Form FEMA Form 085-0-1 FEMA Form 085-0-1 Local Government Resolution - Collateral Security

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O. M. B. No. 1660-0083
Expires June 30, 2012

LOCAL GOVERNMENT RESOLUTION - COLLATERIAL SECURITY
RESOLUTION
BE IT RESOLVED BY

OF

(Governing Body)

(Public Entity)

THAT we pledge the following listed collateral security to the Department of Homeland Security/Federal Emergency Management Agency
(DHS/FEMA) on the Promissory Note for a Community Disaster Loan for $
, 20

executed on

pursuant to Section 417 of the Robert T. Stafford Relief and Emergency Assistance Act, Public Law 93-288, as amended, and

FEMA Regulation, 44 CFR 206, Subpart K. We further understand that failure to repay any outstanding principal and related interest on those
portions of the loan which do not qualify for loan cancellation as determined by DHS/FEMA or any successor agency will result in forfeiture of
as much as the listed colleterial security as is necessary to collect such outstanding principal and interest. (List the collateral security below.
Use additional sheets if needed.)

List the collateral security

Passed and approved this

day of

,20

.

(Name and Title)

(Name and Title)

(Name and Title)

CERTIFICATION
I,

, duly appointed and

(Title)

, do herby certify that the above is a true and correct copy of a
resolution passed and approved by the
on the

of

(Governing Body)

day of

, 20

( Public Entity)

.

DATED:
(Official Position)

[SEAL]

FEMA Form 085-0-0-1, JUL 09

(Signature)

of

RECORDED
I,

,

(Name)

authorized official of

, a responsible and

(Title)

, do hereby attest that the

(Public Entity)

Collateral Security Resolution which accompanies this form has been duly recorded at

(Indicate where Recorded)

The Colleterial Security Resolution was recorded on the

day of

, 20

.

DATED:

(Official Position)

(Signature)

[SEAL]

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 10 hours per response. The burden estimates includes time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form.
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 (1660-0017). NOTE: Do not send your completed questionnaire to this address.
PRIVACY NOTICE
This information is being collected under the authority of Section 417 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act,
Public Law 93-288, as amended, (42 U.S.C. 5121-5207), and 44 CFR, § 206.364. DHS/FEMA will use this information to provide operational
funding to help local governments that have incurred a significant loss in revenue, due to a major disaster, that has or will adversely affect
their ability to provide essential municipal services. The information will be used by and disclosed to DHS personnel and contractors, state
government officials, or other agents who need the information to assist in activities related to disaster relief. In addition, the information on
this form may be disclosed as generally permitted under the Freedom of Information Act, as amended (5 U.S.C. § 552). Furnishing this
information is voluntary; however, failure to furnish the requested information may delay or prevent the completion of your loan application and
disbursement.

FEMA Form 085-0-0-1, JUL 09