Form FEMA Form 010-0-13 FEMA Form 010-0-13 Request for Presidential Disaster Delcaration

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

OMB No. 1660-0009 Expires December 31,2012

REQUEST FOR PRESIDENTIAL DISASTER DECLARATION
MAJOR DISASTER OR EMERGENCY

1. Request Date

Burden Disclosure Notice
Public reporting burden for this form is estimated to average 9 hours 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 the form . This collection of information is
required to obtain a benefit. 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 (1660-0009) NOTE: Do not send your completed form to this address.
Completion of this form including applicable attachments satisfies legal requirements for emergency and major disaster declaration requests under 42
U.S.C. 5170 and 5191, respectively, as implemented at 44 C.F.R. 206.35 and 206.36. Failure to use this form may result in a failure to meet these
requirements and/or a delay in processing the request.
2a. Name of State requesting declaration (as defined in Stafford Act 102, 42 U.S.C. 5122)

3. Governor's Name

2b. State Population (as reported by 2010 Census)

4a. Designation of State Coordinating Officer upon declaration (if available) and phone number

4b. Designation of Governor's Authorized Representative upon declaration (if available) and phone number

6. Declaration Request For:
7. Incident Date

Major Disaster (Stafford Act Sec. 401)

Beginning Date

End Date

or

Emergency (Stafford Act Sec. 501(a))

Continuing

If requesting a "continuing" incident period, enclose an official
statement from a qualified Federal government agency
acknowledged as a national authority in a specific incident field
(e.g., United States Geological Survey for seismic incidents, the
National Weather Service for flooding).

7b. Type of Incident (Check all that apply)
Drought

Earthquake

Explosion

Severe Storm

(rain, high water, wind-driven rain, hail lighting)

Tidal Wave

Tornado

Tropical
Depression

Fire

Flood

Hurricane

Snowstorm

Landslide

(Must include Enclosure D: Historic and Current Snowfall Data)

Tropical Storm

Tsunami

Volcanic Eruption

Mudslide
Straight-Line Winds
Winter Storm

Other (please specify)
8. Description of damages (Short description of impacts of disaster on affected area and population). Include additional details in enclosed Governor's
cover letter.

9. Description of the nature and amount of State and local resources which have been or will be committed. Include additional details in enclosed
Governor's cover letter.

FEMA Form 010-0-13, (6/12)

10. Joint Preliminary Damage Assessment*
Individual Assistance

Dates Performed

Requested

Start

End

Individual Assistance Accessibility Problems (Areas that could not be accessed, and why)

Public Assistance

Dates Performed

Requested

Start

End

Public Assistance Accessibility Problems (Areas that could not be accessed, and why)

11. Programs and Areas Requested
Individual Assistance

N/A

Individual and Households
Program

Crisis Counseling Program

All

Disaster Case Management

Disaster Legal Services

Disaster Unemployment Assistance

For the following jurisdictions (specify counties, parishes, independent cities) If additional space is needed, please enclose additional documentation.

Identify Federally recognized Tribes in the requested counties.

Please see Enclosure A: Supplemental Information for Individual Assistance for additional information in support of this request*
*Not Required for Emergency Declaration Request

11. Programs and Areas Requested (Continued)
Public Assistance

N/A

Debris Removal (Category A)

Emergency Protective Measures
(Category B)

Permanent Work (Categories C-G)*

For the following jurisdictions (Specify counties, parishes, independent cities) If additional space is needed or your request includes different
categories of work for different jurisdictions, please enclose additional documentation.

Identify Federally recognized Tribes included in the requested counties.

Please see Enclosure B: Supplemental Information for Public Assistance for additional information in support of this request*
Indemnification for Debris Removal Activity
I do not anticipate the need for debris removal
I anticipate the need for debris removal, which poses an immediate threat to lives, public health and safety. Pursuant to Sections 403 and 407 of
the Stafford Act, 42 U.S.C. §§ 5170b & 5173, the State agrees to indemnify and hold harmless the United States of America for any claims
arising from the removal of debris or wreckage for this disaster. The State agrees that debris removal from public and private property will not
occur until the landowner signs an unconditional authorization for the removal of debris.
Request for Direct Federal Assistance
I do not request direct Federal assistance at this time
I request direct Federal assistance for work and services to save lives and protect property, and:
a. I request the following type(s) of assistance:

b. List of reasons why State and local governments cannot perform, or contract for, required work and services.

c. In accordance with 44 C.F.R. 206.208, the State agrees that it will, with respect to direct Federal assistance: (1) Provide without cost to the United
States all lands, easements and rights-of-ways necessary to accomplish the approved work; (2) Hold and save the United States free from damages
due to the requested work, and shall indemnify the Federal Government against any claims arising from such work; (3) Provide reimbursement to
FEMA for the non-Federal share of the cost of such work in accordance with the provisions of the FEMA-State Agreement; and (4) Assist the
performing Federal agency in all support and local jurisdictional matters.
Request for Snow Assistance
N/A

I request snow assistance

Snow assistance for the following jurisdictions (Specify counties, independent cities)

Please see Enclosure D: Historic and Current Snowfall Data for additional information in support of this request*
*Not Required for Emergency Declaration Request

11. Programs and Areas Requested (Continued)
Hazard Mitigation*

Statewide

OR

For the following specific counties, parishes, independent cities.

12. Mitigation Plan Information*
b. Type of Plan

a. Mitigation Plan Expiration Date

Enhanced

Standard

13. Other Federal Agency Programs
I do not anticipate requirement from Other Federal Agencies

I do anticipate requirement from Other Federal Agencies

Please see Enclosure C: Requirements for Other Federal Agency Programs for additional information in support of this request*
14. Findings and Certifications
I certify the following:
a. I have determined that this incident is of such severity and magnitude that effective response is beyond the capabilities of the State and the
affected local government and that supplementary federal assistance is necessary.
b. In response to this incident, I have taken appropriate action under State law and have directed the execution of the State Emergency Plan
on
in accordance with the Stafford Act.
c. The State and local governments will assume all applicable non-Federal share of costs required by the Stafford Act.
15. List of Enclosures and Supporting Documentation
Cover Letter

Enclosure A (Individual Assistance)*

Enclosure C (Requirements for Other Federal Agency Programs)

Enclosure B (Public Assistance)*
Enclosure D (Historic and Current Snowfall Data)

Additional Supporting Documentation

Governor's Signature

Date

If anyone except the Governor signs this document, please provide the documentation that establishes that this individual has the legal authority to
act on of the Governor.

*Not Required for Emergency Declaration Request