Form FEMA Form 055-0-0- FEMA Form 055-0-0- Arbitration From

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

OMB No. 1660-0017 Expires July 31, 2016
Date Request Submitted

REQUEST FOR ARBITRATION

Burden Disclosure Notice
Public reporting burden for this form is estimated to average 1 hour 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
voluntary. You are not required to respond to this collection of information unless it displays a valid OMB control number is displayed in the upper right
corner of 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 form to this address.
Privacy Statement
Authority: The Robert T. Stafford Disaster Relief and Emergency Assistance Act, §§ 403, 406, and 407, 42 U.S.C. §§ 5170b, 5172, 5173; Sandy
Recovery Improvement Act of 2013, Pub. L. No. 113-2, 127 Stat. 43 (Jan. 29, 2013), 42 U.S.C. 5189a note; and 44 C.F.R. § 206.210.
Purpose: FEMA is collecting this information to provide assistance to eligible jurisdictions and organizations to facilitate an efficient recovery from
major disasters.
Routine Uses: The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as
amended. This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 004 Grant Management
Information Files System of Records, 74 Fed. Reg. 39,705 (Aug. 7, 2009), and upon written request, by agreement, or as required by law.
Disclosure: The disclosure of information on this form is voluntary; however, failure to provide the requested information may delay or prevent the
agency from receiving funds from FEMA's Public Assistance Program.
1. Applicant's Name

2. Applicant's Designated
Representative and Contact
Information (Telephone
number and E-mail address)

3. Grantee's Name

4. Reference Number of
Project Worksheets in Dispute

7. Requesting Arbitration Instead of Second Administrative Appeal?

Yes

5. FEMA Region

6. Disaster Number

No

8. Identification of issue to be arbitrated

8a. Date of First Appeal Determination

8b. Date Applicant Received Notice of First Appeal Determination

9. Amount in Dispute in First Appeal (Amount in Dispute is the difference between the amount requested by the applicant
and the amount determined eligible by FEMA)

$

10. Current Amount in Dispute (Current Amount in Dispute is the difference between the amount requested by the Applicant
and the amount determined eligible by FEMA in the First Appeal Determination)

$

11. Related matters, if any

12. Category of Dispute (Please check all that apply)
1.
2.
3.
4.
5.
6.
7.

Alternate Project
Audit Findings/Report
Codes and Standards
Contracting
Deobligation
Documentation
Duplication of Benefit

8.
9.
10.
11.
12.
13.
14.

Eligibility (Applicant)
Eligibility (Facility)
Eligibility (Work)
Eligibility (Cost)
Environmental Compliance
406 Hazard Mitigation Proposal
Improved Project

15.
16.
17.
18.
19.
20.
21.

Insurance
22.
Landslide
Other Federal Agency Authority
Pre-Disaster Condition
Repair/Replace (50% Rule)
Temporary Facility
Time Extension/Deadlines

Other
Other Specify

13. Brief 1-2 Sentence Description of Specifics of Dispute

By signing below, I acknowledge as the Applicant's Designated Representative, that the Applicant is seeking final resolution through binding
arbitration and forfeiting its rights to a second appeal under 44 C.F.R. § 206.206.
Signature of Applicant

FEMA FORM 055-0-0-1, (7/13)

Date