Form FEMA Form 009-0-49 FEMA Form 009-0-49 Request for Public Assistance

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. NO. 1660-0017
Expires April 30, 2013

REQUEST FOR PUBLIC ASSISTANCE

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 0.25 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.
APPLICANT (Political subdivision or eligible applicant)

DATE SUBMITTED

COUNTY (Location of Damages. If located in multiple counties, please indicate)
APPLICANT PHYSICAL LOCATION
STREET ADDRESS
CITY

COUNTY

ZIP CODE

STATE

MAILING ADDRESS (If different from Physical Location)
STREET ADDRESS
POST OFFICE BOX

CITY

STATE

Primary Contact/Applicant's Authorized Agent

Alternate Contact

NAME

NAME

TITLE

TITLE

BUSINESS PHONE

BUSINESS PHONE

FAX NUMBER

FAX NUMBER

HOME PHONE (Optional)

HOME PHONE (Optional)

CELL PHONE

CELL PHONE

E-MAIL ADDRESS

E-MAIL ADDRESS

PAGER & PIN NUMBER

PAGER & PIN NUMBER

Did you participate in the Federal/State Preliminary Damage Assessment (PDA)?
Private Non-Profit Organization?

YES

ZIP CODE

YES

NO

NO

If yes, which of the facilities identified below best describe your organization?
Title 44 CFR, part 206.221(e) defines an eligible private non-profit facility as: "... any private non-profit educational, utility, emergency, medical or custodial
care facility, including a facility for the aged or disabled, and other facility providing essential governmental type services to the general public, and such
facilities on Indian reservations." "Other essential governmental service facility means museums, zoos, community centers, libraries, homeless shelters,
senior citizen centers, rehabilitation facilities, shelter workshops and facilities which provide health and safety safety services of a governmental nature.
All such facilities must be open to the general public."
Private Non-Profit Organizations must attach copies of their Tax Exemption Certificate and Organization Charter or By-Laws. If your
organization is a school or educational facility, please attach information on accreditation or certification.

OFFICIAL USE ONLY: FEMA FEMA Form 009-0-49, (4/10)

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FIPS#

PREVIOUS EDITION OBSOLETE

DATE RECEIVED