Form FEMA Form 009-0-12 FEMA Form 009-0-12 PNP Facility Questionaire

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
PNP FACILITY QUESTIONNAIRE

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

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average .5 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.
FEMA and State personnel will use this questionnaire to determine the eligibility of specific facilities of an approved Private Non-Profit (PNP) organization (See
44 CFR 206.221). Owners of critical facilities (i.e., power, water (including providing by an irrigation organization or facility, if it is not provided solely for
irrigation purposes), sewer, wastewater treatment, communications and emergency medical care) can apply directly to FEMA for assistance for emergency
work (debris removal and emergency protective measures) and permanent work (repair, restore or replace a damaged facility). Owners of non-critical facilities
can apply directly to FEMA for assistance for emergency work, but must first apply to the U. S. Small Business Administration (SBA) for assistance for
permanent work. If the owner of a non-critical facility does not qualify for an SBA loan or the cost to repair the damaged facility exceeds the SBA loan amount,
the owner may apply to FEMA for assistance.
1. Name of PNP Organization

2. Name of the damaged facility and location

3. What was the primary purpose of the damaged facility
Yes

No

7. Was the facility in use at the time of the disaster?

Yes

No

8. Did the facility sustain damage as a direct result of the disaster?

Yes

No

Yes

No

4. Is the facility a critical facility as described above?
5. Who may use the facility
6. What fee, if any, is charged for the use of the facility

9. What type of assistance is being requested?
10. Does the PNP organization own the facility?
11. If "Yes" obtain proof of ownership; check here if attached.
Yes

12. Does the PNP organization have the legal responsibility to repair the facility?
13. If "Yes", provide proof of legal responsibility; check here if attached.

Yes

No

14. Is the facility insured?

Yes

No

No

15. If "Yes", obtain a copy of the insurance policy; check here if attached.
Additional information or comments:

Date

Contact Person

FEMA Form 009-0-121, (4/2010)

PREVIOUS EDITION OBSOLETE