & Breakfast

Apartment Building

FEMA # :
College/University

Property Information (Bolded information is required.)
Property Name
General Manager

Federal Employer ID Number (EIN)

Street Address

City

State

Phone Number

Fax Number

Zip Code

P.O. Box

Property E-mail Address

Smoke Alarms

Web Site Address

Check One :

Yes

No

Each guestroom is equipped with at least one hard-wired single station smoke alarm installed in accordance with National Fire Protection Association (NFPA)
Standard 72.
Note: Smoke alarms that are solely battery-operated do not qualify.

Automatic Sprinkler Systems (required unless three stories or fewer in height)
Number of Floors :
1. If sprinkler installed on or after October 25, 1992 -- This property has an automatic sprinkler system installed in accordance with NFPA
Standard 13 or 13R, whichever is appropriate, in accordance with the requirements of the Act.
2. If sprinkler installed before October 25, 1992 -- This property has an automatic sprinkler system installed in compliance with an applicable
standard (adopted by the governmental authority having jurisdiction, and in effect, at the time of installation), provided such standard required the
placement of a sprinkler head in the sleeping area of each guestroom.
3. This property does not exceed three stories in height and is therefore exempted from the Act's automatic fire sprinkler requirements.

E-mail, Fax or Mail the completed form to the United States Fire Administration
I hereby attest that the information supplied on this form is true and accurate to the best of my knowledge and belief. Therefore,

(name of property) is entitled to be included in the National Master List (NML) of public accommodations compiled by the United States Fire
Administration. I understand that this information is subject to verification by Federal, state, and local authorities, and that I am subject to
fines of up to $ 10,000 and/or imprisonment for up to five years if I knowingly make false or fraudulent statements to the government.

Printed Name (contact)

Signature (Not required for e-mail)

Date

Title

Organization

Phone Number

E-mail

For more information contact the U.S. Fire Administration, 16825 S. Seton Ave. Emmitsburg, MD 21727
Tel. 301-447-1263, www.usfa.dhs.gov/hotel, Fax 301-447-1651
FEMA Form 516-0-1, APR 09

PREVIOUSLY FEMA Form 75-13

Fax #

PAPERWORK BURDEN DISCLOSURE NOTICE
Property Owners/Managers

Public reporting burden for this data collection is estimated to average 15 minutes per response. The burden estimate includes
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and submitting this form. This collection of information is voluntary. You are not required to respond to this
collection of information unless a valid OMB control number is displayed on this form. 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, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork
Reduction Project (1660-0068) NOTE: Do not send your completed form to this address.
PAPERWORK BURDEN DISCLOSURE NOTICE
States

Public reporting burden for this data collection is estimated to average 20 minutes per response. The burden estimate includes
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and submitting this form. This collection of information is voluntary. You are not required to respond to this
collection of information unless a valid OMB control number is displayed on this form. 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, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork
Reduction Project (1660-0068) NOTE: Do not send your completed form to this address.