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 (as defined in Stafford Act 102, 42 U.S.C. § 5122) or Indian tribal government requesting declaration.	2b. State Population (as reported by 2010 Census)    or estimated population of Indian tribal government’s damaged area(s).  	
3. Governor's or Tribal Chief Executive’s Name  
	4. Designation of State or Tribal Coordinating Officer upon declaration (if available) and phone number	
5.. Designation of Governor's Authorized Representative or Tribal Chief Executive Representative upon declaration (if available) and phone number	
6. Declaration Request  For:	Major Disaster (Stafford Act Sec. 401)	Emergency (Stafford Act Sec. 501(a))	
7. Incident Period	Beginning Date	End Date	If requesting a "continuing" incident period, enclose an official
or	Continuing    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	Fire	Flood	Hurricane	Landslide	Mudslide
Severe Storm	Snowstorm	Straight-Line Winds
(rain, high water, wind-driven rain, hail, lightning)	(Must include Enclosure D: Historic and Current Snowfall Data)
Tidal Wave	Tornado	Tropical	Tropical Storm	Tsunami	Volcanic Eruption	Winter Storm
Depression
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 or Tribal Chief Executive’s cover letter. 	
9. Description of the nature and amount of State, local, or Indian tribal government  resources which have been or will be committed. Include additional details in enclosed Governor's or Tribal Chief Executive’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	Disaster Unemployment Assistance

All	Disaster Case Management	Disaster Legal Services

For the following jurisdictions, specify programs and areas (counties, parishes, independent cities, for Indian tribal government, list tribe(s)  and/or tribal area(s)).   If additional space is needed, please enclose additional documentation.

For States, identify Federally recognized Tribes in the requested counties (if applicable).

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)
(not available for Emergency Declaration Requests)

For the following jurisdictions, specify programs and areas (counties, parishes, independent cities, for Indian tribal government, list tribes and/or tribal areas).  If additional space is needed or your request includes different categories of work for different jurisdictions, please enclose additional documentation.

For States, identify Federally recognized Tribes included in the requested counties (if applicable).

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 or Indian tribal government 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 or Indian tribal government 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,local, or Indian tribal government cannot perform, or contract for, required work and services.

c. In accordance with 44 C.F.R. § 206.208, the State or Indian tribal government 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, or tribes and//or tribal areas.

12. Mitigation Plan Information*

a. Mitigation Plan Expiration Date

b. Type of Plan

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, or Indian tribal government and that supplementary federal assistance is necessary.

b. In response to this incident, I have taken appropriate action under State or tribal law and have directed the execution of the State Emergency Plan on  	in accordance with the Stafford Act.

c. The State and local governments, or Indian tribal government 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 B (Public Assistance)*

Enclosure C (Requirements for Other Federal Agency Programs)	Enclosure D (Historic and Current Snowfall Data)

Additional Supporting Documentation

Governor's or Tribal Chief Executive’s Signature	Date

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

*Not Required for Emergency Declaration Request