Form FEMA Form 90-5 FEMA Form 90-5 Application For Loan Cancellation

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. No. 1660-0082
Expires January 31, 2010

APPLICATION FOR LOAN CANCELLATION

PAPERWORK BURDEN DISCLOSURE NOTICE

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Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, and Paperwork
Reduction Project (1660-0082). Note: Do not send your completed form to this address.
1. NAME AND ADDRESS OF APPLICANT

FOR FEDERAL GOVERNMENT USE ONLY
LOAN NUMBER
CDL

___

DISASTER DECLARATION DATE
2. TOTAL AMOUNT OF LOAN ALREADY RECEIVED

3. DATE LOAN APPROVED

4. TERM OF LOAN

5. INTEREST RATE

$
SUMMARY OF CANCELLATION INFORMATION
FISCAL YEAR
PRECEDING
DISASTER
(Information)

FISCAL YEAR OF
DISASTER
(Information)

FIRST POST
DISASTER YEAR
(a)

SECOND POST
DISASTER YEAR
(d)

THIRD POST
DISASTER YEAR
(c)

TOTAL
(a) + (b) + (c)
= (d)

6. ANNUAL OPERATING BUDGET
7. TOTAL ACTUAL REVENUE CDL
PROCEEDS (Lines 12)
8. NORMAL ACTUAL EXPENDITURES
9. DISASTER RELATED EXPENSE
10. TOTAL ACTUAL EXPENDITURES
(Line 8 + line 9)
11. NET REVENUE (Expense)
(Line 7 - line 10)
12. CDL LOAN FUNDS RECEIVED
(Disbursed from Treasury)
13. CANCELLATION REQUEST (total of line 11,
deficit, up to amount of CDL, line 12)
Based on the information contained in the Application for the Community Disaster Loan, the Promissory Note executed
And the information furnished above apply for loan cancellation in the amount of $

20
in connection with the loan already made as a result of the

loss caused by a major disaster declaration on

SIGNATURE OF APPLICANT

DATE
FORWARDED

NAME AND TITLE OF APPROVAL OFFICIAL (Governor's Authorized Representative)

SIGNATURE

DATE

FOR FEMA USE ONLY
RECOMMENDATION:

APPROVAL

NAME AND TITLE OF APPROVAL OFFICIAL (EP&RD Regional Director)
PRINCIPAL CANCELLATION IN THE AMOUNT OF $

DISAPPROVAL
SIGNATURE

PLUS RELATED INTEREST IS HEREBY
APPROVED

NAME AND TITLE OF APPROVAL OFFICIAL

FEMA Form 90-5, DEC 07

DATE

DISAPPROVED
SIGNATURE

DATE