Form FEMA Form 010-0-11 FEMA Form 010-0-11 Individuals and Households Program (IHP) - Other Needs A

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

INDIVIDUALS AND HOUSEHOLDS PROGRAM (IHP) - OTHER NEEDS ASSISTANCE
ADMINISTRATIVE OPTION SELECTION

O.M.B. No. 1660-0061
Expires May 31, 2014

Instructions: This form must be completed and submitted to the Federal Emergency Management Agency (FEMA) by November 30 every year.
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1.08 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 this form. This collection of information is required to
obtain or retain benefits. 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, 500 C Street, SW, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0061).
NOTE: Do not send your completed form to this address.
PRIVACY ACT STATEMENT
AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act as amended, 42 U.S.C. § 5121 -5207 and Reorganization Plan No. 3 of
1978; 4 U.S.C. §§ 2904 and 2906; 4 C.F.R. § 206.2(a)(27); the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Pub. L. 104-193) and
Executive Order 13411. DHS asks for your SSN pursuant to the Debt Collection Improvement Act of 1996, 31 U.S.C. § 3325(d) and § 7701(c) (1).
PRINCIPAL PURPOSE(S): FEMA collects this information to determine eligibility and to administer financial assistance under a Presidentially-declared disaster.
FEMA may also review this information internally for quality assurance control purposes and use it to assess FEMA's customer service to disaster assistance
applicants.
ROUTINE USE(S): FEMA may share the information collected on this form externally as permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as
amended. This includes sharing this information with state, local, tribal and voluntary organizations to enable individuals to receive additional disaster assistance
and as necessary and authorized by other routine uses published in DHS/FEMA-008 Disaster Recovery Assistance Files System of Records, 78 Fed. Reg.
25,282 (April 30, 2013), 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 information requested may delay or prevent the individual
from receiving disaster assistance.

STATE/INDIAN TRIBAL GOVERNMENT SELECTION AND LINE ITEM MAXIMUM
The State/Indian Tribal Government of

selects the following administrative option for the

administration of the Other Needs Assistance provision of the Individuals and Households Program:
FEMA Option: FEMA Administers & Processes.
JOINT Option: State/Indian Tribal Government Administers & FEMA Participates:
FEMA Processing System Auto-determination ON
FEMA Processing System Auto-determination OFF
STATE/INDIAN TRIBAL GOVERNMENT Option: State/Indian Tribal Government Administers & Processes.
The State/Indian Tribal Government approves the following line item amounts to be awarded for ONA:
Transportation Repair:

$

Transportation Replace (Total loss)

$

Funeral Maximum (Unmet Need):

$

Child Care Assistance (Maximum)

$

The State/Indian Tribal Government approves the additional ONA Personal Property and/or Miscellaneous items.
Attached is the list of additional items, the justification, and situations for use.
This administrative option is agreed upon by:

STATE/INDIAN TRIBAL GOVERNMENT AUTHORIZING SIGNATURE

Governor/Tribal Chief Executive or Designee
FEMA Form 010-0-11

DATE

FEMA AUTHORIZING SIGNATURE

Regional Administrator or Designee

DATE
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DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

INDIVIDUALS AND HOUSEHOLDS PROGRAM (IHP) - OTHER NEEDS ASSISTANCE
ADMINISTRATIVE OPTION SELECTION
SUMMARY OF THE ADMINISTRATIVE OPTIONS

FEMA OPTION: Under this option, FEMA will be the administrator of Other Needs Assistance. The State/Indian Tribal Government shall
coordinate ONA activities with FEMA. FEMA shall be responsible for functional elements 1 through 10.
JOINT OPTION: Under this option, the State/Indian Tribal Government will be the administrator of Other Needs Assistance. FEMA shall
participate in providing ONA with the State/Indian Tribal Government. FEMA shall be responsible for functional elements 1,2,3,& 8. The State/
Indian Tribal Government shall be responsible for functional elements 4,5,6,7,9, & 10.
STATE/INDIAN TRIBAL GOVERNMENT OPTION: Under this option, the State/Indian Tribal Government will be the administrator of Other
Needs Assistance. The State/Indian Tribal Government shall report ONA activities to FEMA. The State/Indian Tribal Government shall be
responsible for functional elements 1 through 10.
DESCRIPTION OF FUNCTIONAL ELEMENTS
This section explains the 10 functional elements that must be addressed to successfully implement the Other Needs Assistance mission.
Functional Element 1:
Registration Intake is a systematic procedure for accepting applications (Application/Registration for Disaster
Assistance FEMA Form 009-0-1) from disaster survivors who are in need of Federal disaster assistance. The Procedures must provide for the
acceptance of late applications, up to the prescribed time limitation as described in 44 CFR 206.112.
Functional Element 2:
Inspection Services is a standard procedure for inspecting and verifying individually reported disaster-related
damages, which will be used to determine the level of Federal disaster assistance.
Functional Element 3:
Processing System is a prearranged procedure for making uniformed eligibility determinations, to include methods
for determining cost for personal property and tracking eligibility decisions.
Functional Element 4:

Disbursing Awards is a set procedure for issuing funds to applicants.

Functional Element 5:
Staffing includes the responsibility for having adequate space and an appropriate number of trained personnel. It
also includes the responsibility for having appropriate equipment necessary to process assistance (i.e. computers, phones and facsimile
machines).
Functional Element 6:

Recovery of Funds is an arranged procedure for collecting erroneously awarded funds.

Functional Element 7:

Case Processing is a standard system to process applications and respond to applicant inquiries.

Functional Element 8:

Mail Processing is a standard procedure for sending program decisions and receiving incoming mail.

Functional Element 9:

Appeals is an official protocol for evaluating an applicant request to have a program decision reviewed.

Functional Element 10: Preparation of Closeout Material involves the preparation of the narrative and statistical documents that compromise
a model closeout package. The duties of this function include ensuring that there are no cases pending and that all funds are reconciled for
grants and reimbursement of State/Indian Tribal Government expenses.
Auto-Determination is the process of allowing the NEMIS business rules to routinely process information received from registrations and
inspections and make an eligibility determination without manual intervention.

FEMA Form 010-0-11

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DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

INDIVIDUALS AND HOUSEHOLDS PROGRAM (IHP) - OTHER NEEDS ASSISTANCE
ADMINISTRATIVE OPTION SELECTION
ADDITIONAL ONA ITEMS

If the State/Indian Tribal Government is requesting additional ONA Personal Property, Essential Tools, and/or Miscellaneous items, list the
additional items below, provide the justification, and situation for use.

Line Item:

ONA Category:

Standard Quantity:

Maximum Quantity Awarded:

Justification/Situations for Use:

FEMA USE ONLY

Approved

Initial

Not Approved

Initial

Line Item:

ONA Category:

Standard Quantity:

Maximum Quantity Awarded:

Justification/Situations for Use:

FEMA USE ONLY

Approved

Initial

Not Approved

Initial

Line Item:

ONA Category:

Standard Quantity:

Maximum Quantity Awarded:

Justification/Situations for Use:

FEMA USE ONLY

Approved

Initial

Not Approved

Initial

Line Item:

ONA Category:

Standard Quantity:

Maximum Quantity Awarded:

Justification/Situations for Use:

FEMA USE ONLY
FEMA Form 010-0-11

Approved

Initial

Not Approved

Initial
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